Aims

Patients with recurrent anterior dislocation of the shoulder commonly have an anterior osseous defect of the glenoid. Once the defect reaches a critical size, stability may be restored by bone grafting. The critical size of this defect under non-physiological loading conditions has previously been identified as 20% of the length of the glenoid. As the stability of the shoulder is load-dependent, with higher joint forces leading to a loss of stability, the aim of this study was to determine the critical size of an osseous defect that leads to further anterior instability of the shoulder under physiological loading despite a Bankart repair.

Aims

The aim of this study was to compare the results of 16S/28S rRNA sequencing with the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and synovial fluid analysis in the diagnosis of prosthetic joint infection (PJI).

Aims

The pathogenesis of intraneural ganglion cysts is controversial. Recent reports in the literature described medial plantar intraneural ganglion cysts (mIGC) with articular branches to subtalar joints. The aim of the current study was to provide further support for the principles underlying the articular theory, and to explain the successes and failures of treatment of mICGs.

Aims

The aims of this study were to evaluate the clinical and radiological outcomes of instrumented posterolateral fusion (PLF) performed in patients with rheumatoid arthritis (RA).

Periprosthetic joint infection (PJI) is one of the most feared and challenging complications following total knee arthroplasty. We provide a detailed description of our current understanding regarding the management of PJI of the knee, including diagnostic aids, pre-operative planning, surgical treatment, and outcome.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):20–9.

The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ.

Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology.

There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention.

This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention.

Cite this article: Bone Joint J 2013;95-B:721–31.

It is probable that both genetic and environmental factors play some part in the aetiology of most cases of degenerative hip disease. Geneticists have identified some single gene disorders of the hip, but have had difficulty in identifying the genetics of many of the common causes of degenerative hip disease. The heterogeneity of the phenotypes studied is part of the problem. A detailed classification of phenotypes is proposed. This study is based on careful documentation of 2003 consecutive total hip replacements performed by a single surgeon between 1972 and 2000. The concept that developmental problems may initiate degenerative hip disease is supported. The influences of gender, age and body mass index are outlined. Biomechanical explanations for some of the radiological appearances encountered are suggested. The body weight lever, which is larger than the abductor lever, causes the abductor power to be more important than body weight. The possibility that a deficiency in joint lubrication is a cause of degenerative hip disease is discussed. Identifying the phenotypes may help geneticists to identify genes responsible for degenerative hip disease, and eventually lead to a definitive classification.

The aim of this study was to determine whether exposure of human articular cartilage to hyperosmotic saline (0.9%, 600 mOsm) reduces in situ chondrocyte death following a standardised mechanical injury produced by a scalpel cut compared with the same assault and exposure to normal saline (0.9%, 285 mOsm). Human cartilage explants were exposed to normal (control) and hyperosmotic 0.9% saline solutions for five minutes before the mechanical injury to allow in situ chondrocytes to respond to the altered osmotic environment, and incubated for a further 2.5 hours in the same solutions following the mechanical injury.

Using confocal laser scanning microscopy, we identified a sixfold (p = 0.04) decrease in chondrocyte death following mechanical injury in the superficial zone of human articular cartilage exposed to hyperosmotic saline compared with normal saline.

These data suggest that increasing the osmolarity of joint irrigation solutions used during open and arthroscopic articular surgery may reduce chondrocyte death from surgical injury and could promote integrative cartilage repair.

Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management.

This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia.

Smoking is known to have an adverse effect on wound healing and musculoskeletal conditions. This case-controlled study looked at whether smoking has a deleterious effect in the outcome of autologous chondrocyte implantation for the treatment of full thickness chondral defects of the knee.

The mean Modified Cincinatti Knee score was statistically significantly lower in smokers (n = 48) than in non-smokers (n = 66) both before and after surgery (p < 0.05). Smokers experienced significantly less improvement in the knee score two years after surgery (p < 0.05). Graft failures were only seen in smokers (p = 0.016). There was a strong negative correlation between the number of cigarettes smoked and the outcome following surgery (Pearson’s correlation coefficient −0.65, p = 0.004).

These results suggest that patients who smoke have worse pre-operative function and obtain less benefit from this procedure than non-smokers. The counselling of patients undergoing autologous chondrocyte implantation should include smoking, not only as a general cardiopulmonary risk but also because poorer results can be expected in smokers following this procedure.

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings.

In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications.

The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO.

Fractures of the proximal interphalangeal joint include a wide spectrum of injuries, from stable avulsion fractures to complex fracture-dislocations. Stability of the joint is paramount in determining the appropriate treatment, which should aim to facilitate early mobilisation and restoration of function.

We reviewed 15 consecutive patients, 11 women and four men, with a mean age of 48.7 years (37.3 to 62.6), who between July 2004 and August 2007 had undergone percutaneous sacroiliac fusion using hollow modular anchorage screws filled with demineralised bone matrix.

Each patient was carefully assessed to exclude other conditions and underwent pre-operative CT and MR scans. The diagnosis of symptomatic sacroiliac disease was confirmed by an injection of local anaesthetic and steroid under image intensifier control.

The short form-36 questionnaire and Majeed’s scoring system were used for pre- and post-operative functional evaluation. Post-operative radiological evaluation was performed using plain radiographs.

Intra-operative blood loss was minimal and there were no post-operative clinical or radiological complications. The mean follow-up was for 17 months (9 to 39). The mean short form-36 scores improved from 37 (23 to 51) to 80 (67 to 92) for physical function and from 53 (34 to 73) to 86 (70 to 98) for general health (p = 0.037). The mean Majeed’s score improved from 37 (18 to 54) pre-operatively to 79 (63 to 96) post-operatively (p = 0.014). There were 13 good to excellent results. The remaining two patients improved in short form-36 from a mean of 29 (26 to 35) to 48 (44 to 52). Their persistent pain was probably due to concurrent lumbar pathology.

We conclude that percutaneous hollow modular anchorage screws are a satisfactory method of achieving sacroiliac fusion.

The aim of this study was to determine whether subchondral bone influences in situ chondrocyte survival. Bovine explants were cultured in serum-free media over seven days with subchondral bone excised from articular cartilage (group A), subchondral bone left attached to articular cartilage (group B), and subchondral bone excised but co-cultured with articular cartilage (group C). Using confocal laser scanning microscopy, fluorescent probes and biochemical assays, in situ chondrocyte viability and relevant biophysical parameters (cartilage thickness, cell density, culture medium composition) were quantified over time (2.5 hours vs seven days). There was a significant increase in chondrocyte death over seven days, primarily within the superficial zone, for group A, but not for groups B or C (p < 0.05). There was no significant difference in cartilage thickness or cell density between groups A, B and C (p > 0.05). Increases in the protein content of the culture media for groups B and C, but not for group A, suggested that the release of soluble factors from subchondral bone may have influenced chondrocyte survival. In conclusion, subchondral bone significantly influenced chondrocyte survival in articular cartilage during explant culture.

The extrapolation of bone-cartilage interactions in vitro to the clinical situation must be made with caution, but the findings from these experiments suggest that future investigation into in vivo mechanisms of articular cartilage survival and degradation must consider the interactions of cartilage with subchondral bone.

Hallux rigidus was first described in 1887. Many aetiological factors have been postulated, but none has been supported by scientific evidence. We have examined the static and dynamic imbalances in the first metatarsophalangeal joint which we postulated could be the cause of this condition. We performed a finite-element analysis study on a male subject and calculated a mathematical model of the joint when subjected to both normal and abnormal physiological loads.

The results gave statistically significant evidence for an increase in tension of the plantar fascia as the cause of abnormal stress on the articular cartilage rather than mismatch of the articular surfaces or subclinical muscle contractures. Our study indicated a clinical potential cause of hallux rigidus and challenged the many aetiological theories. It could influence the choice of surgical procedure for the treatment of early grades of hallux rigidus.

The sternoclavicular joint is vulnerable to the same disease processes as other synovial joints, the most common of which are instability from injury, osteoarthritis, infection and rheumatoid disease. Patients may also present with other conditions, which are unique to the joint, or are manifestations of a systemic disease process. The surgeon should be aware of these possibilities when assessing a patient with a painful, swollen sternoclavicular joint

Treatment strategies for osteoarthritis most commonly involve the removal or replacement of damaged joint tissue. Relatively few treatments attempt to arrest, slow down or reverse the disease process. Such options include peri-articular osteotomy around the hip or knee, and treatment of femoro-acetabular impingement, where early intervention may potentially alter the natural history of the disease. A relatively small proportion of patients with osteoarthritis have a clear predisposing factor that is both suitable for modification and who present early enough for intervention to be deemed worthwhile. This paper reviews recent advances in our understanding of the pathology, imaging and progression of early osteoarthritis.

We audited the relationship between obesity and the age at which hip and knee replacement was undertaken at our centre. The database was analysed for age, the Oxford hip or knee score and the body mass index (BMI) at the time of surgery. In total, 1369 patients were studied, 1025 treated by hip replacement and 344 by knee replacement. The patients were divided into five groups based on their BMI (normal, overweight, moderately obese, severely obese and morbidly obese).

The difference in the mean Oxford score at surgery was not statistically significant between the groups (p > 0.05). For those undergoing hip replacement, the mean age of the morbidly obese patients was ten years less than that of those with a normal BMI. For those treated by knee replacement, the difference was 13 years. The age at surgery fell significantly for those with a BMI > 35 kg/m² for both hip and knee replacement (p > 0.05). This association was stronger for patients treated by knee than by hip replacement.

The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.