We report the five year outcomes of a two-stage
approach for infected total hip replacement. This is a single-surgeon
experience at a tertiary centre where the more straightforward cases
are treated using single-stage exchange. This study highlights the
vital role of the multidisciplinary team in managing these cases. A total of 125 patients (51 male, 74 female) with a mean age
of 68 years (42 to 78) were reviewed prospectively. Functional status
was assessed using the Harris hip score (HHS). The mean HHS improved
from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively.
Staphylococcus species were isolated in 85 patients (68%). . The rate of control of infection was 96% at five years. In all,
19 patients died during the period of the study. This represented
a one year mortality of 0.8% and an overall mortality of 15.2% at
five years. No patients were lost to follow-up. . We report excellent control of infection in a series of complex
patients and infections using a two-stage revision protocol supported
by a
The patient with a painful arthritic knee awaiting
total knee arthroplasty (TKA) requires a
Giant cell tumours (GCT) of the synovium and
tendon sheath can be classified into two forms: localised (giant
cell tumour of the tendon sheath, or nodular tenosynovitis) and
diffuse (diffuse-type giant cell tumour or pigmented villonodular
synovitis). The former principally affects the small joints. It
presents as a solitary slow-growing tumour with a characteristic
appearance on MRI and is treated by surgical excision. There is
a significant risk of multiple recurrences with aggressive diffuse
disease. A
Dislocation of the shoulder may occur during
seizures in epileptics and other patients who have convulsions. Following
the initial injury, recurrent instability is common owing to a tendency
to develop large bony abnormalities of the humeral head and glenoid
and a susceptibility to further seizures. Assessment is difficult
and diagnosis may be missed, resulting in chronic locked dislocations
with protracted morbidity. Many patients have medical comorbidities,
and successful treatment requires a
The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a
Desmoid tumours are a rare fibroblastic proliferation of monoclonal origin, arising in deep soft-tissues. Histologically, they are characterized by locally aggressive behaviour and an inability to metastasize, and clinically by a heterogeneous and unpredictable course. Desmoid tumours can occur in any anatomical site, but commonly arise in the limbs. Despite their benign nature, they can be extremely disabling and sometimes life-threatening, causing severe pain and functional limitations. Their surgical management is complex and challenging, due to uncertainties surrounding the biological and clinical behaviour, rarity, and limited available literature. Resection has been the first-line approach for patients with a desmoid tumour but, during the last few decades, a shift towards a more conservative approach has occurred, with an initial ‘wait and see’ policy. Many medical and regional forms of treatment are also available for the management of this condition, and others have recently emerged with promising results. However, many areas of controversy remain, and further studies and global collaboration are needed to obtain prospective and randomized data, in order to develop an appropriate shared stepwise approach. Cite this article:
Periprosthetic joint infection (PJI) remains an extremely challenging complication. We have focused on this issue more over the last decade than previously, but there are still many unanswered questions. We now have a workable definition that everyone should align to, but we need to continue to focus on identifying the organisms involved. Surgical strategies are evolving and care is becoming more patient-centred. There are some good studies under way. There are, however, still numerous problems to resolve, and the challenge of PJI remains a major one for the orthopaedic community. This annotation provides some up-to-date thoughts about where we are, and the way forward. There is still scope for plenty of research in this area. Cite this article:
We reviewed retrospectively 236 consecutive patients seen in our soft-tissue sarcoma clinic. Of these, 95 had had a primary soft-tissue sarcoma excised elsewhere, but with histologically inadequate resection margins. All these patients had a secondary and wider re-excision. The tissues removed at the secondary re-excision were examined histologically for the presence of residual tumour. Definite tumour tissue was found in 29 of 55 lower-limb specimens, 16 of 25 upper-limb, 7 of 10 trunk and 4 of 5 head and neck specimens. In 31 cases some residual tumour was visible macroscopically, and in 56 of the 95 patients (59%) the primary tumour had been incompletely excised. Our results indicate that surgical assessment of the adequacy of excision is very inaccurate and that most local recurrences are the consequence of inadequate primary surgery. The large number of patients who had inadequate initial treatment emphasises the need for a co-ordinated
The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed. A total of 60 patients (25 females, 35 males; mean age 39 years (SD 18)) undergoing iliosacral resection were reviewed. Most resections were performed for primary malignant tumours (n = 54; 90%). The mean follow-up for surviving patients was nine years (2 to 19).Aims
Methods
The number of revision arthroplasties being performed in the elderly is expected to rise, including revision for infection. The primary aim of this study was to measure the treatment success rate for octogenarians undergoing revision total hip arthroplasty (THA) for periprosthetic joint infection (PJI) compared to a younger cohort. Secondary outcomes were complications and mortality. Patients undergoing one- or two-stage revision of a primary THA for PJI between January 2008 and January 2021 were identified. Age, sex, BMI, American Society of Anesthesiologists grade, Charlson Comorbidity Index (CCI), McPherson systemic host grade, and causative organism were collated for all patients. PJI was classified as ‘confirmed’, ‘likely’, or ‘unlikely’ according to the 2021 European Bone and Joint Infection Society criteria. Primary outcomes were complications, reoperation, re-revision, and successful treatment of PJI. A total of 37 patients aged 80 years or older and 120 patients aged under 80 years were identified. The octogenarian group had a significantly lower BMI and significantly higher CCI and McPherson systemic host grades compared to the younger cohort.Aims
Methods
Nonagenarians (aged 90 to 99 years) have experienced the fastest percent decile population growth in the USA recently, with a consequent increase in the prevalence of nonagenarians living with joint arthroplasties. As such, the number of revision total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) in nonagenarians is expected to increase. We aimed to determine the mortality rate, implant survivorship, and complications of nonagenarians undergoing aseptic revision THAs and revision TKAs. Our institutional total joint registry was used to identify 96 nonagenarians who underwent 97 aseptic revisions (78 hips and 19 knees) between 1997 and 2018. The most common indications were aseptic loosening and periprosthetic fracture for both revision THAs and revision TKAs. Mean age at revision was 92 years (90 to 98), mean BMI was 27 kg/m2 (16 to 47), and 67% (n = 65) were female. Mean time between primary and revision was 18 years (SD 9). Kaplan-Meier survival was used for patient mortality, and compared to age- and sex-matched control populations. Reoperation risk was assessed using cumulative incidence with death as a competing risk. Mean follow-up was five years.Aims
Methods
We first sought to compare survival for patients treated surgically for solitary and multiple metastases in the appendicular skeleton, and second, to explore the role of complete and incomplete resection (R0 and R1/R2) in patients with a solitary bony metastasis in the appendicular skeleton. We conducted a retrospective study on a population-based cohort of all adult patients treated surgically for bony metastases of the appendicular skeleton between January 2014 and December 2019. We excluded patients in whom the status of bone metastases and resection margin was unknown. Patients were followed until the end of the study or to their death. We had no loss to follow-up. We used Kaplan-Meier analysis (with log-rank test) to evaluate patient survival. We identified 506 operations in 459 patients. A total of 120 operations (in 116 patients) were for solitary metastases and 386 (in 345 patients) for multiple metastases. Of the 120 operations, 70 (in 69 patients) had no/an unknown status of visceral metastases (solitary group) and 50 (in 49 patients) had visceral metastases. In the solitary group, 45 operations (in 44 patients) were R0 (resections for cure or complete remission) and 25 (in 25 patients) were R1/R2 (resections leaving microscopic or macroscopic tumour, respectively). The most common types of cancer in the solitary group were kidney (n = 27), lung (n = 25), and breast (n = 20).Aims
Methods
To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment. Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients’ willingness to participate, clinicians’ capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments.Aims
Methods
Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years. This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed.Aims
Methods
We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a
Musculoskeletal diseases are having a growing impact worldwide. It is therefore crucial to have an evidence base to most effectively and efficiently implement future health services across different healthcare systems. International trials are an opportunity to address these challenges and have many potential benefits. They are, however, complex to set up and deliver, which may impact on the efficient and timely delivery of a project. There are a number of models of how international trials are currently being delivered across a range of orthopaedic patient populations, which are discussed here. The examples given highlight that the key to overcoming these challenges is the development of trusted and equal partnerships with collaborators in each country. International trials have the potential to address a global burden of disease, and in turn optimize the benefit to patients in the collaborating countries and those with similar health services and care systems. Cite this article:
This study aimed to analyze the accuracy and errors associated with 3D-printed, patient-specific resection guides (3DP-PSRGs) used for bone tumour resection. We retrospectively reviewed 29 bone tumour resections that used 3DP-PSRGs based on 3D CT and 3D MRI. We evaluated the resection amount errors and resection margin errors relative to the preoperative plans. Guide-fitting errors and guide distortion were evaluated intraoperatively and one month postoperatively, respectively. We categorized each of these error types into three grades (grade 1, < 1 mm; grade 2, 1 to 3 mm; and grade 3, > 3 mm) to evaluate the overall accuracy.Aims
Methods
Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality. Using a multicentre study design, independent of registry data, we included adult patients sustaining a PPF around a knee arthroplasty between 1 January 2010 and 31 December 2019. Univariate, then multivariable, logistic regression analyses were performed to study the impact of patient, fracture, and treatment on mortality.Aims
Methods
The aim of this study was to assess the clinical and radiological outcomes of an antiprotrusio acetabular cage (APC) when used in the surgical treatment of periacetabular bone metastases. This retrospective cohort study using a prospectively collected database involved 56 patients who underwent acetabular reconstruction for periacetabular bone metastases or haematological malignancy using a single APC between January 2009 and 2020. The mean follow-up was 20 months (1 to 143). The primary outcome measure was implant survival. Postoperative radiographs were analyzed for loosening and failure. Patient and implant survival were assessed using a competing risk analysis. Secondary parameters included primary malignancy, oncological treatment, surgical factors, length of stay in hospital, and postoperative complications.Aims
Methods
The aim of this study was to investigate the outcome of periprosthetic fractures of the humerus and to assess the uniformity of the classifications used for these fractures (including those around elbow and/or shoulder arthroplasties) by performing a systematic review of the literature. A systematic search was conducted using the National Institute for Health and Care Excellence Healthcare Databases Advance Search. For inclusion, studies had to report clinical outcomes following the management of periprosthetic fractures of the humerus. The protocol was registered on the PROSPERO database.Aims
Methods
The incidence of bone metastases is between 20% to 75% depending on the type of cancer. As treatment improves, the number of patients who need surgical intervention is increasing. Identifying patients with a shorter life expectancy would allow surgical intervention with more durable reconstructions to be targeted to those most likely to benefit. While previous scoring systems have focused on surgical and oncological factors, there is a need to consider comorbidities and the physiological state of the patient, as these will also affect outcome. The primary aim of this study was to create a scoring system to estimate survival time in patients with bony metastases and to determine which factors may adversely affect this. This was a retrospective study which included all patients who had presented for surgery with metastatic bone disease. The data collected included patient, surgical, and oncological variables. Univariable and multivariable analysis identified which factors were associated with a survival time of less than six months and less than one year. A model to predict survival based on these factors was developed using Cox regression.Aims
Methods
To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle. We carried out a retrospective search of our records from 2000 to 2019 of patients seen in our adult tertiary referral foot and ankle unit with a diagnosis of functional dystonia.Aims
Methods
Orthopaedic and reconstructive surgeons are faced with large defects after the resection of malignant tumours of the sacrum. Spinopelvic reconstruction is advocated for resections above the level of the S1 neural foramina or involving the sacroiliac joint. Fixation may be augmented with either free vascularized fibular flaps (FVFs) or allograft fibular struts (AFSs) in a cathedral style. However, there are no studies comparing these reconstructive techniques. We reviewed 44 patients (23 female, 21 male) with a mean age of 40 years (SD 17), who underwent en bloc sacrectomy for a malignant tumour of the sacrum with a reconstruction using a total (n = 20), subtotal (n = 2), or hemicathedral (n = 25) technique. The reconstructions were supplemented with a FVF in 25 patients (57%) and an AFS in 19 patients (43%). The mean length of the strut graft was 13 cm (SD 4). The mean follow-up was seven years (SD 5).Aims
Methods
One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions. In this single-centre, case-control study, 57 patients who underwent one-stage revision arthroplasty for PJI of the hip and required resection of the proximal femur between 2009 and 2018 were identified. The control group consisted of 57 patients undergoing one-stage revision without bony resection. Logistic regression analysis was performed to identify any correlation with resection and the risk factors for re-revisions. Rates of all-causes re-revision, reinfection, and instability were compared between groups.Aims
Methods
In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months’ follow-up.Aims
Methods
Echocardiography is commonly used in hip fracture patients to evaluate perioperative cardiac risk. However, echocardiography that delays surgical repair may be harmful. The objective of this study was to compare surgical wait times, mortality, length of stay (LOS), and healthcare costs for similar hip fracture patients evaluated with and without preoperative echocardiograms. A population-based, matched cohort study of all hip fracture patients (aged over 45 years) in Ontario, Canada between 2009 and 2014 was conducted. The primary exposure was preoperative echocardiography (occurring between hospital admission and surgery). Mortality rates, surgical wait times, postoperative LOS, and medical costs (expressed as 2013$ CAN) up to one year postoperatively were assessed after propensity-score matching.Aims
Methods
With recent progress in cancer treatment, the number of advanced-age patients with spinal metastases has been increasing. It is important to clarify the influence of advanced age on outcomes following surgery for spinal metastases, especially with a focus on subjective health state values. We prospectively analyzed 101 patients with spinal metastases who underwent palliative surgery from 2013 to 2016. These patients were divided into two groups based on age (< 70 years and ≥ 70 years). The Eastern Cooperative Oncology Group (ECOG) performance status (PS), Barthel index (BI), and EuroQol-5 dimension (EQ-5D) score were assessed at study enrolment and at one, three, and six months after surgery. The survival times and complications were also collected.Aims
Methods
Tenosynovial giant cell tumour (TGCT) is one of the most common soft-tissue tumours of the foot and ankle and can behave in a locally aggressive manner. Tumour control can be difficult, despite the various methods of treatment available. Since treatment guidelines are lacking, the aim of this study was to review the multidisciplinary management by presenting the largest series of TGCT of the foot and ankle to date from two specialized sarcoma centres. The Oxford Tumour Registry and the Leiden University Medical Centre Sarcoma Registry were retrospectively reviewed for patients with histologically proven foot and ankle TGCT diagnosed between January 2002 and August 2019.Aims
Methods
The aim of this prospective multicentre study was to describe trends in length of stay and early complications and readmissions following unicompartmental knee arthroplasty (UKA) performed at eight different centres in Denmark using a fast-track protocol and to compare the length of stay between centres with high and low utilization of UKA. We included data from eight dedicated fast-track centres, all reporting UKAs to the same database, between 2010 and 2018. Complete ( > 99%) data on length of stay, 90-day readmission, and mortality were obtained during the study period. Specific reasons for a length of stay of > two days, length of stay > four days, and 30- and 90-day readmission were recorded. The use of UKA in the different centres was dichotomized into ≥ 20% versus < 20% of arthroplasties which were undertaken being UKAs, and ≥ 52 UKAs versus < 52 UKAs being undertaken annually.Aims
Methods
We reviewed 190 children with brucellosis admitted over a 7.8-year period. Seventy of these had articular involvement (36%) and the most common site was the hip (18%). All but one patient had unilateral infection. The hip was the only joint infected in 20 patients (57%). The next most common articular site was the knee. All patients had painful limitation of movement and this was the only articular sign in 28 (80%). Extra-articular signs included fever and hepatosplenomegaly. Brucella infection should be considered in every child from an endemic area who presents with fever and joint symptoms. The insidious onset and a normal or low leucocyte count help the differentiation from acute septic arthritis. Children with hip involvement had a slower response to treatment, longer hospital stays and a higher incidence of complications and relapse than those without. Complications included dislocation (n = 4) and avascular necrosis of the femoral head (n = 1). Treatment by combination chemotherapy for 6 to 12 weeks usually achieves cure and prevents relapse. A
To investigate the experience and emotional impact of prosthetic joint infection (PJI) on orthopaedic surgeons and identify holistic strategies to improve the management of PJI and protect surgeons’ wellbeing. In total, 18 prosthetic joint surgeons in Sweden were recruited using a purposive sampling strategy. Content analysis was performed on transcripts of individual in-person interviews conducted between December 2017 and February 2018.Aims
Methods
The aim of this study was to identify modifiable risk factors associated with mortality in patients requiring revision total hip arthroplasty (THA) for periprosthetic hip fracture. The electronic records of consecutive patients undergoing revision THA for periprosthetic hip fracture between December 2011 and October 2018 were reviewed. The data which were collected included age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, the preoperative serum level of haemoglobin, time to surgery, operating time, blood transfusion, length of hospital stay, and postoperative surgical and medical complications. Univariate and multivariate logistic regression analyses were used to determine independent modifiable factors associated with mortality at 90 days and one year postoperatively.Aims
Methods
Tranexamic acid (TXA) has been shown to significantly reduce transfusion rates in primary total hip arthroplasties (THAs), but high-quality evidence is limited in the revision setting. The purpose of the current study was to compare the rate of blood transfusions and symptomatic venous thromboembolic events (VTEs) in a large cohort of revision THAs treated with or without intravenous (IV) TXA. We performed a retrospective review of 3264 revision THAs (2645 patients) between 2005 and 2014, of which 1142 procedures received IV TXA (1 g at incision and 1 g at closure). The mean age in the revision group with TXA was 65 years (28 to 95), with 579 female patients (51%). The mean age in the revision group treated without TXA was 67 years (21 to 98), with 1160 female patients (55%). Outcomes analyzed included rates of transfusion and symptomatic VTEs between procedures undertaken with and without TXA. These comparisons were performed for the overall cohort, as well as within cases subcategorized for aseptic or septic aetiologies. A propensity score was developed to minimize bias between groups and utilized age at revision THA, sex, body mass index, American Society of Anesthesiologists (ASA) score, preoperative anticoagulation, and year of surgery.Aims
Patients and Methods
Psychological factors play a critical role in patient presentation, satisfaction, and outcomes. Pain catastrophizing, anxiety, and depression are important to consider, as they are associated with poorer outcomes and are potentially modifiable. The aim of this study was to assess the level of pain catastrophizing, anxiety, and depression in patients with a range of hip pathology and to evaluate their relationship with patient-reported psychosocial and functional outcome measures. Patients presenting to a tertiary-centre specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, and depression. Validated assessments were undertaken such as: the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), and the 12-Item Short-Form Health Survey (SF-12). Patient characteristics and demographics were also recorded. Multiple linear regression modelling, with adaptive least absolute shrinkage and selection operator (LASSO) variable selection, was used for analysis.Aims
Patients and Methods
The aims of this study were to report the efficacy of revision surgery for patients with co-infective bacterial and fungal prosthetic joint infections (PJIs) presenting to a single institution, and to identify prognostic factors that would guide management. A total of 1189 patients with a PJI were managed in our bone infection service between 2006 and 2015; 22 (1.85%) with co-infective bacterial and fungal PJI were included in the study. There were nine women and 13 men, with a mean age at the time of diagnosis of 64.5 years (47 to 83). Their mean BMI was 30.9 kg/m2 (24 to 42). We retrospectively reviewed the outcomes of these PJIs, after eight total hip arthroplasties and 14 total knee arthroplasties. The mean clinical follow-up was 4.1 years (1.4 to 8.8).Aims
Patients and Methods
Myxofibrosarcomas (MFSs) are malignant soft-tissue sarcomas characteristically
presenting as painless slowly growing masses in the extremities.
Locally infiltrative growth means that the risk of local recurrence
is high. We reviewed our experience to make recommendations about
resection strategies and the role of the multidisciplinary team
in the management of these tumours. Patients with a primary or recurrent MFS who were treated surgically
in our unit between 1997 and 2012 were included in the study. Clinical
records and imaging were reviewed. A total of 50 patients with a
median age of 68.4 years (interquartile range 61.6 to 81.8) were
included. There were 35 men; 49 underwent surgery in our unit.Aims
Patients and Methods
Neuropathic changes in the foot are common with
a prevalence of approximately 1%. The diagnosis of neuropathic arthropathy
is often delayed in diabetic patients with harmful consequences
including amputation. The appropriate diagnosis and treatment can
avoid an extensive programme of treatment with significant morbidity
for the patient, high costs and delayed surgery. The pathogenesis
of a Charcot foot involves repetitive micro-trauma in a foot with impaired
sensation and neurovascular changes caused by pathological innervation
of the blood vessels. In most cases, changes are due to a combination
of both pathophysiological factors. The Charcot foot is triggered
by a combination of mechanical, vascular and biological factors
which can lead to late diagnosis and incorrect treatment and eventually
to destruction of the foot. This review aims to raise awareness of the diagnosis of the Charcot
foot (diabetic neuropathic osteoarthropathy and the differential
diagnosis, erysipelas, peripheral arterial occlusive disease) and
describe the ways in which the diagnosis may be made. The clinical
diagnostic pathways based on different classifications are presented. Cite this article:
The mucopolysaccharidoses (MPS) are a group of
inherited lysosomal storage disorders with clinical manifestations relevant
to the orthopaedic surgeon. Our aim was to review the recent advances
in their management and the implications for surgical practice. The current literature about MPSs is summarised, emphasising
orthopaedic complications and their management. Recent advances in the diagnosis and management of MPSs include
the recognition of slowly progressive, late presenting subtypes,
developments in life-prolonging systemic treatment and potentially
new indications for surgical treatment. The outcomes of surgery
in these patients are not yet validated and some procedures have
a high rate of complications which differ from those in patients
who do not have a MPS. The diagnosis of a MPS should be considered in adolescents or
young adults with a previously unrecognised dysplasia of the hip.
Surgeons treating patients with a MPS should report their experience
and studies should include the assessment of function and quality
of life to guide treatment. Cite this article:
Periprosthetic joint infection (PJI) complicates
between 0.5% and 1.2% primary total hip arthroplasties (THAs) and
may have devastating consequences. The traditional assessment of
patients suffering from PJI has involved the serological study of
inflammatory markers and microbiological analysis of samples obtained
from the joint space. Treatment has involved debridement and revision
arthroplasty performed in either one or two stages. We present an update on the burden of PJI, strategies for its
diagnosis and treatment, the challenge of resistant organisms and
the need for definitive evidence to guide the treatment of PJI after
THA. Cite this article:
Infected nonunion of a long bone continues to
present difficulties in management. In addition to treating the infection,
it is necessary to establish bony stability, encourage fracture
union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in
66 patients treated in a multidisciplinary unit. The operative treatment
of patients suitable for limb salvage was performed as a single
procedure. Antibiotic regimes were determined by the results of
microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%)
had an infection-free united fracture in a functioning limb. Seven
others required amputation (three as primary treatment, three after
late failure of limb salvage and one for recalcitrant pain after
union). The initial operation achieved union in 54 (84%) of the salvaged
limbs at a mean of nine months (three to 26), with recurrence of
infection in 9%. Further surgery in those limbs that remained ununited
increased the union rate to 62 (97%) of the 64 limbs treated by
limb salvage at final follow-up. The use of internal fixation was
associated with a higher risk of recurrent infection than external
fixation. Cite this article:
Exsanguination is the second most common cause
of death in patients who suffer severe trauma. The management of
haemodynamically unstable high-energy pelvic injuries remains controversial,
as there are no universally accepted guidelines to direct surgeons
on the ideal use of pelvic packing or early angio-embolisation.
Additionally, the optimal resuscitation strategy, which prevents
or halts the progression of the trauma-induced coagulopathy, remains
unknown. Although early and aggressive use of blood products in
these patients appears to improve survival, over-enthusiastic resuscitative
measures may not be the safest strategy. This paper provides an overview of the classification of pelvic
injuries and the current evidence on best-practice management of
high-energy pelvic fractures, including resuscitation, transfusion
of blood components, monitoring of coagulopathy, and procedural
interventions including pre-peritoneal pelvic packing, external
fixation and angiographic embolisation. Cite this article:
Non-tuberculous mycobacterial (NTM) infection
of the musculoskeletal tissue is a rare disease. An early and accurate diagnosis
is often difficult because of the indolent clinical course and difficulty
of isolating pathogens. Our goal was to determine the clinical features
of musculoskeletal NTM infection and to present the treatment outcomes.
A total of 29 patients (nine females, 20 males between 34 and 85
years old, mean age 61.7 years; 34 to 85) with NTM infection of the
musculoskeletal system between 1998 to 2011 were identified and
their treatment retrospectively analysed. Microbiological studies
demonstrated NTM in 29 patients: the isolates were Cite this article:
The pre-operative differentiation between enchondroma,
low-grade chondrosarcoma and high-grade chondrosarcoma remains a
diagnostic challenge. We reviewed the accuracy and safety of the
radiological grading of cartilaginous tumours through the assessment
of, first, pre-operative radiological and post-operative histological agreement,
and second the rate of recurrence in lesions confirmed as high-grade
on histology. We performed a retrospective review of major long
bone cartilaginous tumours managed by curettage as low grade between
2001 and 2012. A total of 53 patients with a mean age of 47.6 years
(8 to 71) were included. There were 23 men and 30 women. The tumours
involved the femur (n = 20), humerus (n = 18), tibia (n = 9), fibula
(n = 3), radius (n = 2) and ulna (n = 1). Pre-operative diagnoses
resulted from multidisciplinary consensus following radiological
review alone for 35 tumours, or with the addition of pre-operative
image guided needle biopsy for 18. The histologically confirmed diagnosis
was enchondroma for two (3.7%), low-grade chondrosarcoma for 49
(92.6%) and high-grade chondrosarcoma for two (3.7%). Three patients
with a low-grade tumour developed a local recurrence at a mean of 15
months (12 to 17) post-operatively. A single high-grade recurrence
(grade II) was treated with tibial diaphyseal replacement. The overall
recurrence rate was 7.5% at a mean follow-up of 4.7 years (1.2 to
12.3). Cartilaginous tumours identified as low-grade on pre-operative
imaging with or without additional image-guided needle biopsy can
safely be managed as low-grade without pre-operative histological
diagnosis. A few tumours may demonstrate high-grade features histologically,
but the rates of recurrence are not affected. Cite this article:
We report our early experience with the use of
a new prosthesis, the Modular Hemipelvic Prosthesis II, for reconstruction
of the hemipelvis after resection of a primary malignant peri-acetabular
tumour involving the sacroiliac joint. We retrospectively reviewed the outcome of 17 patients who had
undergone resection of a pelvic tumour and reconstruction with this
prosthesis between July 2002 and July 2010. One patient had a type I+II+III+IV resection (ilium + peri-acetabulum
+ pubis/ischium + sacrum) and 16 had a type I+II+IV resection (ilium
+ acetabulum + sacrum). The outcome was assessed at a mean follow-up
of 33 months (15 to 59). One patient was alive with disease, 11
were alive without disease and five had died of disease. The overall
five-year survival rate was 62.4%. Six patients had a local recurrence.
The mean Musculoskeletal Tumour Society score was 58% (33 to 77).
Deep infection occurred in two patients, problems with wound healing
in five and dislocation in one. For patients with a primary malignant peri-acetabular sarcoma
involving the sacroiliac joint, we believe that this new prosthesis
is a viable option for reconstruction of the bony defect left following
resection of the tumour. It results in a satisfactory functional
outcome with an acceptable rate of complications. Cite this article:
Fractures of the odontoid peg are common spinal
injuries in the elderly. This study compares the survivorship of
a cohort of elderly patients with an isolated fracture of the odontoid
peg A total of 32 patients with an isolated odontoid fracture were
identified. The rate of mortality was 37.5% (n = 12) at one year.
The period of greatest mortality was within the first 12 weeks.
Time made a lesser contribution from then to one year, and there
was no impact of time on the rate of mortality thereafter. The rate
of mortality at one year was 41.2% for male patients (7 of 17) compared
with 33.3% for females (5 of 15). The rate of mortality at one year was 32% (225 of 702) for patients
with a fracture of the hip and 4% (9 of 221) for those with a fracture
of the wrist. There was no statistically significant difference
in the rate of mortality following a hip fracture and an odontoid
peg fracture (p = 0.95). However, the survivorship of the wrist
fracture group was much better than that of the odontoid peg fracture
group (p <
0.001). Thus, a fracture of the odontoid peg in the
elderly is not a benign injury and is associated with a high rate
of mortality, especially in the first three months after the injury. Cite this article:
The purpose of this study was to identify changing
trends in the pattern of distribution of the type and demographics
of fractures of the hip in the elderly between 2001 and 2010. A
retrospective cross-sectional comparison was conducted between 179
fractures of the hip treated in 2001, 357 treated in 2006 and 454
treated in 2010. Patients aged <
60 years and those with pathological
and peri-prosthetic fractures were excluded. Fractures were classified
as stable extracapsular, unstable extracapsular or intracapsular
fractures. The mean age of the 179 patients (132 women (73.7%)) treated
in 2001 was 80.8 years (60 to 96), 81.8 years (61 to 101) in the
357 patients (251 women (70.3%)) treated in 2006 and 82.0 years
(61 to 102) in the 454 patients (321 women (70.1%)) treated in 2010
(p = 0.17). There was no difference in the gender distribution between
the three study years (p = 0.68). The main finding was a steep rise in the proportion of unstable
peritrochanteric fractures. The proportion of unstable extracapsular
fractures was 32% (n = 57) in 2001, 35% (n = 125) in 2006 and 45%
(n = 204) in 2010 (p <
0.001). This increase was not significant
in patients aged between 60 and 69 years (p = 0.84), marginally
significant in those aged between 70 and 79 years (p = 0.04) and
very significant in those aged >
80 years (p <
0.001). The proportion
of intracapsular fractures did not change (p = 0.94). At present, we face not only an increasing number of fractures
of the hip, but more demanding and complex fractures in older patients
than a decade ago. This study does not provide an explanation for
this change. Cite this article:
We performed a systematic review of the optimal management of septic arthritis in children as recommended in the current English literature using MEDLINE, EMBASE, CINAHL, the Cochrane Library and reference lists of retrieved articles without date restrictions up to 31 January 2009. From 2236 citations, 227 relevant full-text articles were screened in detail; 154 papers fulfilled the inclusion criteria, from which conclusions were drawn on the management of infected joints in children. Our review showed that no single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively joint infection. The roles of aspiration, arthrotomy and arthroscopy in treatment are not clear cut, and the ideal duration of antibiotic therapy is not yet fully defined. These issues are discussed. Further large-scale, multi-centre studies are needed to delineate the optimal management of paediatric septic arthritis.
We report our experience with glenohumeral arthrodesis
as a salvage procedure for epilepsy-related recurrent shoulder instability.
A total of six patients with epilepsy underwent shoulder fusion
for recurrent instability and were followed up for a mean of 39 months
(12 to 79). The mean age at the time of surgery was 31 years (22
to 38). Arthrodesis was performed after a mean of four previous
stabilisation attempts (0 to 11) in all but one patient in whom
the procedure was used as a primary treatment. All patients achieved
bony union, with a mean time to fusion of 2.8 months (2 to 7). There
were no cases of re-dislocation. One revision was undertaken for
loosening of the metalwork, and then healed satisfactorily. An increase
was noted in the mean subjective shoulder value, which improved
from 37 (5 to 50) pre-operatively to 42 (20 to 70) post-operatively
although it decreased in two patients. The mean Oxford shoulder
instability score improved from 13 pre-operatively (7 to 21) to
24 post-operatively (13 to 36). In our series, glenohumeral arthrodesis
eliminated recurrent instability and improved functional outcome. Fusion
surgery should therefore be considered in this patient population.
However, since the majority of patients are young and active, they
should be comprehensively counselled pre-operatively given the functional
deficit that results from the procedure. Cite this article:
We reviewed 101 patients with injuries of the
terminal branches of the infraclavicular brachial plexus sustained between
1997 and 2009. Four patterns of injury were identified: 1) anterior
glenohumeral dislocation (n = 55), in which the axillary and ulnar
nerves were most commonly injured, but the axillary nerve was ruptured
in only two patients (3.6%); 2) axillary nerve injury, with or without
injury to other nerves, in the absence of dislocation of the shoulder
(n = 20): these had a similar pattern of nerve involvement to those
with a known dislocation, but the axillary nerve was ruptured in
14 patients (70%); 3) displaced proximal humeral fracture (n = 15),
in which nerve injury resulted from medial displacement of the humeral
shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension
of the arm (n = 11): these were characterised by disruption of the
musculocutaneous nerve. There was variable involvement of the median
and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular
injury associated with dislocation of the shoulder. Early exploration
of the nerves should be considered in patients with an axillary
nerve palsy without dislocation of the shoulder and for musculocutaneous
nerve palsy with median and/or radial nerve palsy. Urgent operation
is needed in cases of nerve injury resulting from fracture of the
humeral neck to relieve pressure on nerves.
Deep prosthetic joint infection remains an uncommon but serious complication of total hip replacement. We reviewed 24 patients with recalcitrant hip wounds following infected total hip replacement treated with either pedicled rectus femoris or vastus lateralis muscle flaps between 1998 and 2009. The mean age of the patients was 67.4 years (42 to 86) with ten men and 14 women. There had been a mean of four (1 to 8) previous attempts to close the wound. A total of 20 rectus femoris and five vastus lateralis flaps were used, with one of each type of flap failing and requiring further reconstruction. All patients had positive microbiology. At a mean follow-up of 47 months (9 to 128), 22 patients had a healed wound and two had a persistent sinus. The prosthesis had been retained in five patients. In the remainder it had been removed, and subsequently re-implanted in nine patients. Six patients continued to take antibiotics at final follow-up. This series demonstrates the effectiveness of pedicled muscle flaps in healing these infected wounds. The high number of previous debridements suggests that these flaps could have been used earlier.
Biofilm-associated infections in wounds or on implants are difficult to treat. Eradication of the bacteria is nearly always impossible, despite the use of specific antibiotics. The bactericidal effects of high-energy extracorporeal shock waves on The biofilm-cultured washers were exposed to low-energy shock waves at 0.16 mJ/mm2 for 500 impulses. The washers were then treated with cefuroxime, rifampicin and fosfomycin, both alone and in combination. All tests were carried out in triplicate. Viable cells were counted to determine the bactericidal effect. The control groups of We conclude that shock waves combined with antibiotics could be tested in an
A delay in the diagnosis of paediatric acute
and subacute haematogenous osteomyelitis can lead to potentially devastating
morbidity. There are no definitive guidelines for diagnosis, and
recommendations in the literature are generally based on expert
opinions, case series and cohort studies. All articles in the English literature on paediatric osteomyelitis
were searched using MEDLINE, CINAHL, EMBASE, Google Scholar, the
Cochrane Library and reference lists. A total of 1854 papers were
identified, 132 of which were examined in detail. All aspects of
osteomyelitis were investigated in order to formulate recommendations. On admission 40% of children are afebrile. The tibia and femur
are the most commonly affected long bones. Clinical examination,
blood and radiological tests are only reliable for diagnosis in
combination. Most studies were retrospective and there is a need for large,
multicentre, randomised, controlled trials to define protocols for
diagnosis and treatment. Meanwhile, evidence-based algorithms are
suggested for accurate and early diagnosis and effective treatment.
Two-stage exchange remains the gold standard
for treatment of peri-prosthetic joint infection after total hip replacement
(THR). In the first stage, all components and associated cement
if present are removed, an aggressive debridement is undertaken
including a complete synovectomy, and an antibiotic-loaded cement
spacer is put in place. Patients are then treated with six weeks
of parenteral antibiotics, followed by an ‘antibiotic free period’
to help ensure the infection has been eradicated. If the clinical
evaluation and serum inflammatory markers suggest the infection
has resolved, then the second stage can be completed, which involves
removal of the cement spacer, repeat debridement, and placement
of a new THR. Cite this article:
Periprosthetic infection following total hip replacement can be a catastrophic complication for the patient. The treatments available include single-stage exchange, and two-stage exchange. We present a series of 50 consecutive patients with a diagnosis of infected total hip replacement who were assessed according to a standardised protocol. Of these, 11 underwent single-stage revision arthroplasty with no recurrence of infection at a mean of 6.8 years follow-up (5.5 to 8.8). The remaining 39 underwent two-stage revision, with two recurrences of infection successfully treated by a second two-stage procedure. At five years, significant differences were found in the mean Harris Hip Scores (single-stage 87.8; two-stage 75.5; p = 0.0003) and in a visual analogue score for satisfaction (8.6; 6.9; p = 0.001) between the single- and two-stage groups. Single-stage exchange is successful in eradicating periprosthetic infection and results in excellent functional and satisfaction scores. Identification of patients suitable for the single-stage procedure allows individualisation of care and provides as many as possible with the correct strategy in successfully tackling their periprosthetic infection
There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful and debilitating condition. We conducted a review of the evidence of the effectiveness of interventions used to manage primary frozen shoulder using the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Physiotherapy Evidence Database, MEDLINE and EMBASE without language or date restrictions up to April 2009. Two authors independently applied selection criteria and assessed the quality of systematic reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Data were synthesised narratively, with emphasis placed on assessing the quality of evidence. In total, 758 titles and abstracts were identified and screened, which resulted in the inclusion of 11 systematic reviews. Although these met most of the AMSTAR quality criteria, there was insufficient evidence to draw firm conclusions about the effectiveness of treatments commonly used to manage a frozen shoulder. This was mostly due to poor methodological quality and small sample size in primary studies included in the reviews. We found no reviews evaluating surgical interventions. More rigorous randomised trials are needed to evaluate the treatments used for frozen shoulder.
We performed a retrospective study of a departmental database to assess the efficacy of a new model of orthopaedic care on the outcome of patients with a fracture of the proximal femur. All 1578 patients admitted to a university teaching hospital with a fracture of the proximal femur between December 2007 and December 2009 were included. The allocation of Foundation doctors years 1 and 2 was restructured from individual teams covering several wards to pairs covering individual wards. No alterations were made in the numbers of doctors, their hours, out-of-hours cover, or any other aspect of standard patient care. Outcome measures comprised 30-day mortality and cause, complications and length of stay. Mortality was reduced from 11.7% to 7.6% (p = 0.007, Cox’s regression analysis); adjusted odds ratio was 1.559 (95% confidence interval 1.128 to 2.156). Reductions were seen in These findings may have implications for all specialties caring for patients on several wards, and we believe they justify a prospective trial to further assess this effect.
The outcome after total hip replacement has improved
with the development of surgical techniques, better pain management
and the introduction of enhanced recovery pathways. These pathways
require a multidisciplinary team to manage pre-operative education,
multimodal pain control and accelerated rehabilitation. The current economic
climate and restricted budgets favour brief hospitalisation while
minimising costs. This has put considerable pressure on hospitals
to combine excellent results, early functional recovery and shorter
admissions. In this review we present an evidence-based summary of some common
interventions and methods, including pre-operative patient education,
pre-emptive analgesia, local infiltration analgesia, pre-operative
nutrition, the use of pulsed electromagnetic fields, peri-operative
rehabilitation, wound dressings, different surgical techniques, minimally
invasive surgery and fast-track joint replacement units. Cite this article:
Metastatic epidural compression of the spinal cord is a significant source of morbidity in patients with systemic cancer. With improved oncological treatment, survival in these patients is improving and metastatic cord compression is encountered increasingly often. The treatment is mostly palliative. Surgical management involves early circumferential decompression of the cord with concomitant stabilisation of the spine. Patients with radiosensitive tumours without cord compression benefit from radiotherapy. Spinal stereotactic radiosurgery and minimally invasive techniques, such as vertebroplasty and kyphoplasty, with or without radiofrequency ablation, are promising options for treatment and are beginning to be used in selected patients with spinal metastases. In this paper we review the surgical management of patients with metastatic epidural spinal cord compression.
Skeletal metastases from hepatocellular carcinoma are highly destructive vascular lesions which severely reduce the quality of life. Pre-existing liver cirrhosis presents unique challenges during the surgical management of such lesions. We carried out a retrospective study of 42 patients who had been managed surgically for skeletal metastases from hepatocellular carcinoma affecting the appendicular skeleton between January 2000 and December 2006. There were 38 men and four women with a mean age of 60.2 years (46 to 77). Surgery for a pathological fracture was undertaken in 30 patients and because of a high risk of fracture in 12. An intralesional surgical margin was achieved in 36 and a wide margin in six. Factors influencing survival were determined by univariate and multivariate analyses. The survival rates at one, two and three years after surgery were 42.2%, 25.8% and 19.8%, respectively. The median survival time was ten months (95% confidence interval 6.29 to 13.71). The number of skeletal metastases and the Child-Pugh grade were identified as independent prognostic factors by Cox regression analysis. The method of management of the hepatocellular carcinoma, its status in the liver, the surgical margin for skeletal metastases, the presence of a pathological fracture and adjuvant radiotherapy were not found to be significantly related to the survival of the patient, which was affected by hepatic function, as represented by the Child-Pugh grade.
Painful neuromas may follow traumatic nerve injury. We carried out a double-blind controlled trial in which patients with a painful neuroma of the lower limb (n = 20) were randomly assigned to treatment by resection of the neuroma and translocation of the proximal nerve stump into either muscle tissue or an adjacent subcutaneous vein. Translocation into a vein led to reduced intensity of pain as assessed by visual analogue scale (5.8 (sd 2.7) vs 3.8 (sd 2.4); p <
0.01), and improved sensory, affective and evaluative dimensions of pain as assessed by the McGill pain score (33 (sd 18) vs 14 (sd 12); p <
0.01). This was associated with an increased level of activity (p <
0.01) and improved function (p <
0.01). Transposition of the nerve stump into an adjacent vein should be preferred to relocation into muscle.
A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.
Evaluation of patients with painful total knee replacement requires a thorough clinical examination and relevant investigations in order to reach a diagnosis. Awareness of the common and uncommon problems leading to painful total knee replacement is useful in the diagnostic approach. This review article aims to act as a guide to the evaluation of patients with painful total knee replacement.
We have analysed the management and clinical outcome of a series of consecutive patients who had a total hip replacement and developed post-operative surgical site infection (SSI) with methicillin-resistant Methicillin-resistant
Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure. Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months. Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion. Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement.
Injuries to the acromioclavicular joint are common but underdiagnosed. Sprains and minor subluxations are best managed conservatively, but there is debate concerning the treatment of complete dislocations and the more complex combined injuries in which other elements of the shoulder girdle are damaged. Confusion has been caused by existing systems for classification of these injuries, the plethora of available operative techniques and the lack of well-designed clinical trials comparing alternative methods of management. Recent advances in arthroscopic surgery have produced an even greater variety of surgical options for which, as yet, there are no objective data on outcome of high quality. We review the current concepts of the treatment of these injuries.
We compared case-mix and outcome variables in 1310 patients who sustained an acute fracture at the age of 80 years or over. A group of 318 very elderly patients (≥ 90 years) was compared with a group of 992 elderly patients (80 to 89 years), all of whom presented to a single trauma unit between July 2007 and June 2008. The very elderly group represented only 0.6% of the overall population, but accounted for 4.1% of all fractures and 9.3% of all orthopaedic trauma admissions. Patients in this group were more likely to require hospital admission (odds ratio 1.4), less likely to return to independent living (odds ratio 3.1), and to have a significantly longer hospital stay (ten days, p = 0.01). The 30- and 120-day unadjusted mortality was greater in the very elderly group. The 120-day mortality associated with non-hip fractures of the lower limb was equal to that of proximal femoral fractures, and was significantly increased with a delay to surgery >
48 hours for both age groups (p = 0.04). This suggests that the principle of early surgery and mobilisation of elderly patients with hip fractures should be extended to include all those in this vulnerable age group.
