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The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1249 - 1256
1 Nov 2024
Mangwani J Houchen-Wolloff L Malhotra K Booth S Smith A Teece L Mason LW

Aims

Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE.

Methods

This was a multicentre, prospective national collaborative audit with data collection over nine months for all patients undergoing foot and ankle surgery in an operating theatre or TA rupture treatment, within participating UK hospitals. The association between VTE and thromboprophylaxis was assessed with a univariable logistic regression model. A multivariable logistic regression model was used to identify key predictors for the risk of VTE.


The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1342 - 1347
1 Nov 2024
Onafowokan OO Jankowski PP Das A Lafage R Smith JS Shaffrey CI Lafage V Passias PG

Aims

The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD).

Methods

Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes.


The Bone & Joint Journal
Vol. 106-B, Issue 11 | Pages 1348 - 1360
1 Nov 2024
Spek RWA Smith WJ Sverdlov M Broos S Zhao Y Liao Z Verjans JW Prijs J To M Åberg H Chiri W IJpma FFA Jadav B White J Bain GI Jutte PC van den Bekerom MPJ Jaarsma RL Doornberg JN

Aims

The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.

Methods

The CNN was trained and tested on radiographs sourced from 11 hospitals in Australia and externally validated on radiographs from the Netherlands. Each radiograph was paired with corresponding CT scans to serve as the reference standard based on dual independent evaluation by trained researchers and attending orthopaedic surgeons. Presence of a fracture, classification (non- to minimally displaced; two-part, multipart, and glenohumeral dislocation), and four characteristics were determined on 2D and 3D CT scans and subsequently allocated to each series of radiographs. Fracture characteristics included greater tuberosity displacement ≥ 1 cm, NSA ≤ 100°, shaft translation (0% to < 75%, 75% to 95%, > 95%), and the extent of articular involvement (0% to < 15%, 15% to 35%, or > 35%).


The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 450 - 459
1 May 2024
Clement ND Galloway S Baron J Smith K Weir DJ Deehan DJ

Aims

The aim was to assess whether robotic-assisted total knee arthroplasty (rTKA) had greater knee-specific outcomes, improved fulfilment of expectations, health-related quality of life (HRQoL), and patient satisfaction when compared with manual TKA (mTKA).

Methods

A randomized controlled trial was undertaken (May 2019 to December 2021), and patients were allocated to either mTKA or rTKA. A total of 100 patients were randomized, 50 to each group, of whom 43 rTKA and 38 mTKA patients were available for review at 12 months following surgery. There were no statistically significant preoperative differences between the groups. The minimal clinically important difference in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score was defined as 7.5 points.


The Bone & Joint Journal
Vol. 106-B, Issue 3 Supple A | Pages 121 - 129
1 Mar 2024
Orce Rodríguez A Smith PN Johnson P O'Sullivan M Holder C Shimmin A

Aims

In recent years, the use of a collared cementless femoral prosthesis has risen in popularity. The design intention of collared components is to transfer some load to the resected femoral calcar and prevent implant subsidence within the cancellous bone of the metaphysis. Conversely, the load transfer for a cemented femoral prosthesis depends on the cement-component and cement-bone interface interaction. The aim of our study was to compare the three most commonly used collared cementless components and the three most commonly used tapered polished cemented components in patients aged ≥ 75 years who have undergone a primary total hip arthroplasty (THA) for osteoarthritis (OA).

Methods

Data from the Australian Orthopaedic Association National Joint Replacement Registry from 1 September 1999 to 31 December 2022 were analyzed. Collared cementless femoral components and cemented components were identified, and the three most commonly used components in each group were analyzed. We identified a total of 11,278 collared cementless components and 47,835 cemented components. Hazard ratios (HRs) from Cox proportional hazards models, adjusting for age and sex, were obtained to compare the revision rates between the groups.


The Bone & Joint Journal
Vol. 105-B, Issue 12 | Pages 1279 - 1285
1 Dec 2023
Baker JF Nadar AC Jouflas AC Smith LS Sachdeva S Yakkanti MR Malkani AL

Aims

The use of cementless total knee arthroplasty (TKA) components has increased during the past decade. The initial design of cementless metal-backed patellar components had shown high failure rates due to many factors. The aim of this study was to evaluate the clinical results of a second-generation cementless, metal-backed patellar component of a modern design.

Methods

This was a retrospective review of 707 primary TKAs in 590 patients from a single institution, using a cementless, metal-backed patellar component with a mean follow-up of 6.9 years (2 to 12). A total of 409 TKAs were performed in 338 females and 298 TKAs in 252 males. The mean age of the patients was 63 years (34 to 87) and their mean BMI was 34.3 kg/m2 (18.8 to 64.5). The patients were chosen to undergo a cementless procedure based on age and preoperative radiological and intraoperative bone quality. Outcome was assessed using the Knee Society knee and function scores and range of motion (ROM), complications, and revisions.


The Bone & Joint Journal
Vol. 105-B, Issue 10 | Pages 1132 - 1132
1 Oct 2023
Clement ND Galloway S Baron YJ Smith K Weir DJ Deehan DJ


The Bone & Joint Journal
Vol. 105-B, Issue 9 | Pages 961 - 970
1 Sep 2023
Clement ND Galloway S Baron YJ Smith K Weir DJ Deehan DJ

Aims

The primary aim was to assess whether robotic total knee arthroplasty (rTKA) had a greater early knee-specific outcome when compared to manual TKA (mTKA). Secondary aims were to assess whether rTKA was associated with improved expectation fulfilment, health-related quality of life (HRQoL), and patient satisfaction when compared to mTKA.

Methods

A randomized controlled trial was undertaken, and patients were randomized to either mTKA or rTKA. The primary objective was functional improvement at six months. Overall, 100 patients were randomized, 50 to each group, of whom 46 rTKA and 41 mTKA patients were available for review at six months following surgery. There were no differences between the two groups.


The Bone & Joint Journal
Vol. 105-B, Issue 9 | Pages 971 - 976
1 Sep 2023
Bourget-Murray J Piroozfar S Smith C Ellison J Bansal R Sharma R Evaniew N Johnson A Powell JN

Aims

This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection.

Methods

This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality.


The Bone & Joint Journal
Vol. 105-B, Issue 8 | Pages 895 - 904
1 Aug 2023
Smith TO Dainty J Loveday DT Toms A Goldberg AJ Watts L Pennington MW Dawson J van der Meulen J MacGregor AJ

Aims

The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures.

Methods

Patients listed for a primary TAA at 19 NHS hospitals between February 2016 and October 2017 were eligible. PROMs data were collected preoperatively and at six and 12 months including: Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ (foot and ankle)) and the EuroQol five-dimension five-level questionnaire (EQ-5D-5L). Radiological pre- and postoperative data included Kellgren-Lawrence score and implant position measurement. This was supplemented by data from the National Joint Registry through record linkage to determine: American Society of Anesthesiologists (ASA) grade at index procedure; indication for surgery, index ankle previous fracture; tibial hind foot alignment; additional surgery at the time of TAA; and implant type. Multivariate regression models assessed outcomes, and the relationship between MOXFQ and EQ-5D-5L outcomes, with patient characteristics.


The Bone & Joint Journal
Vol. 105-B, Issue 2 | Pages 198 - 208
1 Feb 2023
Cheok T Smith T Wills K Jennings MP Rawat J Foster B

Aims

We investigated the prevalence of late developmental dysplasia of the hip (DDH), abduction bracing treatment, and surgical procedures performed following the implementation of universal ultrasound screening versus selective ultrasound screening programmes.

Methods

A systematic search of PubMed, Embase, The Cochrane Library, OrthoSearch, and Web of Science from the date of inception of each database until 27 March 2022 was performed. The primary outcome of interest was the prevalence of late detection of DDH, diagnosed after three months. Secondary outcomes of interest were the prevalence of abduction bracing treatment and surgical procedures performed in childhood for dysplasia. Only studies describing the primary outcome of interest were included.


The Bone & Joint Journal
Vol. 104-B, Issue 11 | Pages 1209 - 1214
1 Nov 2022
Owen AR Amundson AW Larson DR Duncan CM Smith HM Johnson RL Taunton MJ Pagnano MW Berry DJ Abdel MP

Aims

Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anaesthesia in primary TKAs from a single, high-volume academic centre.

Methods

We retrospectively identified 17,690 primary TKAs (13,297 patients) from 2001 to 2016 using our institutional total joint registry, where 52% had general anaesthesia and 48% had spinal anaesthesia. Baseline characteristics were similar between cohorts with a mean age of 68 years (SD 10), 58% female (n = 7,669), and mean BMI of 32 kg/m2 (SD 7). Pain was evaluated using oral morphine equivalents (OMEs) and numerical pain rating scale (NPRS) data. Complications including 30- and 90-day readmissions were studied. Data were analyzed using an inverse probability of treatment weighted model based on propensity score that included many patient and surgical factors. Mean follow-up was seven years (2 to 18).


The Bone & Joint Journal
Vol. 104-B, Issue 5 | Pages 559 - 566
1 May 2022
Burden EG Batten T Smith C Evans JP

Aims

Arthroplasty is being increasingly used for the management of distal humeral fractures (DHFs) in elderly patients. Arthroplasty options include total elbow arthroplasty (TEA) and hemiarthroplasty (HA); both have unique complications and there is not yet a consensus on which implant is superior. This systematic review asked: in patients aged over 65 years with unreconstructable DHFs, what differences are there in outcomes, as measured by patient-reported outcome measures (PROMs), range of motion (ROM), and complications, between distal humeral HA and TEA?

Methods

A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on PROMs, ROM, and complications. PROMs and ROM results were reported descriptively and a meta-analysis of complications was conducted. Quality of methodology was assessed using Wylde’s non-summative four-point system. The study was registered with PROSPERO (CRD42021228329).


The Bone & Joint Journal
Vol. 104-B, Issue 3 | Pages 311 - 320
1 Mar 2022
Cheok T Smith T Siddiquee S Jennings MP Jayasekera N Jaarsma RL

Aims

The preoperative diagnosis of periprosthetic joint infection (PJI) remains a challenge due to a lack of biomarkers that are both sensitive and specific. We investigated the performance characteristics of polymerase chain reaction (PCR), interleukin-6 (IL6), and calprotectin of synovial fluid in the diagnosis of PJI.

Methods

We performed systematic search of PubMed, Embase, The Cochrane Library, Web of Science, and Science Direct from the date of inception of each database through to 31 May 2021. Studies which described the diagnostic accuracy of synovial fluid PCR, IL6, and calprotectin using the Musculoskeletal Infection Society criteria as the reference standard were identified.


The Bone & Joint Journal
Vol. 104-B, Issue 1 | Pages 83 - 90
1 Jan 2022
Batten TJ Gallacher S Evans JP Harding RJ Kitson J Smith CD Thomas WJ

Aims

The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up.

Methods

Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening.


The Bone & Joint Journal
Vol. 104-B, Issue 1 | Pages 59 - 67
1 Jan 2022
Kingsbury SR Smith LK Shuweihdi F West R Czoski Murray C Conaghan PG Stone MH

Aims

The aim of this study was to conduct a cross-sectional, observational cohort study of patients presenting for revision of a total hip, or total or unicompartmental knee arthroplasty, to understand current routes to revision surgery and explore differences in symptoms, healthcare use, reason for revision, and the revision surgery (surgical time, components, length of stay) between patients having regular follow-up and those without.

Methods

Data were collected from participants and medical records for the 12 months prior to revision. Patients with previous revision, metal-on-metal articulations, or hip hemiarthroplasty were excluded. Participants were retrospectively classified as ‘Planned’ or ‘Unplanned’ revision. Multilevel regression and propensity score matching were used to compare the two groups.


The Bone & Joint Journal
Vol. 103-B, Issue 6 | Pages 1160 - 1167
1 Jun 2021
Smith JRA Fox CE Wright TC Khan U Clarke AM Monsell FP

Aims

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

Methods

Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score.


The Bone & Joint Journal
Vol. 103-B, Issue 6 | Pages 1111 - 1118
1 Jun 2021
Dainty JR Smith TO Clark EM Whitehouse MR Price AJ MacGregor AJ

Aims

To determine the trajectories of patient reported pain and functional disability over five years following total hip arthroplasty (THA) or total knee arthroplasty (TKA).

Methods

A prospective, longitudinal cohort sub-study within the National Joint Registry (NJR) was undertaken. In all, 20,089 patients who underwent primary THA and 22,489 who underwent primary TKA between 2009 and 2010 were sent Oxford Hip Score (OHS) and Oxford Knee Score (OKS) questionnaires at six months, and one, three, and five years postoperatively. OHS and OKS were disaggregated into pain and function subscales. A k-means clustering procedure assigned each patient to a longitudinal trajectory group for pain and function. Ordinal regression was used to predict trajectory group membership using baseline OHS and OKS score, age, BMI, index of multiple deprivation, sex, ethnicity, geographical location, and American Society of Anesthesiologists grade.


The Bone & Joint Journal
Vol. 103-B, Issue 6 Supple A | Pages 59 - 66
1 Jun 2021
Abhari S Hsing TM Malkani MM Smith AF Smith LS Mont MA Malkani AL

Aims

Alternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment.

Methods

A total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019.


The Bone & Joint Journal
Vol. 103-B, Issue 6 Supple A | Pages 32 - 37
1 Jun 2021
Restrepo S Smith EB Hozack WJ

Aims

Cementless total knee arthroplasty (TKA) offers the potential for strong biological fixation compared with cemented TKA where fixation is achieved by the mechanical integration of the cement. Few mid-term results are available for newer cementless TKA designs, which have used additive manufacturing (3D printing). The aim of this study was to present mid-term clinical outcomes and implant survivorship of the cementless Stryker Triathlon Tritanium TKA.

Methods

This was a single institution registry review of prospectively gathered data from 341 cementless Triathlon Tritanium TKAs at four to 6.8 years follow-up. Outcomes were determined by comparing pre- and postoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) scores, and pre- and postoperative 12-item Veterans RAND/Short Form Health Survey (VR/SF-12) scores. Aseptic loosening and revision for any reason were the endpoints which were used to determine survivorship at five years.


The Bone & Joint Journal
Vol. 103-B, Issue 5 | Pages 813 - 821
1 May 2021
Burden EG Batten TJ Smith CD Evans JP

Aims

This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH).

Methods

A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and patient-reported outcome measures (PROMs). Meta-analysis was conducted on the reported proportion of complications, weighted by sample size, and PROMs were pooled using the reported standardized mean difference (SMD). Quality of methodology was assessed using Wylde’s non-summative four-point system. The study was registered with PROSPERO (CRD42020193041).


The Bone & Joint Journal
Vol. 103-B, Issue 3 | Pages 522 - 529
1 Mar 2021
Nichol T Callaghan J Townsend R Stockley I Hatton PV Le Maitre C Smith TJ Akid R

Aims

The aim of this study was to develop a single-layer hybrid organic-inorganic sol-gel coating that is capable of a controlled antibiotic release for cementless hydroxyapatite (HA)-coated titanium orthopaedic prostheses.

Methods

Coatings containing gentamicin at a concentration of 1.25% weight/volume (wt/vol), similar to that found in commercially available antibiotic-loaded bone cement, were prepared and tested in the laboratory for: kinetics of antibiotic release; activity against planktonic and biofilm bacterial cultures; biocompatibility with cultured mammalian cells; and physical bonding to the material (n = 3 in all tests). The sol-gel coatings and controls were then tested in vivo in a small animal healing model (four materials tested; n = 6 per material), and applied to the surface of commercially pure HA-coated titanium rods.


The Bone & Joint Journal
Vol. 103-B, Issue 1 | Pages 105 - 112
1 Jan 2021
Lynch JT Perriman DM Scarvell JM Pickering MR Galvin CR Neeman T Smith PN

Aims

Modern total knee arthroplasty (TKA) prostheses are designed to restore near normal kinematics including high flexion. Kneeling is a high flexion, kinematically demanding activity after TKA. The debate about design choice has not yet been informed by six-degrees-of-freedom in vivo kinematics. This prospective randomized clinical trial compared kneeling kinematics in three TKA designs.

Methods

In total, 68 patients were randomized to either a posterior stabilized (PS-FB), cruciate-retaining (CR-FB), or rotating platform (CR-RP) design. Of these patients, 64 completed a minimum one year follow-up. Patients completed full-flexion kneeling while being imaged using single-plane fluoroscopy. Kinematics were calculated by registering the 3D implant models onto 2D-dynamic fluoroscopic images and exported for analysis.


The Bone & Joint Journal
Vol. 102-B, Issue 7 Supple B | Pages 116 - 121
1 Jul 2020
Heise G Black CM Smith R Morrow BR Mihalko WM

Aims

This study aimed to determine if macrophages can attach and directly affect the oxide layers of 316L stainless steel, titanium alloy (Ti6Al4V), and cobalt-chromium-molybdenum alloy (CoCrMo) by releasing components of these alloys.

Methods

Murine peritoneal macrophages were cultured and placed on stainless steel, CoCrMo, and Ti6Al4V discs into a 96-well plate. Cells were activated with interferon gamma and lipopolysaccharide. Macrophages on stainless steel discs produced significantly more nitric oxide (NO) compared to their control counterparts after eight to ten days and remained elevated for the duration of the experiment.


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1179 - 1183
1 Oct 2019
Parsons N Carey-Smith R Dritsaki M Griffin X Metcalfe D Perry D Stengel D Costa M


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1300 - 1306
1 Oct 2019
Oliver WM Smith TJ Nicholson JA Molyneux SG White TO Clement ND Duckworth AD

Aims

The primary aim of this study was to develop a reliable, effective radiological score to assess the healing of humeral shaft fractures, the Radiographic Union Score for HUmeral fractures (RUSHU). The secondary aim was to assess whether the six-week RUSHU was predictive of nonunion at six months after the injury.

Patients and Methods

Initially, 20 patients with radiographs six weeks following a humeral shaft fracture were selected at random from a trauma database and scored by three observers, based on the Radiographic Union Scale for Tibial fractures system. After refinement of the RUSHU criteria, a second group of 60 patients with radiographs six weeks after injury, 40 with fractures that united and 20 with fractures that developed nonunion, were scored by two blinded observers.


The Bone & Joint Journal
Vol. 101-B, Issue 6_Supple_B | Pages 91 - 96
1 Jun 2019
Smith A Denehy K Ong KL Lau E Hagan D Malkani A

Aims

Cephalomedullary nails (CMNs) are commonly used for the treatment of intertrochanteric hip fractures. Total hip arthroplasty (THA) may be used as a salvage procedure when fixation fails in these patients. The aim of this study was to analyze the complications of THA following failed intertrochanteric hip fracture fixation using a CMN.

Patients and Methods

Patients who underwent THA were identified from the 5% subset of Medicare Parts A/B between 2002 and 2015. A subgroup involving those with an intertrochanteric fracture that was treated using a CMN during the previous five years was identified and compared with the remaining patients who underwent THA. The length of stay (LOS) was compared using both univariate and multivariate analysis. The incidence of infection, dislocation, revision, and re-admission was compared between the two groups, using multivariate analysis adjusted for demographic, hospital, and clinical factors.


The Bone & Joint Journal
Vol. 100-B, Issue 1 | Pages 56 - 63
1 Jan 2018
Smith NA Parsons N Wright D Hutchinson C Metcalfe A Thompson P Costa ML Spalding T

Aims

Meniscal allograft transplantation is undertaken to improve pain and function in patients with a symptomatic meniscal deficient knee compartment. While case series have shown improvements in patient reported outcome measures (PROMs), its efficacy has not been rigorously evaluated. This study aimed to compare PROMs in patients having meniscal transplantation with those having personalized physiotherapy at 12 months.

Patients and Methods

A single-centre assessor-blinded, comprehensive cohort study, incorporating a pilot randomized controlled trial (RCT) was performed on patients with a symptomatic compartment of the knee in which a (sub)total meniscectomy had previously been performed. They were randomized to be treated either with a meniscal allograft transplantation or personalized physiotherapy, and stratified for malalignment of the limb. They entered the preference groups if they were not willing to be randomized. The Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Lysholm score and complications were collected at baseline and at four, eight and 12 months following the interventions.


The Bone & Joint Journal
Vol. 100-B, Issue 1 | Pages 64 - 65
1 Jan 2018
Smith NA Parsons N Wright D Hutchinson C Metcalfe A Thompson P Costa ML Spalding T


The Bone & Joint Journal
Vol. 99-B, Issue 9 | Pages 1153 - 1156
1 Sep 2017
Harrison PL Harrison T Stockley I Smith TJ

Aims

Tantalum (Ta) trabecular metal components are increasingly used to reconstruct major bone defects in revision arthroplasty surgery. It is known that some metals such as silver have antibacterial properties. Recent reports have raised the question regarding whether Ta components are protective against infection in revision surgery. This laboratory study aimed to establish whether Ta has intrinsic antibacterial properties against planktonic bacteria, or the ability to inhibit biofilm formation.

Materials and Methods

Equal-sized pieces of Ta and titanium (Ti) acetabular components were sterilised and incubated with a low dose inoculum of either Staphylococcus (S.) aureus or S. epidermidis for 24 hours. After serial dilution, colony forming units (cfu) were quantified on Mueller-Hinton agar plates. In order to establish whether biofilms formed to a greater extent on one material than the other, these Ta and Ti pieces were then washed twice, sonicated and washed again to remove loosely adhered planktonic bacteria. They were then re-incubated for 24 hours prior to quantifying the number of cfu. All experiments were performed in triplicate.


The Bone & Joint Journal
Vol. 99-B, Issue 8 | Pages 1067 - 1072
1 Aug 2017
Booker SJ Boyd M Gallacher S Evans JP Auckland C Kitson J Thomas W Smith CD

Aims

Our aim was to investigate the prevalence of Propionibacterium (P.) acnes in the subcutaneous fat and capsule of patients undergoing shoulder surgery for frozen shoulder or instability.

Patients and Methods

A total of 46 patients undergoing either an arthroscopic capsular release or stabilisation had biopsies taken from the subcutaneous fat and capsule of the shoulder at the time of surgery. These samples were sent for culture in enrichment, and also for Nucleic Acid Amplification testing. The prevalence of P. acnes and other microbes was recorded. Fisher's exact test of binary variables was used to calculate the association with significance set at p < 0.05. Assessment of influence of independent variables including a pre-operative glenohumeral injection, fat colonisation and gender, was undertaken using binary linear regression.


The Bone & Joint Journal
Vol. 99-B, Issue 5 | Pages 614 - 622
1 May 2017
Grammatopoulos G Bolduc M Atkins BL Kendrick BJL McLardy-Smith P Murray DW Gundle R Taylor AH

Aims

Advocates of debridement, antibiotics and implant retention (DAIR) in hip periprosthetic joint infection (PJI) argue that a procedure not disturbing a sound prosthesis-bone interface is likely to lead to better survival and functional outcome compared with revision. This case-control study aims were to compare outcome of DAIRs for infected primary total hip arthroplasty (THA) with outcomes following primary THA and two-stage revision of infected primary THAs.

Patients and Methods

We retrospectively reviewed all DAIRs, performed for confirmed infected primary hip arthropasty (n = 82) at out institution, between 1997 and 2013. Data recorded included full patient information and type of surgery. Outcome measures included complications, mortality, implant survivorship and functional outcome. Outcome was compared with two control groups matched for gender and age; a cohort of primary THAs (n = 120) and a cohort of two-stage revisions for infection (n = 66).


The Bone & Joint Journal
Vol. 99-B, Issue 1 | Pages 73 - 77
1 Jan 2017
Frew NM Cannon T Nichol T Smith TJ Stockley I

Aims

Vancomycin is commonly added to acrylic bone cement during revision arthroplasty surgery. Proprietary cement preparations containing vancomycin are available, but are significantly more expensive. We investigated whether the elution of antibiotic from ‘home-made’ cement containing vancomycin was comparable with more expensive commercially available vancomycin impregnated cement.

Materials and Methods

A total of 18 cement discs containing either proprietary CopalG+V; or ‘home-made’ CopalR+G with vancomycin added by hand, were made. Each disc contained the same amount of antibiotic (0.5 g gentamycin, 2 g vancomycin) and was immersed in ammonium acetate buffer in a sealed container. Fluid from each container was sampled at eight time points over a two-week period. The concentrations of gentamicin and vancomycin in the fluid were analysed using high performance liquid chromatography mass spectrometry.


The Bone & Joint Journal
Vol. 98-B, Issue 11 | Pages 1471 - 1478
1 Nov 2016
Mooney LT Smith A Sloan K Clark GW

Aims

The aim of this study was to investigate differences in pain, range of movement function and satisfaction at three months and one year after total knee arthroplasty (TKA) in patients with an oblique pattern of kinematic graph of the knee and those with a varus pattern.

Patients and Methods

A total of 91 patients who underwent TKA were included in this retrospective study. Patients (59 women and 32 men with mean age of 68.7 years; 38.6 to 88.4) were grouped according to kinematic graphs which were generated during navigated TKA and the outcomes between the groups were compared.


The Bone & Joint Journal
Vol. 98-B, Issue 10 | Pages 1395 - 1398
1 Oct 2016
Smith CD Booker SJ Uppal HS Kitson J Bunker TD

Aims

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder. The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has not been described before. We undertook an investigation to correct this omission.

Patients and Methods

The vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded, and the common variants of the terminal branches of the PCHA are described.


The Bone & Joint Journal
Vol. 98-B, Issue 10 | Pages 1347 - 1354
1 Oct 2016
Palan J Smith MC Gregg P Mellon S Kulkarni A Tucker K Blom AW Murray DW Pandit H

Aims

Periprosthetic fracture (PF) after primary total hip arthroplasty (THA) is an uncommon but potentially devastating complication. This study aims to investigate the influence of cemented stem designs on the risk of needing a revision for a PF.

Patients and Methods

We analysed data on 257 202 primary THAs with cemented stems and 390 linked first revisions for PF recorded in the National Joint Registry (NJR) of England, Wales and Northern Ireland to determine if a cemented femoral stem brand was associated with the risk of having revision for a PF after primary THA. All cemented femoral stem brands with more than 10 000 primary operations recorded in the NJR were identified. The four most commonly used cemented femoral stems were the Exeter V40 (n = 146 409), CPT (n = 24 300), C-Stem (n = 15 113) and Charnley (n = 20 182).

We compared the revision risk ratios due to PF amongst the stems using a Poisson regression model adjusting for patient factors. Compared with the Exeter V40, the age, gender and ASA grade adjusted revision rate ratio was 3.89 for the cemented CPT stem (95% confidence interval (CI) 3.07 to 4.93), 0.89 for the C-Stem (95% CI 0.57 to 1.41) and 0.41 for the Charnley stem (95% CI 0.24 to 0.70).


The Bone & Joint Journal
Vol. 98-B, Issue 9 | Pages 1160 - 1166
1 Sep 2016
Smith TO Aboelmagd T Hing CB MacGregor A

Aims

Our aim was to determine whether, based on the current literature, bariatric surgery prior to total hip (THA) or total knee arthroplasty (TKA) reduces the complication rates and improves the outcome following arthroplasty in obese patients.

Methods

A systematic literature search was undertaken of published and unpublished databases on the 5 November 2015. All papers reporting studies comparing obese patients who had undergone bariatric surgery prior to arthroplasty, or not, were included. Each study was assessed using the Downs and Black appraisal tool. A meta-analysis of risk ratios (RR) and 95% confidence intervals (CI) was performed to determine the incidence of complications including wound infection, deep vein thrombosis (DVT), pulmonary embolism (PE), revision surgery and mortality.


The Bone & Joint Journal
Vol. 98-B, Issue 7 | Pages 884 - 891
1 Jul 2016
Elliott DS Newman KJH Forward DP Hahn DM Ollivere B Kojima K Handley R Rossiter ND Wixted JJ Smith RM Moran CG

This article presents a unified clinical theory that links established facts about the physiology of bone and homeostasis, with those involved in the healing of fractures and the development of nonunion. The key to this theory is the concept that the tissue that forms in and around a fracture should be considered a specific functional entity. This ‘bone-healing unit’ produces a physiological response to its biological and mechanical environment, which leads to the normal healing of bone. This tissue responds to mechanical forces and functions according to Wolff’s law, Perren’s strain theory and Frost’s concept of the “mechanostat”. In response to the local mechanical environment, the bone-healing unit normally changes with time, producing different tissues that can tolerate various levels of strain. The normal result is the formation of bone that bridges the fracture – healing by callus. Nonunion occurs when the bone-healing unit fails either due to mechanical or biological problems or a combination of both. In clinical practice, the majority of nonunions are due to mechanical problems with instability, resulting in too much strain at the fracture site. In most nonunions, there is an intact bone-healing unit. We suggest that this maintains its biological potential to heal, but fails to function due to the mechanical conditions. The theory predicts the healing pattern of multifragmentary fractures and the observed morphological characteristics of different nonunions. It suggests that the majority of nonunions will heal if the correct mechanical environment is produced by surgery, without the need for biological adjuncts such as autologous bone graft.

Cite this article: Bone Joint J 2016;98-B:884–91.


The Bone & Joint Journal
Vol. 98-B, Issue 5 | Pages 647 - 653
1 May 2016
Owen DH Agius PA Nair A Perriman DM Smith PN Roberts CJ

Aims

Total wrist arthrodesis (TWA) produces a spectrum of outcomes. We investigated this by reviewing 77 consecutive TWA performed for inflammatory and post-traumatic arthropathies, wrist instability and as a salvage procedure.

Patients and Methods

All operations were performed by a single surgeon using a specifically designed pre-contoured dorsally applied non-locking wrist arthrodesis plate at a single centre.


The Bone & Joint Journal
Vol. 98-B, Issue 5 | Pages 634 - 640
1 May 2016
Pedowitz DI Kane JM Smith GM Saffel HL Comer C Raikin SM

Aims

Few reports compare the contribution of the talonavicular articulation to overall range of movement in the sagittal plane after total ankle arthroplasty (TAA) and tibiotalar arthrodesis. The purpose of this study was to assess changes in ROM and functional outcomes following tibiotalar arthrodesis and TAA.

Patients and Methods

Patients who underwent isolated tibiotalar arthrodesis or TAA with greater than two-year follow-up were enrolled in the study. Overall arc of movement and talonavicular movement in the sagittal plane were assessed with weight-bearing lateral maximum dorsiflexion and plantarflexion radiographs. All patients completed Short Form-12 version 2.0 questionnaires, visual analogue scale for pain (VAS) scores, and the Foot and Ankle Ability Measure (FAAM).


The Bone & Joint Journal
Vol. 98-B, Issue 4 | Pages 452 - 460
1 Apr 2016
Mahmoud SSS Pearse EO Smith TO Hing CB

Aims

The optimal management of intracapsular fractures of the femoral neck in independently mobile patients remains open to debate. Successful fixation obviates the limitations of arthroplasty for this group of patients. However, with fixation failure rates as high as 30%, the outcome of revision surgery to salvage total hip arthroplasty (THA) must be considered. We carried out a systematic review to compare the outcomes of salvage THA and primary THA for intracapsular fractures of the femoral neck.

Patients and Methods

We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) compliant systematic review, using the PubMed, EMBASE and Cochrane libraries databases. A meta-analysis was performed where possible, and a narrative synthesis when a meta-analysis was not possible.


The Bone & Joint Journal
Vol. 98-B, Issue 4 | Pages 504 - 511
1 Apr 2016
Ajami S Blunn GW Lambert S Alexander S Foxall Smith M Coathup MJ

Aims

To assess the extent of osteointegration in two designs of shoulder resurfacing implants. Bony integration to the Copeland cylindrical central stem design and the Epoca RH conical-crown design were compared.

Patients and Methods

Implants retrieved from six patients in each group were pair-matched. Mean time to revision surgery of Copeland implants was 37 months (standard deviation (sd) 23; 14 to 72) and Epoca RH 38 months (sd 28; 12 to 84). The mean age of patients investigated was 66 years (sd 4; 59 to 71) and 58 years (sd 17; 31 to 73) in the Copeland and Epoca RH groups respectively. None of these implants were revised for loosening.


The Bone & Joint Journal
Vol. 97-B, Issue 11 | Pages 1519 - 1524
1 Nov 2015
Salih S Paskins A Nichol T Smith T Hamer A

We investigated whether the indentation of bone cement spacers used in revision of infected joint arthroplasty with a MacDonald dissector increased the elution of antibiotic in vitro. A total of 24 cement discs containing either 0.17 g (0.88% w/w), 0.25 g (1.41% w/w), or 0.33 g (1.75% w/w) gentamicin of constant size were made. Of these, 12 were indented with the dissector. Each disc was immersed in ammonium acetate buffer in a sealed container, and fluid from each container was sampled at zero, one, three, six, 24, 48 and 72 hours and at one, and two weeks. The concentration of gentamicin in the fluid was analysed using high performance liquid chromatography mass spectrometry.

The fluid sampled at 72 hours from the indented discs containing 0.17 g gentamicin (0.88% w/w) contained a mean of 113 mcg/ml (90.12 to 143.5) compared with 44.5 mcg/ml (44.02 to 44.90) in the fluid sampled from the plain discs (p = 0.012). In discs containing 0.33 g gentamicin (1.75% w/w), the concentration eluted from the indented discs at 72 hours was a mean of 316 mcg/ml (223 to 421) compared with a mean of 118 mcg/ml (100 to 140) from the plain discs (p < 0.001).

At two weeks, these significant differences persisted. At nine weeks the indented discs eluted a greater concentration for all gentamicin doses, but the difference was only significant for the discs containing 0.17 g (0.88% w/w, p = 0.006). However if the area under the curve is taken as a measure of the total antibiotic eluted, the indented discs eluted more gentamicin than the plain discs for the 0.17 g (0.88% w/w, p = 0.031), the 0.25 g (1.41% w/w, p < 0.001) and the 0.33 g (1.75% w/w, p < 0.001) discs.

When preparing antibiotic spacers for use in staged revision arthroplasty surgery we recommend indenting the spacer with a MacDonald dissector to increase the elution of antibiotic.

Cite this article: Bone Joint J 2015;97-B:1519–24.


The Bone & Joint Journal
Vol. 97-B, Issue 11 | Pages 1588 - 1588
1 Nov 2015
Klenerman P Smith T Horan F Ross AC


The Bone & Joint Journal
Vol. 97-B, Issue 8 | Pages 1056 - 1062
1 Aug 2015
Kanawati AJ Narulla RS Lorentzos P Facchetti G Smith A Stewart F

The aim of this cadaver study was to identify the change in position of the sciatic nerve during arthroplasty using the posterior surgical approach to the hip. We investigated the position of the nerve during this procedure by dissecting 11 formalin-treated cadavers (22 hips: 12 male, ten female). The distance between the sciatic nerve and the femoral neck was measured before and after dislocation of the hip, and in positions used during the preparation of the femur. The nerve moves closer to the femoral neck when the hip is flexed to > 30° and internally rotated to 90° (90° IR). The mean distance between the nerve and femoral neck was 43.1 mm (standard deviation (sd) 8.7) with the hip at 0° of flexion and 90° IR; this significantly decreased to a mean of 36.1 mm (sd 9.5), 28.8 mm (sd 9.8) and 19.1 mm (sd 9.7) at 30°, 60° and 90° of hip flexion respectively (p < 0.001). In two hips the nerve was in contact with the femoral neck when the hip was flexed to 90°.

This study demonstrates that the sciatic nerve becomes closer to the operative field during hip arthroplasty using the posterior approach with progressive flexion of the hip.

Cite this article: Bone Joint J 2015;97-B:1056–62.


The Bone & Joint Journal
Vol. 97-B, Issue 7 | Pages 963 - 966
1 Jul 2015
Evans JP Guyver PM Smith CD

Frozen shoulder is a recognised complication following simple arthroscopic shoulder procedures, but its exact incidence has not been reported. Our aim was to analyse a single-surgeon series of patients undergoing arthroscopic subacromial decompression (ASD; group 1) or ASD in combination with arthroscopic acromioclavicular joint (ACJ) excision (group 2), to establish the incidence of frozen shoulder post-operatively. Our secondary aim was to identify associated risk factors and to compare this cohort with a group of patients with primary frozen shoulder.

We undertook a retrospective analysis of 200 consecutive procedures performed between August 2011 and November 2013. Group 1 included 96 procedures and group 2 104 procedures. Frozen shoulder was diagnosed post-operatively using the British Elbow and Shoulder Society criteria. A comparative group from the same institution involved 136 patients undergoing arthroscopic capsular release for primary idiopathic frozen shoulder.

The incidence of frozen shoulder was 5.21% in group 1 and 5.71% in group 2. Age between 46 and 60 years (p = 0.002) and a previous idiopathic contralateral frozen shoulder (p < 0.001) were statistically significant risk factors for the development of secondary frozen shoulder. Comparison of baseline characteristics against the comparator groups showed no statistically significant differences for age, gender, diabetes and previous contralateral frozen shoulder.

These results suggest that the risk of frozen shoulder following simple arthroscopic procedures is just over 5%, with no increased risk if the ACJ is also excised. Patients aged between 46 and 60 years and a previous history of frozen shoulder increase the relative risk of secondary frozen shoulder by 7.8 (95% confidence interval (CI) 2.1 to 28.3)and 18.5 (95% CI 7.4 to 46.3) respectively.

Cite this article: Bone Joint J 2015; 97-B:963–6.


The Bone & Joint Journal
Vol. 97-B, Issue 5 | Pages 590 - 594
1 May 2015
Smith NA Costa ML Spalding T

The anatomy and microstructure of the menisci allow the effective distribution of load across the knee. Meniscectomy alters the biomechanical environment and is a potent risk factor for osteoarthritis. Despite a trend towards meniscus-preserving surgery, many tears are irreparable, and many repairs fail.

Meniscal allograft transplantation has principally been carried out for pain in patients who have had a meniscectomy. Numerous case series have reported a significant improvement in patient-reported outcomes after surgery, but randomised controlled trials have not been undertaken.

It is scientifically plausible that meniscal allograft transplantation is protective of cartilage, but this has not been established clinically to date.

Cite this article: Bone Joint J 2015; 97-B:590–4.


The Bone & Joint Journal
Vol. 97-B, Issue 2 | Pages 277 - 282
1 Feb 2015
Shetty RP Mathew M Smith J Morse LP Mehta JA Currie BJ

Little information is available about several important aspects of the treatment of melioidosis osteomyelitis and septic arthritis.

We undertook a retrospective review of 50 patients with these conditions in an attempt to determine the effect of location of the disease, type of surgical intervention and duration of antibiotic treatment on outcome, particularly complications and relapse.

We found that there was a 27.5% risk of osteomyelitis of the adjacent bone in patients with septic arthritis in the lower limb. Patients with septic arthritis and osteomyelitis of an adjacent bone were in hospital significantly longer (p = 0.001), needed more operations (p = 0.031) and had a significantly higher rate of complications and re-presentation (p = 0.048).

More than half the patients (61%), most particularly those with multifocal bone and joint involvement, and those with septic arthritis and osteomyelitis of an adjacent bone who were treated operatively, needed more visits to theatre.

Cite this article: Bone Joint J 2015;97-B:277–82.


The Bone & Joint Journal
Vol. 96-B, Issue 10 | Pages 1290 - 1297
1 Oct 2014
Grammatopoulos G Pandit HG da Assunção R McLardy-Smith P De Smet KA Gill HS Murray DW

There is great variability in acetabular component orientation following hip replacement. The aims of this study were to compare the component orientation at impaction with the orientation measured on post-operative radiographs and identify factors that influence the difference between the two. A total of 67 hip replacements (52 total hip replacements and 15 hip resurfacings) were prospectively studied. Intra-operatively, the orientation of the acetabular component after impaction relative to the operating table was measured using a validated stereo-photogrammetry protocol. Post-operatively, the radiographic orientation was measured; the mean inclination/anteversion was 43° (sd 6°)/ 19° (sd 7°). A simulated radiographic orientation was calculated based on how the orientation would have appeared had an on-table radiograph been taken intra-operatively. The mean difference between radiographic and intra-operative inclination/anteversion was 5° (sd 5°)/ -8° (sd 8°). The mean difference between simulated radiographic and intra-operative inclination/anteversion, which quantifies the effect of the different way acetabular orientation is measured, was 3°/-6° (sd 2°). The mean difference between radiographic and simulated radiographic orientation inclination/anteversion, which is a manifestation of the change in pelvic position between component impaction and radiograph, was 1°/-2° (sd 7°).

This study demonstrated that in order to achieve a specific radiographic orientation target, surgeons should implant the acetabular component 5° less inclined and 8° more anteverted than their target. Great variability (2 sd about ± 15°) in the post-operative radiographic cup orientation was seen. The two equally contributing causes for this are variability in the orientation at which the cup is implanted, and the change in pelvic position between impaction and post-operative radiograph.

Cite this article: Bone Joint J 2014;96-B:1290–7


The Bone & Joint Journal
Vol. 96-B, Issue 9 | Pages 1185 - 1191
1 Sep 2014
Middleton RG Uzoigwe CE Young PS Smith R Gosal HS Holt G

We aimed to determine whether cemented hemiarthroplasty is associated with a higher post-operative mortality and rate of re-operation when compared with uncemented hemiarthroplasty. Data on 19 669 patients, who were treated with a hemiarthroplasty following a fracture of the hip in a nine-year period from 2002 to 2011, were extracted from NHS Scotland’s acute admission database (Scottish Morbidity Record, SMR01). We investigated the rate of mortality at day 0, 1, 7, 30, 120 and one-year post-operatively using 12 case-mix variables to determine the independent effect of the method of fixation. At day 0, those with a cemented hemiarthroplasty had a higher rate of mortality (p < 0.001) compared with those with an uncemented hemiarthroplasty, equivalent to one extra death per 424 procedures. By day one this had become one extra death per 338 procedures. Increasing age and the five-year co-morbidity score were noted as independent risk factors. By day seven, the cumulative rate of mortality was less for cemented hemiarthroplasty though this did not reach significance until day 120. The rate of re-operation was significantly higher for uncemented hemiarthroplasty. Despite adjusting for 12 confounding variables, these only accounted for 15% of the observed variability.

The debate about the choice of the method of fixation for a hemiarthroplasty with respect to the rate of mortality or the risk of re-operation may be largely superfluous. Our results suggest that uncemented hemiarthroplasties may have a role to play in elderly patients with significant co-morbid disease.

Cite this article: Bone Joint J 2014;96-B:1185–91.