We hypothesised that the use of pulsed electromagnetic
field (PEMF) bone growth stimulation in acute scaphoid fractures
would significantly shorten the time to union and reduce the number
of nonunions in a randomised, double-blind, placebo-controlled multicentre
trial. A total of 102 patients (78 male, 24 female; mean age 35
years (18 to 77)) from five different medical centres with a unilateral
undisplaced acute scaphoid fracture were randomly allocated to PEMF
(n = 51) or placebo (n = 51) and assessed with regard to functional
and radiological outcomes (multiplanar reconstructed CT scans) at
6, 9, 12, 24 and 52 weeks. The overall time to clinical and radiological healing
did not differ significantly between the active PEMF group and the
placebo group. We concluded that the addition of PEMF bone growth
stimulation to the conservative treatment of acute scaphoid fractures
does not accelerate bone healing. Cite this article:
The use of pulsed electromagnetic fields (PEMF)
to stimulate bone growth has been recommended as an alternative to
the surgical treatment of ununited scaphoid fractures, but has never
been examined in acute fractures. We hypothesised that the use of
PEMF in acute scaphoid fractures would accelerate the time to union
by 30% in a randomised, double-blind, placebo-controlled, multicentre
trial. A total of 53 patients in three different medical centres
with a unilateral undisplaced acute scaphoid fracture were randomly
assigned to receive either treatment with PEMF (n = 24) or a placebo
(n = 29). The clinical and radiological outcomes were assessed at
four, six, nine, 12, 24 and 52 weeks. A log-rank analysis showed that neither time to clinical and
radiological union nor the functional outcome differed significantly
between the groups. The clinical assessment of union indicated that
at six weeks tenderness in the anatomic snuffbox (p = 0.03) as well
as tenderness on longitudinal compression of the scaphoid (p = 0.008) differed
significantly in favour of the placebo group. We conclude that stimulation of bone growth by PEMF has no additional
value in the conservative treatment of acute scaphoid fractures.
Congenital pseudarthrosis of the tibia remains one of the most difficult orthopaedic problems. We describe early excision and the use of the Masquelet technique to reconstruct the bone defect in a child aged 14 months.
We measured the extent and rate of new bone formation over an 18-month period before, during and after the lengthening of ten leg segments in six patients aged between 8 and 18 years, using dual-energy X-ray absorptiometry (DEXA). New bone formation could be identified within one week of the start of distraction. As lengthening proceeded, the bone density of the gap fell, reaching minimum values at the time of maximal distraction.
The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited regarding outcomes and potential problems. We report on our early experience and raise awareness for the potential of adverse effects from this device. This is a retrospective review of prospective data collected on all patients treated in our institution using this implant. We report the demographics, nail accuracy, reliability, consolidation index, and cases where concerning clinical and radiological findings were encountered. There were 14 STRYDE nails implanted in nine patients (three male and six female) between June 2019 and September 2020. Mean age at surgery was 33 years (14 to 65). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies.Aims
Methods
Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator. A total of 23 patients underwent this surgery, involving 27 segments (23 femora and four tibiae), over a period of ten years. The most common indication was polio in ten segments and rickets in eight; 20 nails were inserted retrograde and seven antegrade. A total of 15 lengthenings were performed in 11 femora and four tibiae, and 12 double-level corrections of deformity without lengthening were performed in the femur. The mean follow-up was 4.9 years (1.1 to 11.4). Four patients with polio had tibial lengthening with arthrodesis of the ankle. We compared the length of time in a fixator and the external fixation index (EFI) with a control group of 27 patients (27 segments) who had double-level procedures with external fixation. The groups were matched for the gain in length, age, and level of difficulty score.Aims
Patients and Methods
The aims of this study were to determine the indications and
frequency of ordering a CT pulmonary angiography (CTPA) following
primary arthroplasty of the hip and knee, and to determine the number
of positive scans in these patients, the location of emboli and
the outcome for patients undergoing CTPA. We analyzed the use of CTPA, as an inpatient and up to 90 days
as an outpatient, in a cohort of patients and reviewed the medical
records and imaging for each patient undergoing CTPA.Aims
Patients and Methods
We report the results of intramedullary leg lengthening conducted between 2002 and 2009 using the Intramedullary Skeletal Kinetic Distractor in 69 unilateral lengthenings involving 58 femora and 11 tibiae. We identified difficulties that occurred during the treatment and assessed whether they were specifically due to the implant or independent of it. Paley’s classification for evaluating problems, obstacles and complications with external fixators was adopted, and implant-specific difficulties were continuously noted. There were seven failures requiring premature removal of the device, in four due to nail breakage and three for other reasons, and five unsuccessful outcomes after completion of the lengthening. In all, 116 difficulties were noted in 45 patients, with only 24 having problem-free courses. In addition to the difficulties arising from the use of external fixators, there were almost the same number again of implant-specific difficulties. Nevertheless, successful femoral lengthening was achieved in 52 of the 58 patients (90%). However, successful tibial lengthening was only achieved in five of 11 patients (45%).
Between 1996 and 2003, 16 patients (nine female, seven male) were treated for a primary bone sarcoma of the femur by wide local excision of the tumour, extracorporeal irradiation and re-implantation. An additional vascularised fibular graft was used in 13 patients (81%). All patients were free from disease when reviewed at a minimum of two years postoperatively (mean 49.7 months (24 to 96). There were no cases of infection. Primary union was achieved after a median of nine months (interquartile range 7 to 11). Five host-donor junctions (16%) united only after a second procedure. Primary union recurred faster at metaphyseal junctions (94% (15) at a median of 7.5 months (interquartile range 4 to 12)) than at diaphyseal junctions (75% (12) at a median of 11.1 months (interquartile range 5 to 18)). Post-operatively, the median Musculoskeletal Tumour Society score was 85% (interquartile range 75 to 96) and the median Toronto Extremity Salvage score 94% (interquartile range 82 to 99). The Mankin score gave a good or excellent result in 14 patients (88%). The range of movement of the knee was significantly worse when the extracorporeally irradiated autografts were fixed by plates rather than by nails (p = 0.035). A total of 16 (62%) of the junctions of the vascularised fibular grafts underwent hypertrophy, indicating union and loading. Extracorporeal irradiation autografting with supplementary vascularised fibular grafting is a promising biological alternative for intercalary reconstruction after wide resection of malignant bone tumours of the femur.
There are few reports describing the technique
of managing acetabular protrusio in primary total hip replacement. Most
are small series with different methods of addressing the challenges
of significant medial and proximal migration of the joint centre,
deficient medial bone and reduced peripheral bony support to the
acetabular component. We describe our technique and the clinical
and radiological outcome of using impacted morsellised autograft
with a porous-coated cementless cup in 30 primary THRs with mild
(n = 8), moderate (n = 10) and severe (n = 12) grades of acetabular
protrusio. The mean Harris hip score had improved from 52 pre-operatively
to 85 at a mean follow-up of 4.2 years (2 to 10). At final follow-up,
27 hips (90%) had a good or excellent result, two (7%) had a fair
result and one (3%) had a poor result. All bone grafts had united
by the sixth post-operative month and none of the hips showed any
radiological evidence of recurrence of protrusio, osteolysis or
loosening. By using impacted morsellised autograft and cementless
acetabular components it was possible to achieve restoration of
hip mechanics, provide a biological solution to bone deficiency
and ensure long-term fixation without recurrence in arthritic hips
with protrusio undergoing THR. Cite this article:
The purpose of this study was to determine whether
patients with a burst fracture of the thoracolumbar spine treated
by short segment pedicle screw fixation fared better clinically
and radiologically if the affected segment was fused at the same
time. A total of 50 patients were enrolled in a prospective study
and assigned to one of two groups. After the exclusion of three
patients, there were 23 patients in the fusion group and 24 in the
non-fusion group. Follow-up was at a mean of 23.9 months (18 to
30). Functional outcome was evaluated using the Greenough Low Back
Outcome Score. Neurological function was graded using the American
Spinal Injury Association Impairment Scale. Peri-operative blood transfusion requirements and duration of
surgery were significantly higher in the fusion group (p = 0.029
and p <
0.001, respectively). There were no clinical or radiological
differences in outcome between the groups (all outcomes p >
0.05).
The results of this study suggest that adjunctive fusion is unnecessary
when managing patients with a burst fracture of the thoracolumbar
spine with short segment pedicle screw fixation.
The use of allografts for the treatment of bone tumours in children is limited by nonunion and the difficulty of finding a suitable graft. Furthermore, appositional growth can’t be expected of an allograft. We used an overlapping allograft in 11 children, with a mean age of ten years (4 to 15), with a mean follow-up of 24.1 months (20 to 33). There were five intercalary and six intra-articular resections, and the tumours were in the femur in six cases and the humerus in five. Rates of union, times to union, remodelling patterns and allograft-associated complications were evaluated. No allograft was removed due to a complication. Of the 16 junctional sites, 15 (94%) showed union at a mean of 3.1 months (2 to 5). Remodelling between host and allograft was seen at 14 junctions at a mean of five months (4 to 7). The mean Musculoskeletal Tumor Society score was 26.5 of 30 (88.3%). One case of nonunion and another with screw protrusion required re-operation. Overlapping allografts have the potential to shorten time to union, decrease rates of nonunion and have positive appositional growth effect.
We compared the complications and outcome of tibial lengthening using the Ilizarov method with and without the use of a supplementary intramedullary nail. In a retrospective case-matched series assembled from 176 patients with tibial lengthening, we matched 52 patients (26 pairs, group A with nail and group B without) according to the following criteria in order of importance: 1) difference in amount of lengthening (± 2 cm); 2) percentage difference in lengthening (± 5%); 3) difference in patient’s age (± seven years); 4) aetiology of the shortening, and 5) level of difficulty in obtaining the correction. The outcome was evaluated using the external fixator index, the healing index and an outcome score according to the criteria of Paley. It was found that some complications were specific to group A or B respectively, but others were common to both groups. The outcome was generally better in lengthenings with a nail, although there was a higher incidence of rectifiable equinus deformity in these patients.
The long-term results of grafting with hydroxyapatite granules for acetabular deficiency in revision total hip replacement are not well known. We have evaluated the results of revision using a modular cup with hydroxyapatite grafting for Paprosky type 2 and 3 acetabular defects at a minimum of ten years’ follow-up. We retrospectively reviewed 49 acetabular revisions at a mean of 135 months (120 to 178). There was one type 2B, ten 2C, 28 3A and ten 3B hips. With loosening as the endpoint, the survival rate was 74.2% (95% confidence interval 58.3 to 90.1). Radiologically, four of the type 3A hips (14%) and six of the type 3B hips (60%) showed aseptic loosening with collapse of the hydroxyapatite layer, whereas no loosening occurred in type 2 hips. There was consolidation of the hydroxyapatite layer in 33 hips (66%). Loosening was detected in nine of 29 hips (31%) without cement and in one of 20 hips (5%) with cement (p = 0.03, Fisher’s exact probability test). The linear wear and annual wear rate did not correlate with loosening. These results suggest that the long-term results of hydroxyapatite grafting with cement for type 2 and 3A hips are encouraging.
We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed. The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60). One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation. We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone.
Cubitus varus and valgus are the most common complications of supracondylar and lateral condylar fractures. Various combinations of osteotomy and fixation have been described to correct these deformities but each is associated with significant complications. In this study, we used distraction osteogenesis and Ilizarov frame fixation to treat 24 elbows in 23 patients with cubitus varus or valgus. Their clinical outcome was evaluated using the protocol of Bellemore et al. The mean time to follow-up was 18.3 months (10 to 36) and the mean time to frame removal was 13.5 weeks (8 to 20). The mean carrying angle was corrected from −18.7° (−10° to −30°) to 6.1° (2° to 10°) in patients with cubitus varus and from 36.5° (25° to 45°) to 9.4° (4° to 15°) in patients with cubitus valgus. There were 18 excellent and six good results. The Ilizarov method with gradual distraction is a safe, stable, adjustable and versatile method of treating deformities at the elbow without the problems of an unsightly scar or limited range of movement, and gives a good clinical and radiological outcome. Tardy ulnar nerve palsy should be treated first by anterior transposition.
Femoral lengthening using the Intramedullary Skeletal Kinetic Distractor is a new technique. However, with intramedullary distraction the surgeon has less control over the lengthening process. Therefore, 33 femora lengthened with this device were assessed to evaluate the effect of operative variables under the surgeon’s control on the course of lengthening. The desired lengthening was achieved in 32 of 33 limbs. Problems encountered included difficulty in achieving length in eight femora (24%) and uncontrolled lengthening in seven (21%). Uncontrolled lengthening was more likely if the osteotomy was placed with less than 80 mm of the thick portion of the nail in the distal fragment (p = 0.052), and a failure to lengthen was more likely if there was over 125 mm in the distal fragment (p = 0.008). The latter problem was reduced with over-reaming by 2.5 mm to 3 mm. Previous intramedullary nailing also predisposed to uncontrolled lengthening (p = 0.042), and these patients required less reaming. Using the Intramedullary Skeletal Kinetic Distractor, good outcomes were obtained; problems were minimised by optimising the position of the osteotomy and the amount of over-reaming performed.
We reviewed the clinical and radiological results of 131 patients who underwent acetabular revision for aseptic loosening with impacted bone allograft and a cemented acetabular component. The mean follow-up was 51.7 months (24 to 156). The mean post-operative Merle D’Aubigné and Postel scores were 5.7 points (4 to 6) for pain, 5.2 (3 to 6) for gait and 4.5 (2 to 6) for mobility. Radiological evaluation revealed migration greater than 5 mm in four acetabular components. Radiological failure matched clinical failure. Asymptomatic radiolucent lines were observed in 31 of 426 areas assessed (7%). Further revision was required in six patients (4.5%), this was due to infection in three and mechanical failure in three. The survival rate for the reconstruction was 95.8% (95% confidence interval 92.3 to 99.1) overall, and 98%, excluding revision due to sepsis. Our study, from an independent centre, has reproduced the results of the originators of the method.
We present a retrospective study of 27 patients treated by callus distraction using a unilateral external fixator of our own design for nonunion with bone loss and shortening of the femur caused by suppurative osteomyelitis. The unilateral external fixator was used either alone or in combination with an intramedullary nail. The mean age of the patients was 13.6 years (8 to 18). The fixator was used alone in 13 patients and with an intramedullary nail in 14. The bone results at a mean follow-up of 88 months (37 to 144) were excellent in 16 patients and good in 11. The functional results were excellent in 18 patients and good in nine. However, four patients still had draining sinuses at the latest follow-up. A residual deformity greater than 7° was present in seven femora, but this did not adversely affect function or require further treatment.