The zona conoidea comprises the area of the lateral
trochlear ridge of the humerus. The purpose of this study is to reintroduce
this term ‘zona conoidea’ to the discussion of the human elbow and
to investigate its significance in the development of osteoarthritis
of the elbow. The upper extremities of 12 cadavers were prepared. With the
forearm in neutral, pronation and supination, the distance between
the bevel of the radial head and zona conoidea was inspected. A
total of 12 healthy volunteers had a CT scan. The distance between
the zona conoidea and the bevelled rim of the radial head was measured
in these positions. In the anatomical specimens, early osteo-arthritic changes were
identified in the posteromedial bevelled rim of the radial head,
and the corresponding zona conoidea in supination. Measurement in
the CT study showed that in full supination, the distance between
the bevel of the radial head and the zona conoidea was at a minimum. This study suggests that the significant contact between the
bevel of the radial head and the zona conoidea in supination is
associated with the initiation of osteoarthritis of the elbow in
this area.
Posterior lumbar interbody fusion (PLIF) is indicated
for many patients with pain and/or instability of the lumbar spine.
We performed 36 PLIF procedures using the patient’s lumbar spinous
process and laminae, which were inserted as a bone graft between
two vertebral bodies without using a cage. The mean lumbar lordosis
and mean disc height to vertebral body ratio were restored and preserved
after surgery. There were no serious complications. These results suggest that this procedure is safe and effective.
We investigated the association between the radiological findings and the symptoms arising from the patellofemoral joint in advanced osteoarthritis (OA) of the knee. Four radiological features, joint space narrowing, osteophyte formation, translation of the patella and focal attrition were assessed in 151 consecutive osteoarthritic knees in 107 patients undergoing total knee replacement. The symptoms which were assessed included anterior knee pain which was scored, the ability to rise from a chair and climb stairs, and quadriceps weakness. Among the radiological features, only patellar translation and obliteration of the joint space had a statistically significant association with anterior knee pain (odds ratio (OR) 4.85; 95% confidence interval (CI) 1.83 to 12.88 and OR 11.23; 95% CI 2.44 to 51.62) respectively. Patellar translation had a statistically significant association with difficulty in rising from a chair (OR 9.06; 95% CI 1.75 to 45.11). Other radiological features, including osteophytes, joint space narrowing, and focal attrition had no significant association. Our study indicates that the radiological findings of patellar translation and significant loss of cartilage are predictive of patellofemoral symptoms and functional limitation in advanced OA of the knee.
Follow-up radiographs are usually used as the
reference standard for the diagnosis of suspected scaphoid fractures. However,
these are prone to errors in interpretation. We performed a meta-analysis
of 30 clinical studies on the diagnosis of suspected scaphoid fractures,
in which agreement data between any of follow-up radiographs, bone scintigraphy,
magnetic resonance (MR) imaging, or CT could be obtained, and combined
this with latent class analysis to infer the accuracy of these tests
on the diagnosis of suspected scaphoid fractures in the absence
of an established standard. The estimated sensitivity and specificity
were respectively 91.1% and 99.8% for follow-up radiographs, 97.8%
and 93.5% for bone scintigraphy, 97.7% and 99.8% for MRI, and 85.2%
and 99.5% for CT. The results were generally robust in multiple
sensitivity analyses. There was large between-study heterogeneity
for the sensitivity of follow-up radiographs and CT, and imprecision
about their sensitivity estimates. If we acknowledge the lack of a reference standard for diagnosing
suspected scaphoid fractures, MRI is the most accurate test; follow-up
radiographs and CT may be less sensitive, and bone scintigraphy
less specific.
The effect of weight-bearing on the height of the patellar using four radiological indices was studied in 25 healthy men using lateral radiographs of the knee in 30° of flexion non-weight-bearing and weight-bearing. The position of the patella was quantified using the Insall-Salvati, the modified Insall-Salvati, the Blackburne-Peel and the Caton indices. The contraction of the quadriceps on weight-bearing resulted in statistically significant proximal displacement of the patella with all four indices studied. The mean Insall-Salvati index was 0.919 ( The effect of quadriceps contraction should be considered in clinical studies where the patellar position indices are reported.
Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck. We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years. Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D. Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years. The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck.
The painful subluxed or dislocated hip in adults
with cerebral palsy presents a challenging problem. Prosthetic dislocation
and heterotopic ossification are particular concerns. We present
the first reported series of 19 such patients (20 hips) treated
with hip resurfacing and proximal femoral osteotomy. The pre-operative
Gross Motor Function Classification System (GMFCS) was level V in
13 (68%) patients, level IV in three (16%), level III in one (5%) and
level II in two (11%). The mean age at operation was 37 years (13
to 57). The mean follow-up was 8.0 years (2.7 to 11.6), and 16 of the
18 (89%) contactable patients or their carers felt that the surgery
had been worthwhile. Pain was relieved in 16 of the 18 surviving
hips (89%) at the last follow-up, and the GMFCS level had improved
in seven (37%) patients. There were two (10%) early dislocations;
three hips (15%) required revision of femoral fixation, and two
hips (10%) required revision, for late traumatic fracture of the
femoral neck and extra-articular impingement, respectively. Hence
there were significant surgical complications in a total of seven
hips (35%). No hips required revision for instability, and there
were no cases of heterotopic ossification. We recommend hip resurfacing with proximal femoral osteotomy
for the treatment of the painful subluxed or dislocated hip in patients
with cerebral palsy.
We present the clinical results and survivorship
of consecutive 100 Birmingham Hip Resurfacings in 90 patients at
a minimum follow-up of ten years. All procedures were carried out
by an independent surgeon who commenced a prospective study in 1998.
Patients were assessed clinically using the Western Ontario and
McMaster Universities osteoarthritis index, Short-Form 36, Harris
hip score and University of California, Los Angeles activity score. Radiological
analysis was performed by an independent observer and blood metal
ion levels concentrations were measured at ten years post-operatively
in 62 patients. The median acetabular component inclination was
46.2° (34° to 59°) and anteversion 11.0° (0° to 30°). The median
chromium concentration in the unilateral group was 1.74 (0.41 to
15.23) and for the bilateral group was 2.98 (1.57 to 18.01). The
equivalent values for cobalt were 1.67 (0.54 to 20.4) and 1.88 (1.38
to 19.32). In total there were eight failures giving an overall survival
at ten years of 92% (95% confidence interval (CI) 86.7 to 97.3).
BHR in male patients had an improved survivorship of 94.6% (95%
CI 89.4 to 100) compared with females at 84.6% (95% CI 70.7 to 98.5),
but this did not reach statistical significance (p = 0.119). Four
of the nine BHRs with a bearing diameter of 42 mm failed. The overall results were consistent with data produced from other
centres in that the clinical outcome of large male patients was
extremely encouraging, whereas the survival of the smaller joints
was less satisfactory.
The aim of this retrospective cohort study was
to identify any difference in femoral offset as measured on pre-operative
anteroposterior (AP) radiographs of the pelvis, AP radiographs of
the hip and corresponding CT scans in a consecutive series of 100
patients with primary end-stage osteoarthritis of the hip (43 men
and 57 women with a mean age of 61 years (45 to 74) and a mean body
mass index of 28 kg/m2 (20 to 45)). Patients were positioned according to a standardised protocol
to achieve reproducible projection and all images were calibrated.
Inter- and intra-observer reliability was evaluated and agreement
between methods was assessed using Bland-Altman plots. In the entire cohort, the mean femoral offset was 39.0 mm (95%
confidence interval (CI) 37.4 to 40.6) on radiographs of the pelvis,
44.0 mm (95% CI 42.4 to 45.6) on radiographs of the hip and 44.7
mm (95% CI 43.5 to 45.9) on CT scans. AP radiographs of the pelvis
underestimated femoral offset by 13% when compared with CT (p <
0.001).
No difference in mean femoral offset was seen between AP radiographs
of the hip and CT (p = 0.191). Our results suggest that femoral offset is significantly underestimated
on AP radiographs of the pelvis but can be reliably and accurately
assessed on AP radiographs of the hip in patients with primary end-stage
hip osteoarthritis. We, therefore, recommend that additional AP radiographs of the
hip are obtained routinely for the pre-operative assessment of femoral
offset when templating before total hip replacement.
We have previously described the mid- to long-term
results of conventional simple varus intertrochanteric osteotomy
for osteonecrosis of the femoral head, showing that 19 of the 26
hips had good or excellent results. We extended the follow-up to
a mean of 18.1 years (10.5 to 26) including a total of 34 hips in
28 patients, with a mean age at surgery of 33 years (19 to 53).
There were 18 men and ten women and 25 hips (74%) had a satisfactory
result with a Harris hip score ≥ 80. In all, six hips needed total
hip replacement (THR) or hemiarthroplasty. The collapse of the femoral
head or narrowing of the joint space was found to have progressed
in nine hips (26%). Leg shortening after osteotomy was a mean of
19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the
endpoint, the ten-year survival rate was 88.2% (95% confidence interval
(CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95%
CI 72.1 to 87.3); four hips were converted at ten years and other
two hips were converted at 20 years. Shortening of the leg after osteotomy remains a concern; however,
the conventional varus half-wedge osteotomy provides favourable
long-term results in hips with less than two-thirds of the medial
part of the femoral head affected by necrotic bone and with normal
bone superolaterally.
The results of further soft-tissue release of 79 feet in 60 children with recurrent idiopathic congenital talipes equinovarus were evaluated. The mean age of the children at the time of re-operation was 5.8 years (15 months to 14.5 years). Soft-tissue release was performed in all 79 feet and combined with distal calcaneal excision in 52 feet. The mean follow-up was 12 years (4 to 32). At the latest follow-up the result was excellent or good in 61 feet (77%) according to the Ghanem and Seringe scoring system. The results was considered as fair in 14 feet (18%), all of whom had functional problems and eight had anatomical abnormalities. Four feet (5%) were graded as poor on both functional and anatomical grounds. The results were independent of the age at which revision was undertaken.
The outcome of an anatomical shoulder replacement
depends on an intact rotator cuff. In 1981 Grammont designed a novel
large-head reverse shoulder replacement for patients with cuff deficiency.
Such has been the success of this replacement that it has led to
a rapid expansion of the indications. We performed a systematic
review of the literature to evaluate the functional outcome of each
indication for the reverse shoulder replacement. Secondary outcome
measures of range of movement, pain scores and complication rates
are also presented.
We measured the contact areas and contact stresses at the post-cam mechanism of a posterior-stabilised total knee arthroplasty when a posterior force of 500 N was applied to the Kirschner Performance, Scorpio Superflex, NexGen LPS Flex Fixed, and NexGen LPS Flex Mobile knee systems. Measurements were made at 90°, 120°, and 150° of flexion both in neutral rotation and 10° of internal rotation of the tibial component. Peak contact stresses at 90°, 120°, and 150° were 24.0, 33.9, and 28.8 MPa, respectively, for the Kirschner; 26.0, 32.4, and 22.1 MPa, respectively, for the Scorpio; and 34.1, 31.5, and 32.5 MPa, respectively, for the NexGen LPS Flex Fixed. With an internally rotated tibia, the contact stress increased significantly with all the fixed-bearing arthroplasties but not with the NexGen LPS Flex Mobile arthroplasty. The post-cam design should be modified in order to provide a larger contact area whilst avoiding any impingement and edge loading.
We have evaluated the clinical outcomes of simple excision, ulnar lengthening and the Sauvé-Kapandji procedure in the treatment of deformities of the forearm in patients with multiple hereditary osteochondromas. The medical records of 29 patients (33 forearms) were reviewed; 22 patients (22 forearms) underwent simple excision (four with ulnar lengthening) and seven the Sauvé-Kapandji procedure. Simple excision increased the mean supination of the forearm from 63.2° to 75.0° (p = 0.049). Ulnar lengthening did not significantly affect the clinical outcome. The Sauvé-Kapandji technique improved the mean pronation from 33.6° to 55.0° (p = 0.047) and supination from 70.0° to 81.4° (p = 0.045). Simple excision may improve the range of movement of the forearm but will not halt the progression of disease, particularly in younger patients. No discernable clinical or radiological improvement was noted with ulnar lengthening. The Sauvé-Kapandji procedure combined with simple excision of osteochondromas can improve stability of the wrist, movement of the forearm and the radiological appearance.
We report our experience of the use of callus distraction with a monolateral fixator for the treatment of acquired radial club-hand deformity after osteomyelitis. Between 1994 and 2004, 13 patients with a mean age of eight years (4 to 15) were treated by callus distraction with a monolateral fixator after a preliminary period of at least four weeks in a corrective short-arm cast. All patients achieved bony union and were satisfied with the functional and cosmetic outcome. There were no major complications, but three patients required cancellous bone grafting at the docking site for delayed union. Local treatment and oral antibiotics were required for pin-site infection in six patients. There were no deep infection or recurrence of osteomyelitis.
We examined the mechanical properties of Vicryl (polyglactin 910) mesh Mesh fibres were visible at six weeks but had been completely resorbed by 12 weeks, with no evidence of chronic inflammation. The tendon-implant neoenthesis was predominantly an indirect type, with tendon attached to the bone-hydroxyapatite surface by perforating collagen fibres.
We describe the results at five years of a prospective study of a new tri-tapered polished, cannulated, cemented femoral stem implanted in 51 patients (54 hips) with osteoarthritis. The mean age and body mass index of the patients was 74 years and 27.9, respectively. Using the anterolateral approach, half of the stems were implanted by a consultant orthopaedic surgeon and half by six different registrars. There were three withdrawals from the study because of psychiatric illness, a deep infection and a recurrent dislocation. Five deaths occurred prior to five-year follow-up and one patient withdrew from clinical review. In the remaining 51 hips the mean pre-operative Oxford hip score was 47 points which decreased to 19 points at five years (45 hips). Of the stems 49 (98%) were implanted within 1° of neutral in the femoral canal. The mean migration of the stem at five years was 1.9 mm and the survivorship for aseptic loosening was 100%. There was no significant difference in outcome between the consultant and registrar groups. At five years, the results were comparable with those of other polished, tapered, cemented stems. Long-term surveillance continues.
We carried out a study to determine the effect of facet tropism on the development of adolescent and adult herniation of the lumbar disc. We assessed 149 levels in 140 adolescents aged between 13 and 18 years and 119 levels in 111 adults aged between 40 and 49 years with herniation. The facet tropism of each patient was measured at the level of the herniated disc by CT. There was no significant difference in facet tropism between the herniated and the normal discs in both the adolescent and adult groups, except at the L4-L5 level in the adults. Facet tropism did not influence the development of herniation of the lumbar disc in either adolescents or adults.
Fracture-dislocations of the tarsometatarsal (Lisfranc) joints are frequently overlooked or misdiagnosed at initial presentation. This is a comparative cohort study over a period of five years comparing primary open reduction and internal fixation in 22 patients (23 feet) with secondary corrective arthrodesis in 22 patients (22 feet) who presented with painful malunion at a mean of 22 months (1.5 to 45) after injury. In the first group primary treatment by open reduction and internal fixation for eight weeks with Kirschner-wires or screws was undertaken, in the second group treatment was by secondary corrective arthrodesis. There was one deep infection in the first group. In the delayed group there was one complete and one partial nonunion. In each group 20 patients were available for follow-up at a mean of 36 months (24 to 89) after operation. The mean American Orthopaedic Foot and Ankle Society midfoot score was 81.4 (62 to 100) after primary treatment and 71.8 (35 to 88) after corrective arthrodesis (t-test; p = 0.031). We conclude that primary treatment by open reduction and internal fixation of tarsometatarsal fracture-dislocations leads to improved functional results, earlier return to work and greater patient satisfaction than secondary corrective arthrodesis, which remains a useful salvage procedure providing significant relief of pain and improvement in function.