The April 2013 Hip &
Pelvis Roundup360 looks at: hip cartilage and magnets; labral repair or resection; who benefits from injection; rotational osteotomy for osteonecrosis; whether ceramic implants risk fracture; dual articulation; and hydroxyapatite.
Resveratrol is a polyphenolic compound commonly found in the
skins of red grapes. Sirtuin 1 (SIRT1) is a human gene that is activated
by resveratrol and has been shown to promote longevity and boost
mitochondrial metabolism. We examined the effect of resveratrol
on normal and osteoarthritic (OA) human chondrocytes. Normal and OA chondrocytes were incubated with various concentrations
of resveratrol (1 µM, 10 µM, 25 µM and 50 µM) and cultured for 24,
48 or 72 hours or for six weeks. Cell proliferation, gene expression,
and senescence were evaluated.Background
Methods
We evaluated the outcome of 41 consecutive Charnley
low-friction arthroplasties (LFAs) performed by a single surgeon
in 28 patients aged ≤ 35 years at operation between 23 and 36 years
previously. There were 20 women and eight men with a mean age of
32 years (23 to 35) at surgery. Two patients (three hips) were lost
to follow-up at 12 and 17 years post-operatively, respectively,
and one patient (one hip) died at 13 years post-operatively. These patients
were excluded from the final evaluation. The survival rate of the
acetabular components was 92.7% (95% confidence interval (CI) 88.7
to 96.7) at ten years, 67.1% (95% CI 59.75 to 74.45) at 20 years
and 53.2% (95% CI 45.3 to 61.1) at 25 years. For the femoral component
the survival was 95.1% (95% CI 91.8 to 98.5) at ten years, 77.1%
(95% CI 73.9 to 80.3) at 20 years and 68.2% (95% CI 60.7 to 75.8)
at 25 years. The results indicate that the Charnley LFA remains
a reasonable choice in the treatment of young patients and can serve
for comparison with newer techniques and implants. Cite this article:
Achieving arthrodesis of the ankle can be difficult
in the presence of infection, deformity, poor soft tissues and bone loss.
We present a series of 48 patients with complex ankle pathology,
treated with the Ilizarov technique. Infection was present in 30
patients and 30 had significant deformity before surgery. Outcome
was assessed clinically and with patient-reported outcome measures
(Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and
the Short-Form (SF-36)). Arthrodesis was achieved in 40 patients with the Ilizarov technique
alone and in six further patients with additional surgery. Infection
was eradicated in all patients at a mean follow-up of 46.6 months
(13 to 162). Successful arthrodesis was less likely in those with
comorbidities and in tibiocalcaneal fusion compared with tibiotalar
fusion. These patients had poor general health scores compared with the
normal population before surgery. The mean MAOFAS score improved
significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to
90) post-operatively, but there was only a modest improvement in
general health; the mean SF-36 improved from 44.8 (19 to 66) to
50.1 (21 to 76). There was a major benefit in terms of pain relief. Arthrodesis using the Ilizarov technique is an effective treatment
for complex ankle pathology, with good clinical outcomes and eradication
of infection. However, even after successful arthrodesis general
health scores remain limited. Cite this article:
The number of surgical procedures performed each year to treat
femoroacetabular impingement (FAI) continues to rise. Although there
is evidence that surgery can improve symptoms in the short-term,
there is no evidence that it slows the development of osteoarthritis
(OA). We performed a feasibility study to determine whether patient
and surgeon opinion was permissive for a Randomised Controlled Trial
(RCT) comparing operative with non-operative treatment for FAI. Surgeon opinion was obtained using validated questionnaires at
a Specialist Hip Meeting (n = 61, 30 of whom stated that they routinely
performed FAI surgery) and patient opinion was obtained from clinical
patients with a new diagnosis of FAI (n = 31).Objectives
Methods
The February 2013 Knee Roundup360 looks at: mobile-bearing TKRs; arthroscopic ACL reconstruction; the use of chondrocytes for osteochondral defects; ACL reconstruction and the return to pivoting sports; ACLs and the MOON study; the benefit of knee navigation; and trabecular metal.
We determined the short-term clinical outcome
and migration within the bone of the humeral cementless component
of the Instrumented Bone Preserving (IBP) total elbow replacement
in a series of 16 patients. There were four men and 12 women with
a mean age at operation of 63 years (40 to 81). Migration was calculated
using radiostereometric analysis. There were no intra-operative
complications and no revisions. At two-year follow-up, all patients
showed a significant reduction in pain and functional improvement
of the elbow (both p <
0.001). Although ten components (63%)
showed movement or micromovement during the first six weeks, 14
(88%) were stable at one year post-operatively. Translation was
primarily found in the proximal direction (median 0.3 mm (interquartile range
(IQR) -0.09 to 0.8); the major rotational movement was an anterior
tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component
continued to migrate during the second year, and one component could
not be followed beyond three months because migration had caused
the markers to break off the prosthesis. This study shows promising early results for the cementless humeral
component of the IBP total elbow replacement. All patients had a
good clinical outcome, and most components stabilised within six
months of the operation. Cite this article:
Osteochondral lesions (OCLs) occur in up to 70%
of sprains and fractures involving the ankle. Atraumatic aetiologies have
also been described. Techniques such as microfracture, and replacement
strategies such as autologous osteochondral transplantation, or
autologous chondrocyte implantation are the major forms of surgical
treatment. Current literature suggests that microfracture is indicated
for lesions up to 15 mm in diameter, with replacement strategies
indicated for larger or cystic lesions. Short- and medium-term results
have been reported, where concerns over potential deterioration
of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of
OCLs, as they potentially enhance the biological environment for
a natural healing response. Further research is required to establish
the critical size of defect, beyond which replacement strategies
should be used, as well as the most appropriate use of biological augmentation.
This paper reviews the current evidence for surgical management
and use of biological adjuncts for treatment of osteochondral lesions
of the talus. Cite this article:
In an initial randomised controlled trial (RCT)
we segregated 180 patients to one of two knee positions following total
knee replacement (TKR): six hours of knee flexion using either a
jig or knee extension. Outcome measures included post-operative
blood loss, fall in haemoglobin, blood transfusion requirements,
knee range of movement, limb swelling and functional scores. A second
RCT consisted of 420 TKR patients randomised to one of three post-operative
knee positions: flexion for three or six hours post-operatively,
or knee extension. Positioning of the knee in flexion for six hours immediately
after surgery significantly reduced blood loss (p = 0.002). There
were no significant differences in post-operative range of movement,
swelling, pain or outcome scores between the various knee positions
in either study. Post-operative knee flexion may offer a simple
and cost-effective way to reduce blood loss and transfusion requirements
following TKR. We also report a cautionary note regarding the potential risks
of prolonged knee flexion for more than six hours observed during
clinical practice in the intervening period between the two trials,
with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy
at their three-month review. Cite this article:
We explored the trends over time and the geographical
variation in the use of subacromial decompression and rotator cuff
repair in 152 local health areas (Primary Care Trusts) across England.
The diagnostic and procedure codes of patients undergoing certain
elective shoulder operations between 2000/2001 and 2009/2010 were extracted
from the Hospital Episode Statistics database. They were grouped
as 1) subacromial decompression only, 2) subacromial decompression
with rotator cuff repair, and 3) rotator cuff repair only. The number of patients undergoing subacromial decompression alone
rose by 746.4% from 2523 in 2000/2001 (5.2/100 000 (95% confidence
interval (CI) 5.0 to 5.4) to 21 355 in 2009/2010 (40.2/100 000 (95%
CI 39.7 to 40.8)). Operations for rotator cuff repair alone peaked
in 2008/2009 (4.7/100 000 (95% CI 4.5 to 4.8)) and declined considerably
in 2009/2010 (2.6/100 000 (95% CI 2.5 to 2.7)). Given the lack of evidence for the effectiveness of these operations
and the significant increase in the number of procedures being performed
in England and elsewhere, there is an urgent need for well-designed
clinical trials to determine evidence of clinical effectiveness. Cite this article: Bone Joint J 2014;96-B:70–4.
We report on the long-term results of 163 bicruciate-retaining
Hermes 2C total knee replacements in 130 patients at a mean follow-up
of 22.4 years (20.3 to 23.5). Even when the anterior cruciate ligament
had a partially degenerative appearance it was preserved as long
as the knee had a normal anterior drawer and Lachman’s test pre-operatively. The
description and surgical technique of this minimally constrained
prosthesis were published in 1983 and the ten-year clinical results
in 1999. A total of 12% of the knees (20 of 163) in this study were revised
because of wear of the polyethylene tibial insert. Excellent stability
was achieved and the incidence of aseptic component loosening was
4.3% (seven of 163). The survival rate using revision for any reason
as the endpoint was 82% (95% confidence interval 76.2 to 88.0). Although this series included a relatively small number of replacements,
it demonstrated that the anterior cruciate ligament, even when partially
degenerated at the time of TKR, remained functional and provided
adequate stability at a long-term follow-up. Cite this article:
Treatment of an infected total elbow replacement
(TER) is often successful in eradicating or suppressing the infection.
However, the extensor mechanism may be compromised by both the infection
and the surgery. The goal of this study was to assess triceps function
in patients treated for deep infection complicating a TER. Between
1976 and 2007 a total of 217 TERs in 207 patients were treated for
infection of a TER at our institution. Superficial infections and
those that underwent resection arthroplasty were excluded, leaving
93 TERs. Triceps function was assessed by examination and a questionnaire.
Outcome was measured using the Mayo Elbow Performance Score (MEPS). Triceps weakness was identified in 51 TERs (49 patients, 55%).
At a mean follow-up of five years (0.8 to 34), the extensor mechanism
was intact in 13 patients, with the remaining 38 having bone or
soft-tissue loss. The mean MEPS was 70 points (5 to 100), with a
mean functional score of 18 (0 to 25) of a possible 25 points. Infection following TER can often be eradicated; however, triceps
weakness occurs in more than half of the patients and may represent
a major functional problem. Cite this article:
We have compared three different methods of treating
symptomatic non-traumatic tears of the supraspinatus tendon in patients
above 55 years of age. A total of 180 shoulders (173 patients) with
supraspinatus tendon tears were randomly allocated into one of three
groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and
physiotherapy (group 2) and rotator cuff repair, acromioplasty and
physiotherapy (group 3). The Constant score was assessed and followed
up by an independent observer pre-operatively and at three, six
and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one
year (follow-up rate of 92.8%). There were 55 shoulders in group
1 (24 in males and 31 in females, mean age 65 years (55 to 79)),
57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79))
and 55 shoulders in group 3 (26 male and 29 female, mean age 65
years (55 to 81)). There were no between-group differences in the
Constant score at final follow-up: 74.1 ( Cite this article:
The purpose of this study was to undertake a
meta-analysis to determine whether there is lower polyethylene wear and
longer survival when using mobile-bearing implants in total knee
replacement when compared with fixed-bearing implants. Of 975 papers
identified, 34 trials were eligible for data extraction and meta-analysis
comprising 4754 patients (6861 knees). We found no statistically
significant differences between the two designs in terms of the incidence
of radiolucent lines, osteolysis, aseptic loosening or survival.
There is thus currently no evidence to suggest that the use of mobile-bearing
designs reduce polyethylene wear and prolong survival after total
knee replacement. Cite this article:
The December 2013 Spine Roundup360 looks at: Just how common is lumbar spinal stenosis?; How much will they bleed?; C5 palsy associated with stenosis; Atlanto-axial dislocations revisited; 3D predictors of progression in scoliosis; No difference in outcomes by surgical approach for fusion; Cervical balance changes after thoracolumbar surgery; and spinal surgeons first in space.
The outcome of total knee replacement (TKR) using
components designed to increase the range of flexion is not fully
understood. The short- to mid-term risk of aseptic revision in high
flexion TKR was evaluated. The endpoint of the study was aseptic
revision and the following variables were investigated: implant
design (high flexion In a cohort of 64 000 TKRs, high flexion components were used
in 8035 (12.5%). The high flexion knees with tibial liners of thickness
>
14 mm had a density of revision of 1.45/100 years of observation,
compared with 0.37/100 in non-high flexion TKR with liners ≤ 14
mm thick. Relative to a standard fixed PS TKR, the NexGen (Zimmer,
Warsaw, Indiana) Gender Specific Female high flexion fixed PS TKR
had an increased risk of revision (hazard ratio (HR) 2.27 (95% confidence
interval (CI) 1.48 to 3.50)), an effect that was magnified when
a thicker tibial insert was used (HR 8.10 (95% CI 4.41 to 14.89)). Surgeons should be cautious when choosing high flexion TKRs,
particularly when thicker tibial liners might be required. Cite this article:
We report our experience of staged revision surgery
for the treatment of infected total elbow arthroplasty (TEA). Between
1998 and 2010 a consecutive series of 33 patients (34 TEAs) underwent
a first-stage procedure with the intention to proceed to second-stage
procedure when the infection had been controlled. A single first-stage procedure
with removal of the components and cement was undertaken for 29
TEAs (85%), followed by the insertion of antibiotic-impregnated
cement beads, and five (15%) required two or more first-stage procedures.
The most common organism isolated was coagulase-negative A second-stage procedure was performed for 26 TEAs (76%); seven
patients (seven TEAs, 21%) had a functional resection arthroplasty
with antibiotic beads There were three recurrent infections (11.5%) in those patients
who underwent a second-stage procedure. The infection presented
at a mean of eight months (5 to 10) post-operatively. The mean Mayo
Elbow Performance Score (MEPS) in those who underwent a second stage
revision without recurrent infection was 81.1 (65 to 95). Staged revision surgery is successful in the treatment of patients
with an infected TEA and is associated with a low rate of recurrent
infection. However, when infection does occur, this study would
suggest that it becomes apparent within ten months of the second
stage procedure. Cite this article:
We investigated the characteristics of patients
who achieved Japanese-style deep flexion (seiza-sitting) after total knee
replacement (TKR) and measured three-dimensional positioning and
the contact positions of the femoral and tibial components. Seiza-sitting
was achieved after surgery by 23 patients (29 knees) of a series
of 463 TKRs in 341 patients. Pre-operatively most of these patients
were capable of seiza-sitting, had a lower body mass index and a favourable
attitude towards the Japanese lifestyle (27 of 29 knees). According
to two-/three-dimensional image registration analysis in the seiza-sitting
position, flexion, varus and internal rotation angles of the tibial
component relative to the femoral component had means of 148° ( Cite this article:
We reviewed the long-term clinical and radiological
results of 63 uncemented Low Contact Stress (LCS) total knee replacements
(TKRs) in 47 patients with rheumatoid arthritis. The mean age of
the patients at the time of surgery was 69 years (53 to 81). At
a mean follow-up of 22 years (20 to 25), 12 patients were alive
(17 TKRs), 27 had died (36 TKRs), and eight (ten TKRs) were lost
to follow-up. Revision was necessary in seven patients (seven TKRs, 11.1%)
at a mean of 12.1 years (0 to 19) after surgery. In the surviving
ten patients who had not undergone revision (15 TKRs), the mean
Oxford knee score was 30.2 (16 to 41) at a mean follow-up of 19.5
years (15 to 24.7) and mean active flexion was 105° (90° to 150°).
The survival rate was 88.9% at 20 years (56 of 63) and the Kaplan–Meier
survival estimate, without revision, was 80.2% (95% confidence interval
37 to 100) at 25 years. Cite this article: