Large femoral heads have become popular in total
hip replacement (THR) as a method of reducing the risk of dislocation.
However, if large heads are used in ceramic-on-ceramic THR, the
liner must be thinner, which may increase the risk of fracture.
To compare the rates of ceramic fracture and dislocation between
28 mm and 32 mm ceramic heads, 120 hips in 109 patients (51 men
and 58 women, mean age 49.2 years) were randomised to THR with either
a 28 mm or a 32 mm ceramic articulation. A total of 57/60 hips assigned
to the 28 mm group and 55/60 hips assigned to the 32 mm group were
followed for at least five years. No ceramic component fractures
occured in any patient in either group. There was one dislocation
in the 32 mm group and none in the 28 mm group (p = 0.464). No hip
had detectable wear, focal osteolysis or prosthetic loosening. In
our small study the 32 mm ceramic articulation appeared to be safe
in terms of ceramic liner fracture. Cite this article:
Surgical repair of posterosuperior rotator cuff
tears has a poorer outcome and a higher rate of failure compared
with repairs of supraspinatus tears. In this prospective cohort
study 28 consecutive patients with an irreparable posterosuperior
rotator cuff tear after failed conservative or surgical treatment
underwent teres major tendon transfer. Their mean age was 60 years
(48 to 71) and the mean follow-up was 25 months (12 to 80). The
mean active abduction improved from 79° (0° to 150°) pre-operatively
to 105° (20° to 180°) post-operatively (p = 0.011). The mean active
external rotation in 90° abduction improved from 25° (0° to 70°)
pre-operatively to 55° (0° to 90°) post-operatively (p <
0.001).
The mean Constant score improved from 43 (18 to 78) pre-operatively
to 65 (30 to 86) post-operatively (p <
0.001). The median post-operative
VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to
5 (0 to 56) post-operatively (p <
0.001). In conclusion, teres major transfer effectively restores function
and relieves pain in patients with irreparable posterosuperior rotator
cuff tears and leads to an overall clinical improvement in a relatively
young and active patient group with limited treatment options. Cite this article:
The lateral compartment is predominantly affected
in approximately 10% of patients with osteoarthritis of the knee. The
anatomy, kinematics and loading during movement differ considerably
between medial and lateral compartments of the knee. This in the
main explains the relative protection of the lateral compartment
compared with the medial compartment in the development of osteoarthritis.
The aetiology of lateral compartment osteoarthritis can be idiopathic,
usually affecting the femur, or secondary to trauma commonly affecting
the tibia. Surgical management of lateral compartment osteoarthritis
can include osteotomy, unicompartmental knee replacement and total
knee replacement. This review discusses the biomechanics, pathogenesis
and development of lateral compartment osteoarthritis and its management. Cite this article:
The April 2013 Children’s orthopaedics Roundup360 looks at: improving stress distribution in dysplastic hips; the dangers of fashion; the natural history of supracondylar fractures; ankles that perform well as knees; intra-articular hip pathology at osteotomy; the safe removal of flexible nails; supracondylar fracture fixation; and talipes.
As many as 25% to 40% of unicompartmental knee
replacement (UKR) revisions are performed for pain, a possible cause
of which is proximal tibial strain. The aim of this study was to
examine the effect of UKR implant design and material on cortical
and cancellous proximal tibial strain in a synthetic bone model.
Composite Sawbone tibiae were implanted with cemented UKR components
of different designs, either all-polyethylene or metal-backed. The tibiae
were subsequently loaded in 500 N increments to 2500 N, unloading
between increments. Cortical surface strain was measured using a
digital image correlation technique. Cancellous damage was measured
using acoustic emission, an engineering technique that detects sonic
waves (‘hits’) produced when damage occurs in material. Anteromedial cortical surface strain showed significant differences
between implants at 1500 N and 2500 N in the proximal 10 mm only
(p <
0.001), with relative strain shielding in metal-backed implants.
Acoustic emission showed significant differences in cancellous bone
damage between implants at all loads (p = 0.001). All-polyethylene implants
displayed 16.6 times the total number of cumulative acoustic emission
hits as controls. All-polyethylene implants also displayed more
hits than controls at all loads (p <
0.001), more than metal-backed
implants at loads ≥ 1500 N (p <
0.001), and greater acoustic
emission activity on unloading than controls (p = 0.01), reflecting
a lack of implant stiffness. All-polyethylene implants were associated
with a significant increase in damage at the microscopic level compared
with metal-backed implants, even at low loads. All-polyethylene
implants should be used with caution in patients who are likely
to impose large loads across their knee joint. Cite this article:
The June 2013 Spine Roundup360 looks at: the benefit of MRI in the follow-up of lumbar disc prolapse; gunshot injury to the spinal cord; the link between depression and back pain; floating dural sack sign; short segment fixation at ten years; whether early return to play is safer than previously thought; infection in diabetic spinal patients; and dynesis.
The October 2014 Shoulder &
Elbow Roundup360 looks at: PRP is not effective in tennis elbow; eccentric physiotherapy effective in subacromial pain; dexamethasone in shoulder surgery; arthroscopic remplissage for engaging Hill-Sach’s lesions; a consistent approach to subacromial impingement; delay in fixation of proximal humeral fractures detrimental to outcomes.
Radiological assessment of total and unicompartmental
knee replacement remains an essential part of routine care and follow-up.
Appreciation of the various measurements that can be identified
radiologically is important. It is likely that routine plain radiographs
will continue to be used, although there has been a trend towards
using newer technologies such as CT, especially in a failing knee,
where it provides more detailed information, albeit with a higher
radiation exposure. The purpose of this paper is to outline the radiological parameters
used to evaluate knee replacements, describe how these are measured
or classified, and review the current literature to determine their
efficacy where possible.
It has previously been suggested that among unstable
ankle fractures, the presence of a malleolar fracture is associated
with a worse outcome than a corresponding ligamentous injury. However,
previous studies have included heterogeneous groups of injury. The
purpose of this study was to determine whether any specific pattern of
bony and/or ligamentous injury among a series of supination-external
rotation type IV (SER IV) ankle fractures treated with anatomical
fixation was associated with a worse outcome. We analysed a prospective cohort of 108 SER IV ankle fractures
with a follow-up of one year. Pre-operative radiographs and MRIs
were undertaken to characterise precisely the pattern of injury.
Operative treatment included fixation of all malleolar fractures.
Post-operative CT was used to assess reduction. The primary and
secondary outcome measures were the Foot and Ankle Outcome Score
(FAOS) and the range of movement of the ankle. There were no clinically relevant differences between the four
possible SER IV fracture pattern groups with regard to the FAOS
or range of movement. In this population of strictly defined SER
IV ankle injuries, the presence of a malleolar fracture was not
associated with a significantly worse clinical outcome than its
ligamentous injury counterpart. Other factors inherent to the injury
and treatment may play a more important role in predicting outcome.
The purpose of this study was to investigate
the clinical predictors of surgical outcome in patients with cervical spondylotic
myelopathy (CSM). We reviewed a consecutive series of 248 patients
(71 women and 177 men) with CSM who had undergone surgery at our
institution between January 2000 and October 2010. Their mean age
was 59.0 years (16 to 86). Medical records, office notes, and operative
reports were reviewed for data collection. Special attention was
focused on pre-operative duration and severity as well as post-operative
persistence of myelopathic symptoms. Disease severity was graded
according to the Nurick classification. Our multivariate logistic regression model indicated that Nurick
grade 2 CSM patients have the highest chance of complete symptom
resolution (p <
0.001) and improvement to normal gait (p = 0.004)
following surgery. Patients who did not improve after surgery had
longer duration of myelopathic symptoms than those who did improve
post-operatively (17.85 months (1 to 101) vs 11.21 months (1 to
69); p = 0.002). More advanced Nurick grades were not associated
with a longer duration of symptoms (p = 0.906). Our data suggest that patients with Nurick grade 2 CSM are most
likely to improve from surgery. The duration of myelopathic symptoms
does not have an association with disease severity but is an independent
prognostic indicator of surgical outcome. Cite this article:
Salter innominate osteotomy is an effective reconstructive
procedure for the treatment of developmental dysplasia of the hip
(DDH), but some children have a poor outcome at skeletal maturity.
In order to investigate factors associated with an unfavourable
outcome, we assessed the development of the contralateral hip. We retrospectively
reviewed 46 patients who underwent a unilateral Salter osteotomy
at between five and seven years of age, with a mean follow-up of
10.3 years (7 to 20). The patients were divided into three groups
according to the centre–edge angle (CEA) of the contralateral hip
at skeletal maturity: normal (>
25°, 22 patients), borderline (20°
to 25°, 17 patients) and dysplastic (<
20°, 7 patients). The
CEA of the affected hip was measured pre-operatively, at eight to
nine years of age, at 11 to 12 years of age and at skeletal maturity.
The CEA of the affected hip was significantly smaller in the borderline
and dysplastic groups at 11 and 12 years of age (p = 0.012) and
at skeletal maturity (p = 0.017) than in the normal group. Severin
group III was seen in two (11.8%) and four hips (57.1%) of the borderline
and dysplastic groups, respectively (p <
0.001). Limited individual development of the acetabulum was associated
with an unfavourable outcome following Salter osteotomy. Cite this article:
We retrospectively assessed the value of identifying
impinging osteophytes using dynamic computer simulation of CT scans
of the elbow in assisting their arthroscopic removal in patients
with osteoarthritis of the elbow. A total of 20 patients were treated
(19 men and one woman, mean age 38 years (19 to 55)) and followed
for a mean of 25 months (24 to 29). We located the impinging osteophytes
dynamically using computerised three-dimensional models of the elbow
based on CT data in three positions of flexion of the elbow. These
were then removed arthroscopically and a capsular release was performed. The mean loss of extension improved from 23° (10° to 45°) pre-operatively
to 9° (0° to 25°) post-operatively, and the mean flexion improved
from 121° (80° to 140°) pre-operatively to 130° (110° to 145°) post-operatively.
The mean Mayo Elbow Performance Score improved from 62 (30 to 85)
to 95 (70 to 100) post-operatively. All patients had pain in the
elbow pre-operatively which disappeared or decreased post-operatively.
According to their Mayo scores, 14 patients had an excellent clinical
outcome and six a good outcome; 15 were very satisfied and five
were satisfied with their post-operative outcome. We recommend this technique in the surgical management of patients
with osteoarthritis of the elbow. Cite this article:
Neurogenic heterotopic ossification (NHO) is
a disorder of aberrant bone formation affecting one in five patients sustaining
a spinal cord injury or traumatic brain injury. Ectopic bone forms
around joints in characteristic patterns, causing pain and limiting
movement especially around the hip and elbow. Clinical sequelae
of neurogenic heterotopic ossification include urinary tract infection,
pressure injuries, pneumonia and poor hygiene, making early diagnosis
and treatment clinically compelling. However, diagnosis remains
difficult with more investigation needed. Our pathophysiological
understanding stems from mechanisms of basic bone formation enhanced
by evidence of systemic influences from circulating humor factors
and perhaps neurological ones. This increasing understanding guides
our implementation of current prophylaxis and treatment including
the use of non-steroidal anti-inflammatory drugs, bisphosphonates,
radiation therapy and surgery and, importantly, should direct future, more
effective ones.
The October 2014 Knee Roundup360 looks at: microfracture equivalent to OATS; examination better than MRI in predicting hamstrings re-injury; a second view on return to play with hamstrings injuries; dislocation risks in the Oxford Unicompartmental Knee; what about the tibia?; getting on top of lateral facet pain post TKR; readmission in TKR; patient-specific instrumentation; treating infrapatellar saphenous neuralgia; and arthroscopy in the middle-aged.
We report the five year outcomes of a two-stage
approach for infected total hip replacement. This is a single-surgeon
experience at a tertiary centre where the more straightforward cases
are treated using single-stage exchange. This study highlights the
vital role of the multidisciplinary team in managing these cases. A total of 125 patients (51 male, 74 female) with a mean age
of 68 years (42 to 78) were reviewed prospectively. Functional status
was assessed using the Harris hip score (HHS). The mean HHS improved
from 38 (6 to 78.5) pre-operatively to 81.2 (33 to 98) post-operatively.
Staphylococcus species were isolated in 85 patients (68%). The rate of control of infection was 96% at five years. In all,
19 patients died during the period of the study. This represented
a one year mortality of 0.8% and an overall mortality of 15.2% at
five years. No patients were lost to follow-up. We report excellent control of infection in a series of complex
patients and infections using a two-stage revision protocol supported
by a multidisciplinary approach. The reason for the high rate of
mortality in these patients is not known. Cite this article:
The aim of this study was to evaluate the functional
and oncological outcome of extracorporeally irradiated autografts
used to reconstruct the pelvis after a P1/2 internal hemipelvectomy. The study included 18 patients with a primary malignant bone
tumour of the pelvis. There were 13 males and five females with
a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic
sarcoma, six a Ewing’s sarcoma, and five a chondrosarcoma. At a
mean follow-up of 51.6 months (4 to 185), nine patients had died
with metastatic disease while nine were free from disease. Local
recurrence occurred in three patients all of whom eventually died of
their disease. Deep infection occurred in three patients and required
removal of their graft in two while the third underwent a hindquarter
amputation for extensive flap necrosis. The mean Musculoskeletal Tumor Society functional score of the
16 patients who could be followed-up for at least 12 months was
77% (50 to 90). Those 15 patients who completed the Toronto Extremity
Salvage Score questionnaire had a mean score of 71% (53 to 85). Extracorporeal irradiation and re-implantation of bone is a valid
method of reconstruction after an internal hemipelvectomy. It has
an acceptable morbidity and a functional outcome that compares favourably
with other available reconstructive techniques. Cite this article:
The technical advances in arthroscopic surgery
of the hip, including the improved ability to manage the capsule
and gain extensile exposure, have been paralleled by a growth in
the number of conditions that can be addressed. This expanding list
includes symptomatic labral tears, chondral lesions, injuries of
the ligamentum teres, femoroacetabular impingement (FAI), capsular
laxity and instability, and various extra-articular disorders, including snapping
hip syndromes. With a careful diagnostic evaluation and technical
execution of well-indicated procedures, arthroscopic surgery of
the hip can achieve successful clinical outcomes, with predictable
improvements in function and pre-injury levels of physical activity
for many patients. This paper reviews the current position in relation to the use
of arthroscopy in the treatment of disorders of the hip. Cite this article:
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:
Orientation of the acetabular component influences
wear, range of movement and the incidence of dislocation after total
hip replacement (THR). During surgery, such orientation is often
referenced to the anterior pelvic plane (APP), but APP inclination
relative to the coronal plane (pelvic tilt) varies substantially
between individuals. In contrast, the change in pelvic tilt from
supine to standing (dPT) is small for nearly all individuals. Therefore,
in THR performed with the patient supine and the patient’s coronal
plane parallel to the operating table, we propose that freehand placement
of the acetabular component placement is reliable and reflects standing
(functional) cup position. We examined this hypothesis in 56 hips
in 56 patients (19 men) with a mean age of 61 years (29 to 80) using
three-dimensional CT pelvic reconstructions and standing lateral
pelvic radiographs. We found a low variability of acetabular component
placement, with 46 implants (82%) placed within a combined range
of 30° to 50° inclination and 5° to 25° anteversion. Changing from
the supine to the standing position (analysed in 47 patients) was associated
with an anteversion change <
10° in 45 patients (96%). dPT was
<
10° in 41 patients (87%). In conclusion, supine THR appears
to provide reliable freehand acetabular component placement. In
most patients a small reclination of the pelvis going from supine
to standing causes a small increase in anteversion of the acetabular component Cite this article: