In a retrospective study we compared 32 HINTEGRA
total ankle replacements (TARs) and 35 Mobility TARs performed between
July 2005 and May 2010, with a minimum follow-up of two years. The
mean follow-up for the HINTEGRA group was 53 months (24 to 76) and
for the Mobility group was 34 months (24 to 45). All procedures
were performed by a single surgeon. There was no significant difference between the two groups with
regard to the mean AOFAS score, visual analogue score for pain or
range of movement of the ankle at the latest follow-up. Most radiological
measurements did not differ significantly between the two groups.
However, the most common grade of heterotopic ossification (HO)
was grade 3 in the HINTEGRA group (10 of 13 TARs, 76.9%) and grade
2 in the Mobility group (four of seven TARs, 57.1%) (p = 0.025).
Although HO was more frequent in the HINTEGRA group (40.6%) than
in the Mobility group (20.0%), this was not statistically significant
(p = 0.065).The difference in peri-operative complications between
the two groups was not significant, but intra-operative medial malleolar
fractures occurred in four (11.4%) in the Mobility group; four (12.5%)
in the HINTEGRA group and one TAR (2.9%) in the Mobility group failed
(p = 0.185). Cite this article:
Some surgeons are reluctant to perform a reverse
total shoulder arthroplasty (RTSA) on both shoulders because of concerns
regarding difficulty with activities of daily living post-operatively
as a result of limited rotation of the shoulders. Nevertheless,
we hypothesised that outcomes and patient satisfaction following
bilateral RTSA would be comparable to those following unilateral
RTSA. A single-surgeon RTSA registry was reviewed for patients who underwent
bilateral staged RTSA with a minimum follow-up of two years. A unilateral
RTSA matched control was selected for each shoulder in those patients
undergoing bilateral procedures. The Constant–Murley score (CMS), American
Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Values
(SSV), visual analogue scale (VAS) for pain, range of movement and
strength were measured pre- and post-operatively. The mean CMS,
ASES, SSV, VAS scores, strength and active forward elevation were
significantly improved
(all p <
0.01) following each operation in those undergoing bilateral
procedures. The mean active external rotation (p = 0.63 and p =
0.19) and internal rotation (p = 0.77 and p = 0.24) were not significantly
improved. The improvement in the mean ASES score after the first
RTSA was greater than the improvement in its control group (p =
0.0039). The improvement in the mean CMS, ASES scores and active
forward elevation was significantly less after the second RTSA than
in its control group (p = 0.0244, p = 0.0183, and p = 0.0280, respectively).
Pain relief and function significantly improved after each RTSA
in those undergoing a bilateral procedure. Bilateral RTSA is thus a reasonable form of treatment for patients
with severe bilateral rotator cuff deficiency, although inferior
results may be seen after the second procedure compared with the
first. Cite this article:
The purpose of this study was to evaluate the
risk of late displacement after the treatment of distal radial fractures with
a locking volar plate, and to investigate the clinical and radiological
factors that might correlate with re-displacement. From March 2007
to October 2009, 120 of an original cohort of 132 female patients
with unstable fractures of the distal radius were treated with a
volar locking plate, and were studied over a follow-up period of
six months. In the immediate post-operative and final follow-up
radiographs, late displacement was evaluated as judged by ulnar
variance, radial inclination, and dorsal angulation. We also analysed
the correlation of a variety of clinical and radiological factors
with re-displacement. Ulnar variance was significantly overcorrected
(p <
0.001) while radial inclination and dorsal angulation were
undercorrected when compared statistically (p <
0.001) with the unaffected
side in the immediate post-operative stage. During follow-up, radial
shortening and dorsal angulation progressed statistically, but none
had a value beyond the acceptable range. Bone mineral density measured
at the proximal femur and the position of the screws in the subchondral
region, correlated with slight progressive radial shortening, which
was not clinically relevant. Volar locking plating of distal radial fractures is a reliable
form of treatment without substantial late displacement. Cite this article:
Lengthening osteotomies of the calcaneus in children are in general
grafted with bone from the iliac crest. Artificial bone grafts have
been introduced, however, their structural and clinical durability
has not been documented. Radiostereometric analysis (RSA) is a very
accurate and precise method for measurements of rigid body movements including
the evaluation of joint implant and fracture stability, however,
RSA has not previously been used in clinical studies of calcaneal
osteotomies. We assessed the precision of RSA as a measurement tool
in a lateral calcaneal lengthening osteotomy (LCLO). LCLO was performed in six fixed adult cadaver feet. Tantalum
markers were inserted on each side of the osteotomy and in the cuboideum.
Lengthening was done with a plexiglas wedge. A total of 24 radiological
double examinations were obtained. Two feet were excluded due to
loose and poorly dispersed markers. Precision was assessed as systematic
bias and 95% repeatability limits.Objectives
Methods
The foot and ankle outcome score (FAOS) has been
evaluated for many conditions of the foot and ankle. We evaluated
its construct validity in 136 patients with osteoarthritis of the
ankle, its content validity in 37 patients and its responsiveness
in 39. Data were collected prospectively from the registry of patients
at our institution. All FAOS subscales were rated relevant by patients. The Pain,
Activities of Daily Living, and Quality of Life subscales showed
good correlation with the Physical Component score of the Short-Form-12v2.
All subscales except Symptoms were responsive to change after surgery. We concluded that the FAOS is a weak instrument for evaluating
osteoarthritis of the ankle. However, some of the FAOS subscales
have relative strengths that allow for its limited use while we
continue to seek other satisfactory outcome instruments. Cite this article:
A high radiographic inclination angle (RI) contributes
to accelerated wear and has been associated with dislocation after
total hip arthroplasty (THA). With freehand positioning of the acetabular
component there is a lack of accuracy, with a trend towards a high
radiographic inclination angle. The aim of this study was to investigate
whether the use of a digital protractor to measure the operative
inclination angle (OI) could improve the positioning of the acetabular
component in relation to a ‘safe zone’. We measured the radiographic inclination angles of 200 consecutive
uncemented primary THAs. In the first 100 the component was introduced
freehand and in the second 100 a digital protractor was used to
measure the operative inclination angle. The mean difference between the operative and the radiographic
inclination angles
(∆RI–OI) in the second cohort was 12.3° (3.8° to 19.8°). There was
a strong correlation between the circumference of the hip and ∆RI–OI.
The number of RI outliers was significantly reduced in the protractor
group (p = 0.002). Adjusting the OI, using a digital protractor and taking into
account the circumference of the patient’s hip, improves the RI
significantly (p <
0.001) and does not require additional operating
time. Cite this article:
The treatment of osteochondral lesions is of
great interest to orthopaedic surgeons because most lesions do not heal
spontaneously. We present the short-term clinical outcome and MRI
findings of a cell-free scaffold used for the treatment of these
lesions in the knee. A total of 38 patients were prospectively evaluated
clinically for two years following treatment with an osteochondral
nanostructured biomimetic scaffold. There were 23 men and 15 women; the
mean age of the patients was 30.5 years (15 to 64). Clinical outcome
was assessed using the Knee Injury and Osteoarthritis Outcome Score
(KOOS), the Tegner activity scale and a Visual Analgue scale for
pain. MRI data were analysed based on the Magnetic Resonance Observation
of Cartilage Repair Tissue (MOCART) scoring system at three, 12
and 24 months post-operatively. There was a continuous significant
clinical improvement after surgery. In two patients, the scaffold
treatment failed (5.3%) There was a statistically significant improvement
in the MOCART precentage scores. The repair tissue filled most of
the defect sufficiently. We found subchondral laminar changes in all
patients. Intralesional osteophytes were found in two patients (5.3%).
We conclude that this one-step scaffold-based technique can be used
for osteochondral repair. The surgical technique is straightforward,
and the clinical results are promising. The MRI aspects of the repair
tissue continue to evolve during the first two years after surgery.
However, the subchondral laminar and bone changes are a concern. Cite this article:
We report the outcome of 32 patients (37 knees) who underwent hemicallostasis with a dynamic external fixator for osteoarthritis of the medial compartment of the knee. There were 16 men (19 knees) and 16 women (18 knees) with a mean age at operation of 54.6 years (27 to 72). The aim was to achieve a valgus overcorrection of 2° to 8° or mechanical axis at 62.5% (± 12.5%). At a mean follow-up of 62.8 months (51 to 81) there was no change in the mean range of movement, and no statistically significant difference in the Insall-Salvati index or tibial slope (p = 0.11 and p = 0.15, respectively). The mean hip-knee-ankle angle changed from 190.6 (183° to 197°) to 176.0° (171° to 181°), with a mean final position of the mechanical axis of 58.5% (35.1% to 71.2%). The desired alignment was attained in 31 of 37 (84%) knees. There were 21 excellent, 13 good, two fair and one poor result according to the Oxford knee score with no correlation between age and final score. This score was at its best at one year with a statistically significant deterioration at two years (p = 0.001) followed by a small but not statistically significant deterioration until the final follow-up (p = 0.17). All the knees with Ahlback grade 1 osteoarthritis had excellent or good results. Complications included pin tract infections involving 16.4% of all pins used, delayed union in two, knee stiffness in four, fracture of the lateral cortex in one and ring sequestrum in one. In conclusion, hemicallostasis provides precision in attaining the desired alignment without interfering with tibial slope or patellar height, and is relatively free of serious complications.
We conducted a randomised prospective study to evaluate the clinical and radiological results of a mobile- and fixed-bearing total knee replacement of similar design in 174 patients who had bilateral simultaneous knee replacement. The mean follow-up was for 5.6 years (5.2 to 6.1). The total knee score, pain score, functional score and range of movement were not statistically different (p >
0.05) between the two groups. Osteolysis was not seen in any knee in either group. Two knees (1%) in the mobile-bearing group required revision because of infection; none in the fixed-bearing group needed revision. Excellent results can be achieved with both mobile- and fixed-bearing prostheses of similar design at mid-term follow-up. We could demonstrate no significant clinical advantage for a mobile bearing.
Progressive degenerative changes in the medial
compartment of the knee following lateral unicompartmental arthroplasty
(UKA) remains a leading indication for revision surgery. The purpose
of this study is to evaluate changes in the congruence and joint
space width (JSW) of the medial compartment following lateral UKA.
The congruence of the medial compartment of 53 knees (24 men, 23
women, mean age 13.1 years; Our data suggest that a well conducted lateral UKA may improve
the congruence and normalise the JSW of the medial compartment,
potentially preventing progression of degenerative change. Cite this article:
Moderate to severe hallux valgus is conventionally
treated by proximal metatarsal osteotomy. Several recent studies
have shown that the indications for distal metatarsal osteotomy
with a distal soft-tissue procedure could be extended to include
moderate to severe hallux valgus. The purpose of this prospective randomised controlled trial was
to compare the outcome of proximal and distal Chevron osteotomy
in patients undergoing simultaneous bilateral correction of moderate
to severe hallux valgus. The original study cohort consisted of 50 female patients (100
feet). Of these, four (8 feet) were excluded for lack of adequate
follow-up, leaving 46 female patients (92 feet) in the study. The
mean age of the patients was 53.8 years (30.1 to 62.1) and the mean
duration of follow-up 40.2 months (24.1 to 80.5). After randomisation,
patients underwent a proximal Chevron osteotomy on one foot and
a distal Chevron osteotomy on the other. At follow-up, the American Orthopedic Foot and Ankle Society
(AOFAS) hallux metatarsophalangeal interphalangeal (MTP-IP) score,
patient satisfaction, post-operative complications, hallux valgus
angle, first-second intermetatarsal angle, and tibial sesamoid position
were similar in each group. Both procedures gave similar good clinical
and radiological outcomes. This study suggests that distal Chevron osteotomy with a distal
soft-tissue procedure is as effective and reliable a means of correcting
moderate to severe hallux valgus as proximal Chevron osteotomy with
a distal soft-tissue procedure. Cite this article:
Hip fracture is a global public health problem.
The National Hip Fracture Database provides a framework for service evaluation
in this group of patients in the United Kingdom, but does not collect
patient-reported outcome data and is unable to provide meaningful
data about the recovery of quality of life. We report one-year patient-reported outcomes of a prospective
cohort of patients treated at a single major trauma centre in the
United Kingdom who sustained a hip fracture between January 2012
and March 2014. There was an initial marked decline in quality of life from baseline
measured using the EuroQol 5 Dimensions score (EQ-5D). It was followed
by a significant improvement to 120 days for all patients. Although
their quality of life improved during the year after the fracture,
it was still significantly lower than before injury irrespective
of age group or cognitive impairment (mean reduction EQ-5D 0.22;
95% confidence interval (CI) 0.17 to 0.26). There was strong evidence
that quality of life was lower for patients with cognitive impairment.
There was a mean reduction in EQ-5D of 0.28 (95% CI 0.22 to 0.35)
in patients <
80 years of age. This difference was consistent
(and fixed) throughout follow-up. Quality of life does not improve
significantly during recovery from hip fracture in patients over
80 years of age (p = 0.928). Secondary measures of function showed
similar trends. Hip fracture marks a step down in the quality of life of a patient:
it accounts for approximately 0.22 disability adjusted life years
in the first year after fracture. This is equivalent to serious
neurological conditions for which extensive funding for research
and treatment is made available. Cite this article:
We evaluated 30 patients with cervical myelopathy before and after decompressive surgery and compared them with 42 healthy controls. All were asked to grip and release their fingers as rapidly as possible for 15 seconds. Films recorded with a digital camera were divided into three files of five seconds each. Three doctors independently counted the number of grip and release cycles in a blinded manner (N1 represents the number of cycles for the first five-second segment, N2 for the second and N3 for the third). N2 and N3 of the pre-operative group were significantly fewer than those of the control group, and the postoperative group’s results were significantly greater than those of the pre-operative group. In the control group, the numbers decreased significantly with each succeeding five-second interval (fatigue phenomenon). In the pre-operative myelopathy group there was no significant difference between N1 and N2 (freezing phenomenon). The 15-second test is shown to be reliable in the quantitative evaluation of cervical myelopathy. Although it requires a camera and animation files, it can detect small changes in neurological status because of its precise and objective nature.
Peri-prosthetic infection is amongst the most
common causes of failure following total knee replacement (TKR).
In the presence of established infection, thorough joint debridement
and removal of all components is necessary following which new components
may be implanted. This can be performed in one or two stages; two-stage revision
with placement of an interim antibiotic-loaded spacer is regarded
by many to be the standard procedure for eradication of peri-prosthetic
joint infection. We present our experience of a consecutive series of 50 single-stage
revision TKRs for established deep infection performed between 1979
and 2010. There were 33 women and 17 men with a mean age at revision
of 66.8 years (42 to 84) and a mean follow-up of 10.5 years (2 to
24). The mean time between the primary TKR and the revision procedure
was 2.05 years (1 to 8). Only one patient required a further revision for recurrent infection,
representing a success rate of 98%. Nine patients required further
revision for aseptic loosening, according to microbiological testing
of biopsies taken at the subsequent surgery. Three other patients
developed a further septic episode but none required another revision. These results suggest that a single-stage revision can produce
comparable results to a two-stage revision. Single-stage revision
offers a reduction in costs as well as less morbidity and inconvenience
for patients. Cite this article:
We report the clinical and radiological outcome of total ankle replacement performed in conjunction with hindfoot fusion or in isolation. Between May 2003 and June 2008, 60 ankles were treated with total ankle replacement with either subtalar or triple fusion, and the results were compared with a control group of 288 ankles treated with total ankle replacement alone. After the mean follow-up of 39.5 months (12 to 73), the ankles with hindfoot fusion showed significant improvement in the mean visual analogue score for pain (p <
0.001), the mean American Orthopaedic Foot and Ankle Society score (p <
0.001), and the mean of a modified version of this score (p <
0.001). The mean visual analogue pain score (p = 0.304) and mean modified American Orthopaedic Foot and Ankle Society score (p = 0.119) were not significantly different between the hindfoot fusion and the control groups. However, the hindfoot fusion group had a significantly lower mean range of movement (p = 0.009) and a higher rate of posterior focal osteolysis (p = 0.04). Both groups showed various complications (p = 0.131) and failure occurring at a similar rate (p = 0.685). Subtalar or triple fusion is feasible and has minimal adverse effects on ankles treated with total ankle replacement up to midterm follow-up. The clinical outcome of total ankle replacement when combined with hindfoot fusion is comparable to that of ankle replacement alone. Thus, hindfoot fusion should be performed in conjunction with total ankle replacement when indicated.
We examined cultured osteoblasts derived from paired samples from the greater tuberosity and acromion from eight patients with large chronic tears of the rotator cuff. We found that osteoblasts from the tuberosity had no apparent response to mechanical stimulation, whereas those derived from the acromion showed an increase in alkaline phosphatase activity and nitric oxide release which is normally a response of bone cells to mechanical strain. By contrast, we found that cells from both regions were able to respond to dexamethasone, a well-established promoter of osteoblastic differentiation, with the expected increase in alkaline phosphatase activity. Our findings indicate that the failure of repair of the rotator cuff may be due, at least in part, to a compromised capacity for mechanoadaptation within the greater tuberosity. It remains to be seen whether this apparent decrease in the sensitivity of bone cells to mechanical stimulation is the specific consequence of the reduced load-bearing history of the greater tuberosity in these patients.
We report the long-term outcome of 33 patients
(37 knees) who underwent proximal tibial open-wedge osteotomy with
hemicallotasis (HCO) for medial osteoarthritis of the knee between
1995 and 2000. Among these, 29 patients with unilateral HCO were
enrolled and 19 were available for review at a mean of 14.2 years
(10 to 15.7) post-operatively. For these 19 patients, the mean Hospital
for Special Surgery knee score was 60 (57 to 62) pre-operatively
and 85 (82 to 87) at final follow-up (p <
0.001; paired Cite this article:
Using a modern cementing technique, we implanted 22 stereolithographic polymeric replicas of the Charnley-Kerboul stem in 11 pairs of human cadaver femora. On one side, the replicas were cemented line-to-line with the largest broach. On the other, one-size undersized replicas were used (radial difference, 0.89 mm CT analysis showed that the line-to-line stems without distal centralisers were at least as well aligned and centered as undersized stems with a centraliser, but were surrounded by less cement and presented more areas of thin (<
2 mm) or deficient (<
1 mm) cement. These areas were located predominantly at the corners and in the middle and distal thirds of the stem. Nevertheless, in line-to-line stems, penetration of cement into cancellous bone resulted in a mean thickness of cement of 3.1 mm ( When Charnley-Kerboul stems are cemented line-to-line, good clinical results are observed because cement-deficient areas are limited and are frequently supported by cortical bone.
Metatarsus primus varus deformity correction
is one of the main objectives in hallux valgus surgery. A ‘syndesmosis’
procedure may be used to correct hallux valgus. An osteotomy is
not involved. The aim is to realign the first metatarsal using soft
tissues and a cerclage wire around the necks of the first and second
metatarsals. We have retrospectively assessed 27 patients (54 feet) using
the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs
and measurements of the plantar pressures after bilateral syndesmosis
procedures. There were 26 women. The mean age of the patients was
46 years (18 to 70) and the mean follow-up was 26.4 months (24 to
33.4). Matched-pair comparisons of the AOFAS scores, the radiological
parameters and the plantar pressure measurements were conducted
pre- and post-operatively, with the mean of the left and right feet.
The mean AOFAS score improved from 62.8 to 94.4 points (p <
0.001).
Significant differences were found on all radiological parameters
(p <
0.001). The mean hallux valgus and first intermetatarsal
angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1°
to 45.3°) (p <
0.001) and from 15.0° (10.2° to 18.6°) to 7.2°
(4.2° to 11.4°) (p <
0.001) respectively. The mean medial sesamoid
position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p <
0.001)
according to the Hardy’s scale (0 to 7). The mean maximum force
and the force–time integral under the hallux region were significantly
increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63
to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70
(1.28 to 19.23)) respectively. The occurrence of the maximum force
under the hallux region was delayed by 11% (p = 0.02), (87.3% stance
(36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data
reflected the restoration of the function of the hallux. Three patients
suffered a stress fracture of the neck of the second metatarsal.
The short-term results of this surgical procedure for the treatment
of hallux valgus are satisfactory. Cite this article:
Oxidised zirconium was introduced as a material for femoral components
in total knee arthroplasty (TKA) as an attempt to reduce polyethylene
wear. However, the long-term survival of this component is not known. We performed a retrospective review of a prospectively collected
database to assess the ten year survival and clinical and radiological
outcomes of an oxidised zirconium total knee arthroplasty with the
Genesis II prosthesis. The Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS)
and a patient satisfaction scale were used to assess outcome.Aims
Methods