High-flexion total knee replacement (TKR) designs
have been introduced to improve flexion after TKR. Although the
early results of such designs were promising, recent literature
has raised concerns about the incidence of early loosening of the
femoral component. We compared the minimum force required to cause
femoral component loosening for six high-flexion and six conventional
TKR designs in a laboratory experiment. Each TKR design was implanted in a femoral bone model and placed
in a loading frame in 135° of flexion. Loosening of the femoral
component was induced by moving the tibial component at a constant
rate of displacement while maintaining the same angle of flexion.
A stereophotogrammetric system registered the relative movement
between the femoral component and the underlying bone until loosening
occurred. Compared with high-flexion designs, conventional TKR designs
required a significantly higher force before loosening occurred
(p <
0.001). High-flexion designs with closed box geometry required
significantly higher loosening forces than high-flexion designs
with open box geometry (p = 0.0478). The presence of pegs further contributed
to the fixation strength of components. We conclude that high-flexion designs have a greater risk for
femoral component loosening than conventional TKR designs. We believe
this is attributable to the absence of femoral load sharing between
the prosthetic component and the condylar bone during flexion.
Our aim was to compare polylevolactic acid screws
with titanium screws when used for fixation of the distal tibiofibular
syndesmosis at mid-term follow-up. A total of 168 patients, with
a mean age of 38.5 years (18 to 72) who were randomly allocated
to receive either polylevolactic acid (n = 86) or metallic (n =
82) screws were included. The Baird scoring system was used to assess
the overall satisfaction and functional recovery post-operatively.
The demographic details and characteristics of the injury were similar
in the two groups. The mean follow-up was 55.8 months (48 to 66).
The Baird scores were similar in the two groups at the final follow-up.
Patients in the polylevolactic acid group had a greater mean dorsiflexion
(p = 0.011) and plantar-flexion of the injured ankles (p <
0.001).
In the same group, 18 patients had a mild and eight patients had
a moderate foreign body reaction. In the metallic groups eight had
mild and none had a moderate foreign body reaction (p <
0.001).
In total, three patients in the polylevolactic acid group and none
in the metallic group had heterotopic ossification (p = 0.246). We conclude that both screws provide adequate fixation and functional
recovery, but polylevolactic acid screws are associated with a higher
incidence of foreign body reactions. Cite this article:
The ideal treatment for traumatic anterior dislocation
of the shoulder in the skeletally immature patient is controversial.
The aim of this study is to evaluate the outcomes after either conservative
and/or surgical treatment using the Latarjet technique. A retrospective
series of 49 out of 80 patients were reviewed. We found no significant differences
between either treatment method regarding functional scores and
pain levels. Although not statistically significant, post-surgical
patients showed better signs of shoulder stability than others who
have a higher rate of recurrence. Further, 92% of the post-surgical
group had returned to the same level of activity Cite this article:
The goal of this study was to determine whether intra-articular
administration of the potentially anti-fibrotic agent decorin influences
the expression of genes involved in the fibrotic cascade, and ultimately
leads to less contracture, in an animal model. A total of 18 rabbits underwent an operation on their right knees
to form contractures. Six limbs in group 1 received four intra-articular
injections of decorin; six limbs in group 2 received four intra-articular
injections of bovine serum albumin (BSA) over eight days; six limbs
in group 3 received no injections. The contracted limbs of rabbits
in group 1 were biomechanically and genetically compared with the
contracted limbs of rabbits in groups 2 and 3, with the use of a
calibrated joint measuring device and custom microarray, respectively.Objectives
Methods
The term developmental dysplasia of the hip (DDH)
describes a spectrum of disorders that results in abnormal development
of the hip joint. If not treated successfully in childhood, these
patients may go on to develop hip symptoms and/or secondary osteoarthritis
in adulthood. In this review we describe the altered anatomy encountered
in adults with DDH along with the management options, and the challenges
associated with hip arthroscopy, osteotomies and arthroplasty for
the treatment of DDH in young adults. Cite this article:
The February 2014 Children’s orthopaedics Roundup360 looks at: flexible plasters; dual 8-plate or ablation for knee epiphysiodesis; ultrasounds for pulled elbow; leg length without the radiation; Boyd amputation in limb deficiencies; gold standard club foot treatment; quadrupled semitendinosis graft effective in paediatric ACL reconstruction; and predicting complications following cerebral palsy hip reconstruction
Antegrade nailing of proximal humeral fractures
using a straight nail can damage the bony insertion of the supraspinatus
tendon and may lead to varus failure of the construct. In order
to establish the ideal anatomical landmarks for insertion of the
nail and their clinical relevance we analysed CT scans of bilateral
proximal humeri in 200 patients (mean age 45.1 years ( We therefore emphasise the need for ‘fastidious’ pre-operative
planning to minimise this risk. Cite this article:
The Oxford unicompartmental knee replacement
(UKR) is an established treatment option in the management of symptomatic
end-stage medial compartmental osteoarthritis (MCOA), which works
well in the young and active patient. However, previous studies
have shown that it is reliable only in the presence of a functionally
intact anterior cruciate ligament (ACL). This review reports the
outcomes, at a mean of five years and a maximum of ten years, of 52
consecutive patients with a mean age of 51 years (36 to 57) who
underwent staged or simultaneous ACL reconstruction and Oxford UKR.
At the last follow-up (with one patient lost to follow-up), the
mean Oxford knee score was 41 ( In summary, ACL reconstruction and Oxford UKR gives good results
in patients with end-stage MCOA secondary to ACL deficiency.
We performed a randomised controlled trial comparing
computer-assisted surgery (CAS) with conventional surgery (CONV)
in total knee replacement (TKR). Between 2009 and 2011 a total of
192 patients with a mean age of 68 years (55 to 85) with osteoarthritis
or arthritic disease of the knee were recruited from four Norwegian
hospitals. At three months follow-up, functional results were marginally
better for the CAS group. Mean differences (MD) in favour of CAS
were found for the Knee Society function score (MD: 5.9, 95% confidence
interval (CI) 0.3 to 11.4, p = 0.039), the Knee Injury and Osteoarthritis
Outcome Score (KOOS) subscales for ‘pain’ (MD: 7.7, 95% CI 1.7 to
13.6, p = 0.012), ‘sports’ (MD: 13.5, 95% CI 5.6 to 21.4, p = 0.001)
and ‘quality of life’ (MD: 7.2, 95% CI 0.1 to 14.3, p = 0.046).
At one-year follow-up, differences favouring CAS were found for
KOOS ‘sports’ (MD: 11.0, 95% CI 3.0 to 19.0, p = 0.007) and KOOS
‘symptoms’ (MD: 6.7, 95% CI 0.5 to 13.0, p = 0.035). The use of
CAS resulted in fewer outliers in frontal alignment (>
3° malalignment),
both for the entire TKR (37.9% Cite this article:
The February 2014 Foot &
Ankle Roundup360 looks at: optimal medial malleolar fixation; resurfacing in the talus; predicting outcome in mobility ankles; whether mal-aligned ankles can be successfully replaced; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; recalcitrant Achilles tendinopathy; and recurrent fifth metatarsal stress fractures.
Children with congenital vertical talus (CVT)
have been treated with extensive soft-tissue releases, with a high
rate of complications. Recently, reverse Ponseti-type casting followed
by percutaneous reduction and fixation has been described, with
excellent results in separate cohorts of children with CVT, of either
idiopathic or teratological aetiology. There are currently no studies
that compare the outcome in these two types. We present a prospective cohort
of 13 children (21 feet) with CVT of both idiopathic and teratological
aetiology, in which this technique has been used. Clinical, radiological
and parent-reported outcomes were obtained at a mean follow-up of
36 months (8 to 57). Six children (nine feet) had associated neuromuscular
conditions or syndromes; the condition was idiopathic in seven children
(12 feet). Initial correction was achieved in all children, with significant
improvement in all radiological parameters. Recurrence was seen
in ten feet. Modification of the technique to include limited capsulotomy
at the initial operation may reduce the risk of recurrence. The reverse Ponseti-type technique is effective in the initial
correction of CVT of both idiopathic and teratological aetiology.
Recurrence is a problem in both these groups, with higher rates
than first reported in the original paper. However, these rates
are less than those reported after open surgical release. Cite this article:
There is currently no consensus about the mean
volume of blood lost during spinal tumour surgery and surgery for metastatic
spinal disease. We conducted a systematic review of papers published
in the English language between 31 January 1992 and 31 January 2012.
Only papers that clearly presented blood loss data in spinal surgery
for metastatic disease were included. The random effects model was
used to obtain the pooled estimate of mean blood loss. We selected 18 papers, including six case series, ten retrospective
reviews and two prospective studies. Altogether, there were 760
patients who had undergone spinal tumour surgery and surgery for
metastatic spinal disease. The pooled estimate of peri-operative
blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic
blood loss as high as 5000 ml, which is rare. Aside from two studies
that reported large amounts of mean blood loss (>
5500 ml), the
resulting funnel plot suggested an absence of publication bias.
This was confirmed by Egger’s test, which did not show any small-study
effects
(p = 0.119). However, there was strong evidence of heterogeneity
between studies (I2 = 90%; p <
0.001). Spinal surgery for metastatic disease is associated with significant
blood loss and the possibility of catastrophic blood loss. There
is a need to establish standardised methods of calculating and reporting
this blood loss. Analysis should include assessment by area of the
spine, primary pathology and nature of surgery so that the amount
of blood loss can be predicted. Consideration should be given to
autotransfusion in these patients. Cite this article:
The purpose of this study was to report the outcome
of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with
anatomical endoscopic reconstruction using hamstring tendon autograft
at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive
men and 100 consecutive women with ‘isolated’ ACL rupture underwent
four-strand hamstring tendon reconstruction with anteromedial portal
femoral tunnel drilling and interference screw fixation by a single
surgeon. Details were recorded pre-operatively and at one, two,
seven and 15 years post-operatively. Outcomes included clinical
examination, subjective and objective scoring systems, and radiological
assessment. At 15 years only eight of 118 patients (7%) had moderate
or severe osteo-arthritic changes (International Knee Documentation
Committee Grades C and D), and 79 of 152 patients (52%) still performed
very strenuous activities. Overall graft survival at 15 years was
83% (1.1% failure per year). Patients aged <
18 years at the
time of surgery and patients with >
2 mm of laxity at one year had
a threefold increase in the risk of suffering a rupture of the graft
(p = 0.002 and p = 0.001, respectively). There was no increase in
laxity of the graft over time. ACL reconstructive surgery in patients with an ‘isolated’ rupture
using this technique shows good results 15 years post-operatively
with respect to ligamentous stability, objective and subjective
outcomes, and does not appear to cause osteoarthritis.
Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.
The medial approach for the treatment of children
with developmental dysplasia of the hip (DDH) in whom closed reduction
has failed requires minimal access with negligible blood loss. In
the United Kingdom, there is a preference for these children to
be treated using an anterolateral approach after the appearance
of the ossific nucleus. In this study we compared these two protocols,
primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the
medial approach (26 hips in 22 children) and the anterolateral approach
(22 hips in 21 children) in children aged <
24 months at the
time of surgery. Osteonecrosis of the femoral head was assessed
with validated scores. The acetabular index (AI) and centre–edge
angle (CEA) were also measured. The mean age of the children at the time of surgery was 11 months
(3 to 24) for the medial approach group and 18 months (12 to 24)
for the anterolateral group, and the combined mean follow-up was
70 months (26 to 228). Osteonecrosis of the femoral head was evident
or asphericity predicted in three of 26 hips (12%) in the medial approach
group and four of 22 (18%) in the anterolateral group (p = 0.52).
The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to
10°), respectively, at two years post-operatively (p = 0.18). There
was no significant difference in CEA values of affected hips between
the two groups. Children treated using an early medial approach did not have
a higher risk of developing osteonecrosis at early to mid-term follow-up
than those treated using a delayed anterolateral approach. The rates
of acetabular remodelling were similar for both protocols. Cite this article:
Osteoporotic vertebral compression fractures
(VCFs) are an increasing public health problem. Recently, randomised
controlled trials on the use of kyphoplasty and vertebroplasty in
the treatment of these fractures have been published, but no definitive conclusions
have been reached on the role of these interventions. The major
problem encountered when trying to perform a meta-analysis of the
available studies for the use of cementoplasty in patients with
a VCF is that conservative management has not been standardised.
Forms of conservative treatment commonly used in these patients
include bed rest, analgesic medication, physiotherapy and bracing. In this review, we report the best evidence available on the
conservative care of patients with osteoporotic VCFs and associated
back pain, focusing on the role of the most commonly used spinal
orthoses. Although orthoses are used for the management of these patients,
to date, there has been only one randomised controlled trial published
evaluating their value. Until the best conservative management for
patients with VCFs is defined and standardised, no conclusions can
be drawn on the superiority or otherwise of cementoplasty techniques
over conservative management.
Controversy remains regarding the optimal post-operative
analgesic regimen following total knee replacement. A delicate balance
is required between the provision of adequate pain relief and early
mobilisation. By reviewing 29 randomised trials we sought to establish
whether local infiltration of analgesia directly into the knee during
surgery provides better pain relief and a more rapid rehabilitation.
Although we were able to conclude that local infiltration can provide
improved post-operative pain relief, and to suggest the most promising
technique of administration, there is no evidence that it reduces
hospital stay.
We reviewed the outcome of patients who had been
treated operatively for symptomatic peri-acetabular metastases and
present an algorithm to guide treatment. The records of 81 patients who had been treated operatively for
symptomatic peri-acetabular metastases between 1987 and 2010 were
identified. There were 27 men and 54 women with a mean age of 61
years (15 to 87). The diagnosis, size of lesion, degree of pelvic
continuity, type of reconstruction, World Health Organization performance
status, survival time, pain, mobility and complications including
implant failure were recorded in each case. The overall patient survivorship at five years was 5%. The longest
lived patient survived 16 years from the date of diagnosis. The
mean survival was 23 months (<
1 to 16 years) and the median
was 15 months. At follow-up 14 patients remained alive. Two cementoplasties
failed because of local disease progression. Three Harrington rods broke:
one patient needed a subsequent Girdlestone procedure. One ‘ice-cream
cone’ prosthesis dislocated and was subsequently revised without
further problems. We recommend the ‘ice-cream cone’ for pelvic discontinuity
and Harrington rod reconstruction for severe bone loss. Smaller
defects can be safely managed using standard revision hip techniques. Cite this article:
There are several methods for evaluating stability
of the joint during total knee replacement (TKR). Activities of daily
living demand mechanical loading to the knee joint, not only in
full extension, but also in mid-flexion. The purpose of this study
was to compare the varus-valgus stability throughout flexion in
knees treated with either cruciate-retaining or posterior-stabilised
TKR, using an intra-operative navigation technique. A total of 34
knees underwent TKR with computer navigation, during which the investigator
applied a maximum varus-valgus stress to the knee while steadily
moving the leg from full extension to flexion both before and after
prosthetic implantation. The femorotibial angle was measured simultaneously
by the navigation system at every 10° throughout the range of movement.
It was found that posterior-stabilised knees had more varus-valgus
laxity than cruciate-retaining knees at all angles examined, and
the differences were statistically significant at 10° (p = 0.0093),
20° (p = 0.0098) and 30° of flexion (p = 0.0252). Cite this article: