Periprosthetic joint infection (PJI) is a devastating
complication for patients and results in greatly increased costs
of care for both healthcare providers and patients. More than 15
500 revision hip and knee procedures were recorded in England, Wales
and Northern Ireland in 2013, with infection accounting for 13%
of revision hip and 23% of revision knee procedures. We report our experience of using antibiotic eluting absorbable
calcium sulphate beads in 15 patients (eight men and seven women
with a mean age of 64.8 years; 41 to 83) as part of a treatment
protocol for PJI in revision arthroplasty. The mean follow-up was 16 months (12 to 22). We report the outcomes
and complications, highlighting the risk of hypercalcaemia which
occurred in three patients. We recommend that serum levels of calcium be routinely sought
following the implantation of absorbable calcium sulphate beads
in orthopaedic surgery. Cite this article:
To date, there is insufficient evidence available to compare
the outcome of cemented and uncemented fixation of the humeral stem
in reverse shoulder arthroplasty (RSA). A systemic review comprising 41 clinical studies was performed
to compare the functional outcome and rate of complications of cemented
and uncemented stems in RSA. These included 1455 cemented and 329
uncemented shoulders. The clinical characteristics of the two groups
were similar. Variables were compared using pooled frequency-weighted means
and relative risk ratios (RR).Aims
Methods
Frozen shoulder is a recognised complication
following simple arthroscopic shoulder procedures, but its exact incidence
has not been reported. Our aim was to analyse a single-surgeon series
of patients undergoing arthroscopic subacromial decompression (ASD;
group 1) or ASD in combination with arthroscopic acromioclavicular
joint (ACJ) excision (group 2), to establish the incidence of frozen
shoulder post-operatively. Our secondary aim was to identify associated
risk factors and to compare this cohort with a group of patients
with primary frozen shoulder. We undertook a retrospective analysis of 200 consecutive procedures
performed between August 2011 and November 2013. Group 1 included
96 procedures and group 2 104 procedures. Frozen shoulder was diagnosed
post-operatively using the British Elbow and Shoulder Society criteria.
A comparative group from the same institution involved 136 patients
undergoing arthroscopic capsular release for primary idiopathic
frozen shoulder. The incidence of frozen shoulder was 5.21% in group 1 and 5.71%
in group 2. Age between 46 and 60 years (p = 0.002) and a previous
idiopathic contralateral frozen shoulder (p <
0.001) were statistically
significant risk factors for the development of secondary frozen
shoulder. Comparison of baseline characteristics against the comparator groups
showed no statistically significant differences for age, gender,
diabetes and previous contralateral frozen shoulder. These results suggest that the risk of frozen shoulder following
simple arthroscopic procedures is just over 5%, with no increased
risk if the ACJ is also excised. Patients aged between 46 and 60
years and a previous history of frozen shoulder increase the relative
risk of secondary frozen shoulder by 7.8 (95% confidence interval
(CI) 2.1 to 28.3)and 18.5 (95% CI 7.4 to 46.3) respectively. Cite this article:
The treatment of a chronic posterior dislocation of the shoulder is often determined by the size of the associated impression fracture of the humeral head. Our hypothesis was that patients with a chronic unreduced posterior dislocation of the shoulder and a defect in the humeral head involving between 25% to 50% of the articular surface, would do better if reconstructed with an allograft from the femoral head rather than treated by a non-anatomical reconstruction. We reviewed ten men and three women with a mean age of 42 years (36 to 51) at a mean follow-up of 54 months (41 to 64) who had this procedure. At follow-up, nine had no pain or restriction of activities of daily living. Their mean Constant-Murley shoulder score was 86.8 (43 to 98). No patient had symptoms of instability of the shoulder. Reconstruction of the defect in the humeral head with an allograft provides good pain relief, stability and function for patients with a locked, chronic posterior dislocation where the defect involves between 25% and 50% of the circumference of the articular surface.
We investigated the functional outcome in patients
who underwent reverse shoulder replacement (RSR) after removal of
a tumour of the proximal humerus. A total of 16 patients (ten women
and six men) underwent this procedure between 1998 and 2011 in our
hospital. Five patients died and one was lost to follow-up. Ten
patients were available for review at a mean follow-up of 46 months
(12 to 136). Eight patients had a primary and two patients a secondary
bone tumour. At final follow up the mean range of active movement was: abduction
78° (30° to 150°); flexion 98° (45° to 180°); external rotation
32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal
Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity
Salvage Score was 70% (30% to 91%). Two patients had a superficial
infection and one had a deep infection and underwent a two-stage
revision procedure. In two patients there was loosening of the RSR;
one dislocated twice. All patients had some degree of atrophy or
pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus
gives acceptable results. Cite this article:
Whereas a general trend in the management of obstetric brachial plexus injuries has been nerve reconstruction in patients without spontaneous recovery of biceps function by three to six months of age, many recent studies suggest this may be unnecessary. In this study, the severity of glenohumeral dysplasia and shoulder function and strength in two groups of matched patients with a C5-6 lesion at a mean age of seven years (2.7 to 13.3) were investigated. One group (23 patients) underwent nerve reconstruction and secondary operations, and the other (52 patients) underwent only secondary operations for similar initial clinical presentations. In the patients with nerve reconstruction shoulder function did not improve and they developed more severe shoulder deformities (posterior subluxation, glenoid version and scapular elevation) and required a mean of 2.4 times as many operations as patients without nerve reconstruction. This study suggests that less invasive management, addressing the muscle and bone complications, is a more effective approach. Nerve reconstruction should be reserved for those less common cases where the C5 and C6 nerve roots will not recover.
We identified 148 patients who had undergone a revision total knee replacement using a single implant system between 1990 and 2000. Of these 18 patients had died, six had developed a peri-prosthetic fracture and ten had incomplete records or radiographs. This left 114 with prospectively-collected radiographs and Bristol knee scores available for study. The height of the joint line before and after revision total knee replacement was measured and classified as either restored to within 5 mm of the pre-operative height or elevated if it was positioned more than 5 mm above the pre-operative height. The joint line was elevated in 41 knees (36%) and restored in 73 (64%). Revision surgery significantly improved the mean Bristol knee score from 41.1 ( Our findings show that restoration of the joint line at revision total knee replacement gives a significantly better result than leaving it unrestored by more than 5 mm. We recommend the greater use of distal femoral augments to help to achieve this goal.
There is little information about the management
of peri-prosthetic fracture of the humerus after total shoulder replacement
(TSR). This is a retrospective review of 22 patients who underwent
a revision of their original shoulder replacement for peri-prosthetic
fracture of the humerus with bone loss and/or loose components.
There were 20 women and two men with a mean age of 75 years (61
to 90) and a mean follow-up 42 months (12 to 91): 16 of these had
undergone a previous revision TSR. Of the 22 patients, 12 were treated
with a long-stemmed humeral component that bypassed the fracture.
All their fractures united after a mean of 27 weeks (13 to 94).
Eight patients underwent resection of the proximal humerus with
endoprosthetic replacement to the level of the fracture. Two patients
were managed with a clam-shell prosthesis that retained the original
components. The mean Oxford shoulder score (OSS) of the original
TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean
OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival
using re-intervention for any reason as the endpoint was 91% (95%
confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at
one and five years, respectively. There were two revisions for dislocation of the humeral head,
one open reduction for modular humeral component dissociation, one
internal fixation for nonunion, one trimming of a prominent screw
and one re-cementation for aseptic loosening complicated by infection,
ultimately requiring excision arthroplasty. Two patients sustained
nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated
with bone loss and/or loose components is a salvage procedure that
can provide a stable platform for elbow and hand function. Good
rates of union can be achieved using a stem that bypasses the fracture.
There is a high rate of complications and function is not as good as
with the original replacement.
Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs. A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p <
0.001), as was resorption of the greater (p <
0.001) and lesser tuberosities (p = 0.009).
We aimed to examine the characteristics of deep venous flow in
the leg in a cast and the effects of a wearable neuromuscular stimulator
(geko; FirstKind Ltd) and also to explore the participants’ tolerance
of the stimulator. This is an open-label physiological study on ten healthy volunteers.
Duplex ultrasonography of the superficial femoral vein measured
normal flow and cross-sectional area in the standing and supine
positions (with the lower limb initially horizontal and then elevated).
Flow measurements were repeated during activation of the geko stimulator
placed over the peroneal nerve. The process was repeated after the
application of a below-knee cast. Participants evaluated discomfort
using a questionnaire (verbal rating score) and a scoring index
(visual analogue scale).Objectives
Methods
Instability after total knee replacement (TKR)
accounts for 10% to 22% of revision procedures. All patients who
present for evaluation of instability require a thorough history to
be taken and physical examination, as well as appropriate imaging.
Deep periprosthetic infection must be ruled out by laboratory testing
and an aspiration of the knee must be carried out. The three main
categories of instability include flexion instability, extension instability
(symmetric and asymmetric), and genu recurvatum. Most recently,
the aetiologies contributing to, and surgical manoeuvres required
to correct, flexion instability have been elucidated. While implant
design and patient-related factors may certainly contribute to the
aetiology, surgical technique is also a significant factor in all
forms of post-operative instability. Cite this article:
This paper describes the current views on the pathology of lesions of the tendon of the long head of biceps and their management. Their diagnosis is described and their surgical management classified, with details of the techniques employed.
The purpose of this study was to evaluate whether
the serum level of interleukin 6 (IL-6) could be used to identify the
persistence of infection after the first stage of a two-stage revision
for periprosthetic joint infection. Between 2010 and 2011, we prospectively studied 55 patients (23
men, 32 women; mean age 69.5 years; 36 to 86) with a periprosthetic
joint infection. Bacteria were identified in two intra-operative
tissue samples during re-implantation in 16 patients. These cases
were classified as representing persistent infection. To calculate a precise cut-off value which could be used in everyday
clinical practice, a 3 x 2 contingency table was constructed and
manually defined. We found that a serum IL-6 ≥ 13 pg/mL can be regarded as indicating
infection: its positive-predictive value is 90.9%. A serum IL-6 ≤ 8
pg/mL can be regarded as indicating an absence of infection: its
negative predictive value is 92.1%. The serum IL-6 level seems to be a reasonable marker for identifying
persistent infection after the first stage of a revision joint arthroplasty
and before attempting re-implantation. Cite this article:
We dissected 12 fresh-frozen leg specimens to
identify the insertional footprint of each fascicle of the Achilles tendon
on the calcaneum in relation to their corresponding muscles. A further
ten embalmed specimens were examined to confirm an observation on
the retrocalcaneal bursa. The superficial part of the insertion
of the Achilles tendon is represented by fascicles from the medial
head of the gastrocnemius muscle, which is inserted over the entire
width of the inferior facet of the calcaneal tuberosity. In three
specimens this insertion was in continuity with the plantar fascia
in the form of periosteum. The deep part of the insertion of the
Achilles tendon is made of fascicles from the soleus tendon, which
insert on the medial aspect of the middle facet of the calcaneal
tuberosity, while the fascicles of the lateral head of the gastrocnemius
tendon insert on the lateral aspect of the middle facet of the calcaneal
tuberosity. A bicameral retrocalcaneal bursa was present in 15 of
the 22 examined specimens. This new observation and description of the insertional footprint
of the Achilles tendon and the retrocalcaneal bursa may allow a
better understanding of the function of each muscular part of the
gastrosoleus complex. This may have clinical relevance in the treatment
of Achilles tendinopathies. Cite this article:
We have undertaken a prospective study in patients with a fracture of the femoral shaft requiring intramedullary nailing to test the hypothesis that the femoral canal could be a potential source of the second hit phenomenon. We determined the local femoral intramedullary and peripheral release of interleukin-6 (IL-6) after fracture and subsequent intramedullary reaming. In all patients, the fracture caused a significant increase in the local femoral concentrations of IL-6 compared to a femoral control group. The concentration of IL-6 in the local femoral environment was significantly higher than in the patients own matched blood samples from their peripheral circulation. The magnitude of the local femoral release of IL-6 after femoral fracture was independent of the injury severity score and whether the fracture was closed or open. In patients who underwent intramedullary reaming of the femoral canal a further significant local release of IL-6 was demonstrated, providing evidence that intramedullary reaming can cause a significant local inflammatory reaction.
We describe three cases of infantile tibia vara
resulting from an atraumatic slip of the proximal tibial epiphysis
upon the metaphysis. There appears to be an association between
this condition and severe obesity. Radiologically, the condition
is characterised by a dome-shaped metaphysis, an open growth plate
and disruption of the continuity between the lateral borders of
the epiphysis and metaphysis, with inferomedial translation of the
proximal tibial epiphysis. All patients were treated by realignment
of the proximal tibia by distraction osteogenesis with an external
circulator fixator, and it is suggested that this is the optimal
method for correction of this complex deformity. There are differences
in the radiological features and management between conventional
infantile Blount’s disease and this ‘slipped upper tibial epiphysis’
variant.
Intact abductors of the hip play a crucial role
in preventing limping and are known to be damaged through the direct lateral
approach. The extent of trauma to the abductors after revision total
hip replacement (THR) is unknown. The aim of this prospective study
was to compare the pre- and post-operative status of the gluteus
medius muscle after revision THR. We prospectively compared changes
in the muscle and limping in 30 patients who were awaiting aseptic
revision THR and 15 patients undergoing primary THR. The direct
lateral approach as described by Hardinge was used for all patients.
MRI scans of the gluteus medius and functional analyses were recorded
pre-operatively and six months post-operatively. The overall mean
fatty degeneration of the gluteus medius increased from 35.8% (1.1
to 98.8) pre-operatively to 41% (1.5 to 99.8) after multiple revision
THRs (p = 0.03). There was a similar pattern after primary THR,
but with considerably less muscle damage (p = 0.001), indicating
progressive muscle damage. Despite an increased incidence of a positive
Trendelenburg sign following revision surgery (p = 0.03) there was
no relationship between the cumulative fatty degeneration in the
gluteus medius and a positive Trendelenburg sign (p = 0.26). The
changes associated with other surgical approaches to the hip warrant
investigation. Cite this article:
The results of proximal humeral replacement following trauma are substantially worse than for osteoarthritis or rheumatoid arthritis. The stable reattachment of the lesser and greater tuberosity fragments to the rotator cuff and the restoration of shoulder biomechanics are difficult. In 1992 we developed a prosthesis designed to improve fixation of the tuberosity fragments in comminuted fractures of the proximal humerus. The implant enables fixation of the fragments to the shaft of the prosthesis and the diaphyseal fragment using screws, washers and a special toothed plate. Between 1992 and 2003 we used this technique in 50 of 76 patients referred to our institution for shoulder reconstruction after trauma. In the remaining 26, reconstruction with a prosthesis and nonabsorbable sutures was performed, as the tuberosity fragments were too small and too severely damaged to allow the use of screws and the toothed plate. The Constant score two years post-operatively was a mean of 12 points better in the acute trauma group and 11 points better in the late post-traumatic group than in the classical suture group. We recommend this technique in patients where the tuberosity fragments are large enough to allow fixation with screws, washers and a toothed plate.
The Oxford mobile-bearing unicompartmental knee
replacement (UKR) is an effective and safe treatment for osteoarthritis
of the medial compartment. The results in the lateral compartment
have been disappointing due to a high early rate of dislocation
of the bearing. A series using a newly designed domed tibial component
is reported. The first 50 consecutive domed lateral Oxford UKRs in 50 patients
with a mean follow-up of three years (2.0 to 4.3) were included.
Clinical scores were obtained prospectively and Kaplan-Meier survival
analysis was performed for different endpoints. Radiological variables
related to the position and alignment of the components were measured. One patient died and none was lost to follow-up. The cumulative
incidence of dislocation was 6.2% (95% confidence interval (CI)
2.0 to 17.9) at three years. Survival using revision for any reason
and aseptic revision was 94% (95% CI 82 to 98) and 96% (95% CI 85
to 99) at three years, respectively. Outcome scores, visual analogue
scale for pain and maximum knee flexion showed a significant improvement
(p <
0.001). The mean Oxford knee score was 43 ( Clinical results are excellent and short-term survival has improved
when compared with earlier series. The risk of dislocation remains
higher using a mobile-bearing UKR in the lateral compartment when
compared with the medial compartment. Patients should be informed
about this complication. To avoid dislocations, care must be taken
not to elevate the lateral joint line.