A suspected fracture of the scaphoid remains difficult to manage despite advances in knowledge and imaging methods. Immobilisation and restriction of activities in a young and active patient must be balanced against the risks of nonunion associated with an undiagnosed and undertreated fracture of the scaphoid. The assessment of diagnostic tests for a suspected fracture of the scaphoid must take into account two important factors. First, the prevalence of true fractures among suspected fractures is low, which greatly reduces the probability that a positive test will correspond with a true fracture, as false positives are nearly as common as true positives. This situation is accounted for by Bayesian statistics. Secondly, there is no agreed reference standard for a true fracture, which necessitates the need for an alternative method of calculating diagnostic performance characteristics, based upon a statistical method which identifies clinical factors tending to associate (latent classes) in patients with a high probability of fracture. The most successful diagnostic test to date is MRI, but in low-prevalence situations the positive predictive value of MRI is only 88%, and new data have documented the potential for false positive scans. The best strategy for improving the diagnosis of true fractures among suspected fractures of the scaphoid may well be to develop a clinical prediction rule incorporating a set of demographic and clinical factors which together increase the pre-test probability of a fracture of the scaphoid, in addition to developing increasingly sophisticated radiological tests.
Osteoarthritis results in changes in the dimensions
of the glenoid. This study aimed to assess the size and radius of curvature
of arthritic glenoids. A total of 145 CT scans were analysed, performed
as part of routine pre-operative assessment before total shoulder
replacement in 91 women and 54 men. Only patients with primary osteoarthritis and
a concentric glenoid were included in the study. The CT scans underwent
three-dimensional (3D) reconstruction and were analysed using dedicated
computer software. The measurements consisted of maximum superoinferior height,
anteroposterior width and a best-fit sphere radius of curvature
of the glenoid. The mean height was 40.2 mm ( With current shoulder replacement systems using a unique backside
radius of curvature for the glenoid component, there is a risk of
undertaking excessive reaming to adapt the bone to the component
resulting in sacrifice of subchondral bone or under-reaming and
instability of the component due to a ’rocking horse‘ phenomenon. Cite this article:
The aim of this study was to assess a specific
protocol for the treatment of patients with a parosteal osteosarcoma of
the distal femur with limb salvage involving hemicortical resection
and reconstruction using recycled pasteurised autograft and internal
fixation. Between January 2000 and January 2010, 13 patients with
a mean age of 26.5 years (17 to 39) underwent this procedure. All
the tumours were staged according to Enneking’s criteria: there
were eight stage IA tumours and five stage IB tumours. The mean
follow-up was 101.6 months (58 to 142), and mean post-operative
Musculoskeletal Tumour Society functional score was 88.6% (80% to
100%) at the final follow-up. All the patients had achieved bony
union; the mean time to union was 11.2 months (6 to 18). Local recurrence
occurred in one patient 27 months post-operatively. No patient had
a pulmonary metastasis. A hemicortical procedure for the treatment of a parosteal osteosarcoma
is safe and effective. Precise pre-operative planning using MRI
is essential in order to define the margins of resection. Although
it is a technically demanding procedure, gratifying results make
it worthwhile for selected patients. Cite this article:
We investigated differences in the location and
mode of labral tears between dysplastic hips and hips with femoroacetabular
impingement (FAI). We also investigated the relationship between
labral tear and adjacent cartilage damage. We retrospectively studied
72 symptomatic hips (in 68 patients: 19 men and 49 women) with radiological
evidence of dysplasia or FAI on high-resolution CT arthrography.
The incidence and location of labral tears and modes of tear associated
with the base of the labrum (Mode 1) or body of the labrum (Mode
2) were compared among FAI, mildly dysplastic and severely dysplastic
hips. The locations predominantly involved with labral tears were
different in FAI and mild dysplastic hips (anterior and anterosuperior
zones) and in severely dysplastic hips (anterosuperior and superior
zones) around the acetabulum. Significant differences were observed
in the prevalence of Mode 1 Hip pathology is significantly related to the locations and modes
of labral tears. Mode 1 tears may be a risk factor for the development
of adjacent acetabular cartilage damage. Cite this article:
The objective of this study was to evaluate the rotation and
translation of each joint in the hindfoot and compare the load response
in healthy feet with that in stage II posterior tibial tendon dysfunction
(PTTD) flatfoot by analysing the reconstructive three-dimensional
(3D) computed tomography (CT) image data during simulated weight-bearing. CT scans of 15 healthy feet and 15 feet with stage II PTTD flatfoot
were taken first in a non-weight-bearing condition, followed by
a simulated full-body weight-bearing condition. The images of the
hindfoot bones were reconstructed into 3D models. The ‘twice registration’
method in three planes was used to calculate the position of the
talus relative to the calcaneus in the talocalcaneal joint, the
navicular relative to the talus in talonavicular joint, and the cuboid
relative to the calcaneus in the calcaneocuboid joint.Objective
Methods
The piriformis muscle is an important landmark
in the surgical anatomy of the hip, particularly the posterior approach
for total hip replacement (THR). Standard orthopaedic teaching dictates
that the tendon must be cut in to allow adequate access to the superior
part of the acetabulum and the femoral medullary canal. However,
in our experience a routine THR can be performed through a posterior
approach without sacrificing this tendon. We dissected the proximal femora of 15 cadavers in order to clarify
the morphological anatomy of the piriformis tendon. We confirmed
that the tendon attaches on the crest of the greater trochanter,
in a position superior to the trochanteric fossa, away from the
entry point for broaching the intramedullary canal during THR. The
tendon attachment site encompassed the summit and medial aspect
of the greater trochanter as well as a variable attachment to the
fibrous capsule of the hip joint. In addition we dissected seven
cadavers resecting all posterior attachments except the piriformis
muscle and tendon in order to study their relations to the hip joint,
as the joint was flexed. At flexion of 90° the piriformis muscle
lay directly posterior to the hip joint. The piriform fossa is a term used by orthopaedic surgeons to
refer the trochanteric fossa and normally has no relation to the
attachment site of the piriformis tendon. In hip flexion the piriformis
lies directly behind the hip joint and might reasonably be considered
to contribute to the stability of the joint. We conclude that the anatomy of the piriformis muscle is often
inaccurately described in the current surgical literature and terms
are used and interchanged inappropriately. Cite this article:
Guidelines for the management of patients with metastatic bone
disease (MBD) have been available to the orthopaedic community for
more than a decade, with little improvement in service provision
to this increasingly large patient group. Improvements in adjuvant
and neo-adjuvant treatments have increased both the number and overall
survival of patients living with MBD. As a consequence the incidence
of complications of MBD presenting to surgeons has increased and
is set to increase further. The British Orthopaedic Oncology Society
(BOOS) are to publish more revised detailed guidelines on what represents
‘best practice’ in managing patients with MBD. This article is designed
to coincide with and publicise new BOOS guidelines and once again
champion the cause of patients with MBD. A series of short cases highlight common errors frequently being
made in managing patients with MBD despite the availability of guidelines.Objectives
Methods
Ankylosing spondylitis (AS) is a progressive
multisystem chronic inflammatory disorder. The hallmark of this pathological
process is a progressive fusion of the zygapophyseal joints and
disc spaces of the axial skeleton, leading to a rigid kyphotic deformity
and positive sagittal balance. The ankylosed spine is unable to
accommodate normal mechanical forces, rendering it brittle and susceptible
to injury. Traumatic hyperextension injury of the cervical spine
leading to atlantoaxial subluxation (AAS) in AS patients can often
be fatal. We report a non-traumatic mechanism of injury in AS progressing
to AAS attributable to persistent hyperextension, which resulted
in fatal migration of C2 through the foramen magnum. Cite this article:
Lateral epicondylitis, or ’tennis elbow’, is
a common condition that usually affects patients between 35 and
55 years of age. It is generally self-limiting, but in some patients
it may continue to cause persistent symptoms, which can be refractory
to treatment. This review discusses the mechanism of disease, symptoms
and signs, investigations, current management protocols and potential
new treatments. Cite this article:
The cause of fracture of the femoral neck after hip resurfacing is poorly understood. In order to evaluate the role of avascular necrosis we compared 19 femoral heads retrieved at revision for fracture of the femoral neck and 13 retrieved for other reasons. We developed a new technique of assessing avascular necrosis in the femoral head by determining the percentage of empty osteocyte lacunae present. Femoral heads retrieved as controls at total hip replacement for osteoarthritis and avascular necrosis had 9% ( In the fracture group the percentage of empty lacunae was 71% ( We conclude that fracture after resurfacing of the hip is associated with a significantly greater percentage of empty osteocyte lacunae within the trabecular bone. This indicates established avascular necrosis and suggests that damage to the blood supply at the time of surgery is a potent risk factor for fracture of the femoral neck after hip resurfacing.
The December 2012 Wrist &
Hand Roundup360 looks at: the imaging of scaphoid fractures; splinting to help Dupuytren’s disease; quality of life after nerve transfers; early failure of Moje thumbs; electra CMCJ arthroplasty; proximal interphalangeal joint replacement; pronator quadratus repair in distal radius fractures; and osteoporosis and wrist fractures.
The December 2012 Trauma Roundup360 looks at: more is not always better, especially when its chemotherapy; new hope for skeletal metastasis; biopsy tracts; intra-operative imaging of sarcomas; curettage with adjuvant therapy; amputation and distal tibial osteosarcoma; and diaphyseal tibial tumours.
In this paper, we will consider the current role
of metal-on-metal bearings by looking at three subtypes of MoM hip
arthroplasty separately: Hip resurfacing, large head (>
36 mm) MoM
THA and MoM THA with traditional femoral head sizes.
Many radiographic techniques have been described for measuring patellar height. They can be divided into two groups: those that relate the position of the patella to the femur (direct) and those that relate it to the tibia (indirect). This article looks at the methods that have been described, the logic behind their conception and the critical analyses that have been performed to test them.
Improvements in the surgical technique of total
knee replacement (TKR) are continually being sought. There has recently
been interest in three-dimensional (3D) pre-operative planning using
magnetic resonance imaging (MRI) and CT. The 3D images are increasingly
used for the production of patient-specific models, surgical guides
and custom-made implants for TKR. The users of patient-specific instrumentation (PSI) claim that
they allow the optimum balance of technology and conventional surgery
by reducing the complexity of conventional alignment and sizing
tools. In this way the advantages of accuracy and precision claimed
by computer navigation techniques are achieved without the disadvantages
of additional intra-operative inventory, new skills or surgical
time. This review describes the terminology used in this area and debates
the advantages and disadvantages of PSI.
With the development of systems of trauma care the management of pelvic disruption has evolved and has become increasingly refined. The goal is to achieve an anatomical reduction and stable fixation of the fracture. This requires adequate visualisation for reduction of the fracture and the placement of fixation. Despite the advances in surgical approach and technique, the functional outcomes do not always produce the desired result. New methods of percutaneous treatment in conjunction with innovative computer-based imaging have evolved in an attempt to overcome the existing difficulties. This paper presents an overview of the technical aspects of percutaneous surgery of the pelvis and acetabulum.
We investigated the development of CT-based bony
radiological parameters associated with femoroacetabular impingement
(FAI) in a paediatric and adolescent population with no known orthopaedic
hip complaints. We retrospectively reformatted and reoriented
225 abdominal CTs into standardised CT pelvic images with neutral
pelvic tilt and inclination (244 female and 206 male hips) in patients
ranging from two to 19 years of age (mean 10.4 years). The Tönnis
angle, acetabular depth ratio, lateral centre–edge angle, acetabular
version and α-angle were assessed. Acetabular measurements demonstrated increased acetabular coverage
with age and/or progressive ossification of the acetabulum. The α-angle
decreased with age and/or progressive cortical bone development
and resultant narrowing of the femoral neck. Cam and pincer morphology
occurred as early as ten and 12 years of age, respectively, and
their prevalence in the adolescent patient population is similar
to that reported in the adult literature. Future aetiological studies
of FAI will need to focus on the early adolescent population. Cite this article:
Giant cell tumours (GCTs) of the small bones
of the hands and feet are rare. Small case series have been published but
there is no consensus about ideal treatment. We performed a systematic
review, initially screening 775 titles, and included 12 papers comprising
91 patients with GCT of the small bones of the hands and feet. The
rate of recurrence across these publications was found to be 72%
(18 of 25) in those treated with isolated curettage, 13% (2 of 15)
in those treated with curettage plus adjuvants, 15% (6 of 41) in
those treated by resection and 10% (1 of 10) in those treated by
amputation. We then retrospectively analysed 30 patients treated for GCT
of the small bones of the hands and feet between 1987 and 2010 in
five specialised centres. The primary treatment was curettage in
six, curettage with adjuvants (phenol or liquid nitrogen with or
without polymethylmethacrylate (PMMA)) in 18 and resection in six.
We evaluated the rate of complications and recurrence as well as
the factors that influenced their functional outcome. At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence
was 50% (n = 3) in those patients treated with isolated curettage,
22% (n = 4) in those treated with curettage plus adjuvants and 17%
(n = 1) in those treated with resection (p = 0.404). The only complication
was pain in one patient, which resolved after surgical removal of remnants
of PMMA. We could not identify any individual factors associated
with a higher rate of complications or recurrence. The mean post-operative
Musculoskeletal Tumor Society scores were slightly higher after
intra-lesional treatment including isolated curettage and curettage
plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to
30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted
in the cure for all patients and is therefore a reasonable treatment
for both primary and recurrent GCT of the small bones of the hands
and feet. 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
Lower limb muscle power is thought to influence outcome following
total knee replacement (TKR). Post-operative deficits in muscle
strength are commonly reported, although not explained. We hypothesised
that post-operative recovery of lower limb muscle power would be
influenced by the number of satellite cells in the quadriceps muscle at
time of surgery. Biopsies were obtained from 29 patients undergoing TKR. Power
output was assessed pre-operatively and at six and 26 weeks post-operatively
with a Leg Extensor Power Rig and data were scaled for body weight.
Satellite cell content was assessed in two separate analyses, the
first cohort (n = 18) using immunohistochemistry and the second
(n = 11) by a new quantitative polymerase chain reaction (q-PCR)
protocol for Pax-7 (generic satellite cell marker) and Neural Cell
Adhesion Molecule (NCAM; marker of activated cells).Objectives
Methods