The aims of this study were to determine the
functional impact and financial burden of isolated and recurrent dislocation
after total hip arthroplasty (THA). Our secondary goal was to determine
whether there was a difference between patients who were treated
non-operatively and those who were treated operatively. We retrospectively reviewed 71 patients who had suffered dislocation
of a primary THA. Their mean age was 67 years (41 to 92) and the
mean follow-up was 3.8 years (2.1 to 8.2). Because patients with recurrent dislocation were three times
more likely to undergo operative treatment (p <
0.0001), they
ultimately had a significantly higher mean Harris Hip Score (HHS)
(p = 0.0001), lower mean Western Ontario and McMaster Universities
Arthritis Index (WOMAC) scores (p = 0.001) and a higher mean SF-12
score (p <
0.0001) than patients with a single dislocation. Likewise,
those who underwent operative treatment had a higher mean HHS (p
<
0.0001), lower mean WOMAC score (p <
0.0001) and a higher
mean SF-12 score (p <
0.0001) than those who were treated non-operatively. Recurrent dislocation and operative treatment increased costs
by 300% (£11 456;
p <
0.0001) and 40% (£5217; p <
0.0001), respectively. The operative treatment of recurrent dislocation results in significantly
better function than non-operative management. Moreover, the increase
in costs for operative treatment is modest compared with that of
non-operative measures. Cite this article:
Things have not been quiet in the Cochrane Collaboration in the four months since the last 'Cochrane Corner', with the publication of six new or updated reviews summarised here, all conducted with the bulletproof Collaboration's methodology representing the pinnacle of evidence relevant to orthopaedic surgeons.
This study evaluated whether obese patients who
lost weight before their total joint replacement and kept it off post-operatively
were at lower risk of surgical site infection (SSI) and re-admission
compared with those who remained the same weight. We reviewed 444 patients who underwent a total hip replacement
and 937 with a total knee replacement who lost weight pre-operatively
and sustained their weight loss after surgery. After adjustments,
patients who lost weight before a total hip replacement and kept
it off post-operatively had a 3.77 (95% confidence interval (CI)
1.59 to 8.95) greater likelihood of deep SSIs and those who lost
weight before a total knee replacement had a 1.63 (95% CI 1.16 to
2.28) greater likelihood of re-admission compared with the reference
group. These findings raise questions about the safety of weight management
before total replacement of the hip and knee joints. Cite this article:
The February 2014 Trauma Roundup360 looks at: predicting nonunion; compartment Syndrome; octogenarian RTCs; does HIV status affect decision making in open tibial fractures?; flap timing and related complications; proximal humeral fractures under the spotlight; restoration of hip architecture with bipolar hemiarthroplasty in the elderly; and short
The purpose of this study was to review the long-term outcomes of a previously reported prospective series of 46 type III acromioclavicular dislocations. These were treated surgically with temporary fixation of the acromioclavicular joint with wires, repair of the acromioclavicular ligaments, and overlapped suture of the deltoid and trapezius muscles. Of the 46 patients, one had died, four could not be traced, and three declined to return for follow-up, leaving 38 patients in the study. There were 36 men and two women, with a mean age at follow-up of 57.3 years (41 to 71). The mean follow-up was 24.2 years (21 to 26). Patients were evaluated using the Imatani and University of California, Los Angeles (UCLA) scoring systems. Their subjective status was assessed using the Disabilities of the Arm, Shoulder and Hand and Simple Shoulder Test questionnaires, and a visual analogue scale for patient satisfaction. The examination included radiographs of the shoulder. At a follow-up of 21 years, the results were satisfactory in 35 (92.1%) patients and unsatisfactory in three (7.9%). In total, 35 patients (92.1%) reported no pain, one slight pain, and two moderate pain. All except two patients had a full range of shoulder movement compared with the opposite side. Unsatisfactory results were the result of early redisplacement in two patients, and osteoarthritis without redisplacement in one. According to the Imatani and UCLA scores, there was no difference between the operated shoulder and the opposite shoulder (p >
0.05). Given the same situation, 35 (92.1%) patients would opt for the same surgical treatment again. Operative treatment of type III acromioclavicular joint injuries produces satisfactory long-term results.
Charcot neuro-osteoarthropathy (CN) of the midfoot
presents a major reconstructive challenge for the foot and ankle
surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and
recommended for patients who have a deformity of the medial column
of the foot due to CN. We present the results from the first nine
patients (ten feet) on which we attempted to perform fusion of the
medial column using this bolt. Six feet had concurrent hindfoot fusion
using a retrograde nail. Satisfactory correction of deformity of
the medial column was achieved in all patients. The mean correction
of calcaneal pitch was from 6°
(-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively;
the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and
the mean talometatarsal angle on dorsoplantar radiographs from 27°
(1° to 48°) to 1° (1° to 3°). However, in all but two feet, at least one joint failed to fuse.
The bolt migrated in six feet, all of which showed progressive radiographic
osteolysis, which was considered to indicate loosening. Four of
these feet have undergone a revision procedure, with good radiological
evidence of fusion. The medial column bolt provided satisfactory correction
of the deformity but failed to provide adequate fixation for fusion
in CN deformities in the foot. In its present form, we cannot recommend the routine use of this
bolt. Cite this article:
The best method of managing a fracture of the
distal humerus in a frail low-demand patient with osteoporotic bone remains
controversial. Total elbow arthroplasty (TEA) has been recommended
for patients in whom open reduction and internal fixation (ORIF)
is not possible. Conservative methods of treatment, including the
‘bag of bones’ technique (acceptance of displacement of the bony
fragments and early mobilisation), are now rarely considered as
they are believed to give a poor functional result. We reviewed 40 elderly and low-demand patients (aged 50 to 93
years, 72% women) with a fracture of the distal humerus who had
been treated conservatively at our hospital between March 2008 and
December 2013, and assessed their short- and medium-term functional
outcome. In the short-term, the mean Broberg and Morrey score improved
from 42 points (poor; 23 to 80) at six weeks after injury to 67
points (fair; 40 to 88) by three months. In the medium-term, surviving patients (n = 20) had a mean Oxford
elbow score of 30 points (7 to 48) at four years and a mean Disabilities
of the Arm, Shoulder and Hand score of 38 points (0 to 75): 95%
reported a functional range of elbow flexion. The cumulative rate
of fracture union at one year was 53%. The mortality at five years approached
40%. Conservative management of a fracture of the distal humerus in
a low-demand patient only gives a modest functional result, but
avoids the substantial surgical risks associated with primary ORIF
or TEA. Cite this article:
Trauma and Orthopaedic care has been through
a rapid evolution over the past few decades. This Editorial discusses
some of the advances. Cite this article:
This review considers the surgical treatment
of displaced fractures involving the knee in elderly, osteoporotic patients.
The goals of treatment include pain control, early mobilisation,
avoidance of complications and minimising the need for further surgery.
Open reduction and internal fixation (ORIF) frequently results in
loss of reduction, which can result in post-traumatic arthritis
and the occasional conversion to total knee replacement (TKR). TKR
after failed internal fixation is challenging, with modest functional
outcomes and high complication rates. TKR undertaken as treatment
of the initial fracture has better results to late TKR, but does
not match the outcome of primary TKR without complications. Given
the relatively infrequent need for late TKR following failed fixation,
ORIF is the preferred management for most cases. Early TKR can be
considered for those patients with pre-existing arthritis, bicondylar
femoral fractures, those who would be unable to comply with weight-bearing restrictions,
or where a single definitive procedure is required.
We present an economic evaluation using data
from the Distal Radius Acute Fracture Fixation Trial (DRAFFT) to compare
the relative cost effectiveness of percutaneous Kirschner wire (K-wire)
fixation and volar locking-plate fixation for patients with dorsally-displaced
fractures of the distal radius. The cost effectiveness analysis (cost per quality-adjusted life
year; QALY) was derived from a multi-centre, two-arm, parallel group,
assessor-blind, randomised controlled trial which took place in
18 trauma centres in the United Kingdom. Data from 460 patients
were available for analysis, which includes both a National Health
Service cost perspective including costs of surgery, implants and
healthcare resource use over a 12-month period after surgery, and
a societal perspective, which includes the cost of time off work
and the need for additional private care. There was only a small difference in QALYs gained for patients
treated with locking-plate fixation over those treated with K-wires.
At a mean additional cost of £714 (95% confidence interval 588 to
865) per patient, locking-plate fixation presented an incremental
cost effectiveness ratio (ICER) of £89 322 per QALY within the first
12 months of treatment. Sensitivity analyses were undertaken to
assess the ICER of locking-plate fixation compared with K-wires.
These were greater than £30 000. Compared with locking-plate fixation, K-wire fixation is a ‘cost
saving’ intervention, with similar health benefits. Cite this article:
The Swansea Morriston Achilles Rupture Treatment
(SMART) programme was introduced in 2008. This paper summarises
the outcome of this programme. Patients with a rupture of the Achilles
tendon treated in our unit follow a comprehensive management protocol
that includes a dedicated Achilles clinic, ultrasound examination,
the use of functional orthoses, early weight-bearing, an accelerated
exercise regime and guidelines for return to work and sport. The
choice of conservative or surgical treatment was based on ultrasound
findings. The rate of re-rupture, the outcome using the Achilles Tendon
Total Rupture Score (ATRS) and the Achilles Tendon Repair Score,
(AS), and the complications were recorded. An elementary cost analysis
was also performed. Between 2008 and 2014 a total of 273 patients presented with
an acute rupture 211 of whom were managed conservatively and 62
had surgical repair. There were three
re-ruptures (1.1%). There were 215 men and 58 women with a mean
age of 46.5 years (20 to 86). Functional outcome was satisfactory.
Mean ATRS and AS at four months was 53.0
( The SMART programme resulted in a low rate of re-rupture, a satisfactory
outcome, a reduced rate of surgical intervention and a reduction
in healthcare costs. Cite this article:
The February 2015 Wrist &
Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures.
The February 2015 Shoulder &
Elbow Roundup360 looks at: Proximal Humerus fractures a comprehensive review, Predicting complications in shoulder ORIF, The Coronoid Revisited, Remplissage and bankart repair for Hill-Sach’s lesions, Diabetes and elbow arthroplasty, Salvage surgery for failed bankart repair, Sternoclavicular Joint Reconstruction, Steroids effective in the short-term for tennis elbow
The aim of this study was to assess the effect
of injecting genetically engineered chondrocytes expressing transforming
growth factor beta 1 (TGF-β1) into the knees of patients with osteoarthritis.
We assessed the resultant function, pain and quality of life. A total of 54 patients (20 men, 34 women) who had a mean age
of 58 years (50 to 66) were blinded and randomised (1:1) to receive
a single injection of the active treatment or a placebo. We assessed
post-treatment function, pain severity, physical function, quality
of life and the incidence of treatment-associated adverse events. Patients
were followed at four, 12 and 24 weeks after injection. At final follow-up the treatment group had a significantly greater
improvement in the mean International Knee Documentation Committee
score than the placebo group (16 points; -18 to 49, This technique may result in improved clinical outcomes, with
the aim of slowing the degenerative process, leading to improvements
in pain and function. However, imaging and direct observational
studies are needed to verify cartilage regeneration. Nevertheless,
this study provided a sufficient basis to proceed to further clinical testing. Cite this article:
The effect of timing of a manipulation under
anaesthetic (MUA) and injection of corticosteroid and local anaesthetic for
the treatment of frozen shoulder has attracted little attention
to date. All studies describe a period of conservative treatment
before proceeding to an MUA. Delay has been associated with a poorer
outcome. We present a retrospective review of a prospectively collected,
single-surgeon, consecutive series of 246 patients with a primary
frozen shoulder treated by MUA within four weeks of presentation.
The mean duration of presenting symptoms was 28 weeks (6 to 156),
and time to initial post-operative assessment was 26 days (5 to
126). The Oxford shoulder score (OSS) improved by a mean of 16 points
(Wilcoxon signed-ranks test,
p <
0.001) with a mean OSS at this time of 43 (7 to 48). Linear
regression analysis showed no correlation between the duration of
presenting symptoms and OSS at initial follow-up
(R2 <
0.001) or peri-operative change in OSS (R2 <
0.001)
or OSS at long-term follow-up
(R2 <
0.03). Further analysis at a mean of 42 months (8 to 127)
revealed a sustained improvement with a mean OSS of 44 (16 to 48). A good outcome follows an MUA and injection of corticosteroid
and local anaesthetic in patients with primary frozen shoulder,
independent of the duration of the presenting symptoms, and this
improvement is maintained in the long term.
Minimal clinically important differences (MCID)
in the scores of patient-reported outcome measures allow clinicians to
assess the outcome of intervention from the perspective of the patient.
There has been significant variation in their absolute values in
previous publications and a lack of consistency in their calculation. The purpose of this study was first, to establish whether these
values, following spinal surgery, vary depending on the surgical
intervention and their method of calculation and secondly, to assess
whether there is any correlation between the two external anchors
most frequently used to calculate the MCID. We carried out a retrospective analysis of prospectively gathered
data of adult patients who underwent elective spinal surgery between
1994 and 2009. A total of 244 patients were included. There were
125 men and 119 women with a mean age of 54 years (16 to 84); the
mean follow-up was 62 months (6 to 199) The MCID was calculated
using three previously published methods. Our results show that the value of the MCID varies considerably
with the operation and its method of calculation. There was good
correlation between the two external anchors. The global outcome
tool correlated significantly better. We conclude that consensus needs to be reached on the best method
of calculating the MCID. This then needs to be defined for each
spinal procedure. Using a blanket value for the MCID for all spinal
procedures should be avoided. Cite this article:
The aim of this study was to examine the rates
and potential risk factors for 28-day re-admission following a fracture
of the hip at a high-volume tertiary care hospital. We retrospectively
reviewed 467 consecutive patients with a fracture of the hip treated
in the course of one year. Causes and risk factors for unplanned
28-day re-admissions were examined using univariate and multivariate
analysis, including the difference in one-year mortality. A total
of 55 patients (11.8%) were re-admitted within 28 days of discharge.
The most common causes were pneumonia in 15 patients (27.3%), dehydration
and renal dysfunction in ten (18.2%) and deteriorating mobility
in ten (18.2%). A moderate correlation was found between chest infection
during the initial admission and subsequent re-admission with pneumonia
(r = 0.44, p <
0.001). A significantly higher mortality rate
at one year was seen in the re-admission group (41.8% (23 of 55)
The December 2014 Shoulder &
Elbow Roundup360 looks at: cuff tears and plexus injury; corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?
The February 2013 Foot &
Ankle Roundup360 looks at: replacement in osteonecrosis of the talus; ankle instability in athletes; long-term follow-up of lateral ankle ligament reconstruction; an operation for Stage II TPD; whether you should operate on Achilles tendon ruptures; Weil osteotomies and Freiberg’s disease; MRI scanning not sensitive for intra-articular lesions; and single-stage debridement and reconstruction in Charcot feet.