Aims

Current National Institute for Health and Clinical Excellence (NICE) guidance advises that MRI direct from the emergency department (ED) should be considered for suspected scaphoid fractures. This study reports the current management of suspected scaphoid fractures in the UK and assesses adherence with NICE guidance.

Aims. What represents clinically significant acetabular undercoverage in patients with symptomatic cam-type femoroacetabular impingement (FAI) remains controversial. The aim of this study was to examine the influence of the degree of acetabular coverage on the functional outcome of patients treated arthroscopically for cam-type FAI. Patients and Methods. Between October 2005 and June 2016, 88 patients (97 hips) underwent arthroscopic cam resection and concomitant labral debridement and/or refixation. There were 57 male and 31 female patients with a mean age of 31.0 years (17.0 to 48.5) and a mean body mass index (BMI) of 25.4 kg/m. 2. (18.9 to 34.9). We used the Hip2Norm, an object-oriented-platform program, to perform 3D analysis of hip joint morphology using 2D anteroposterior pelvic radiographs. The lateral centre-edge angle, anterior coverage, posterior coverage, total femoral coverage, and alpha angle were measured for each hip. The presence or absence of crossover sign, posterior wall sign, and the value of acetabular retroversion index were identified automatically by Hip2Norm. Patient-reported outcome scores were collected preoperatively and at final follow-up with the Hip Disability and Osteoarthritis Outcome Score (HOOS). Results. At a mean follow-up of 2.7 years (1 to 8, . sd. 1.6), all functional outcome scores significantly improved overall. Radiographically, only preoperative anterior coverage had a negative correlation with the improvement of the HOOS symptom subscale (r = -0.28, p = 0.005). No significant difference in relative change in HOOS subscale scores was found according to the presence or absence of radiographic signs of retroversion. Discussion. Our study demonstrated the anterior coverage as an important modifier influencing the functional outcome of arthroscopically treated cam-type FAI. Cite this article: Bone Joint J 2018;100-B:831–8

Aims

This study investigates the effects of intra-articular injection of adipose-derived mesenchymal stem cells (AdMSCs) and platelet-rich plasma (PRP) on lameness, pain, and quality of life in osteoarthritic canine patients.

Objectives. Computed tomography (CT) plays an important role in evaluating wear and periacetabular osteolysis (PAO) in total hip replacements. One concern with CT is the high radiation exposure since standard pelvic CT provides approximately 3.5 millisieverts (mSv) of radiation exposure, whereas a planar radiographic examination with three projections totals approximately 0.5 mSv. The objective of this study was to evaluate the lowest acceptable radiation dose for dual-energy CT (DECT) images when measuring wear and periacetabular osteolysis in uncemented metal components. Materials and Methods. A porcine pelvis with bilateral uncemented hip prostheses and with known linear wear and acetabular bone defects was examined in a third-generation multidetector DECT scanner. The examinations were performed with four different radiation levels both with and without iterative reconstruction techniques. From the high and low peak kilo voltage acquisitions, polychrmoatic images were created together with virtual monochromatic images of energies 100 kiloelectron volts (keV) and 150 keV. Results. We could assess wear and PAO while substantially lowering the effective radiation dose to 0.7 mSv for a total pelvic view with an accuracy of around 0.5 mm for linear wear and 2 mm to 3 mm for PAO. Conclusion. CT for detection of prosthetic wear and PAO could be used with clinically acceptable accuracy at a radiation exposure level equal to plain radiographic exposures. Cite this article: B. Sandgren, M. Skorpil, P. Nowik, H. Olivecrona, J. Crafoord, L. Weidenhielm, A. Persson. Assessment of wear and periacetabular osteolysis using dual energy computed tomography on a pig cadaver to identify the lowest acceptable radiation dose. Bone Joint Res 2016;5:307–313. DOI: 10.1302/2046-3758.57.2000566

Aims. Open reduction is required following failed conservative treatment of developmental dysplasia of the hip (DDH). The Ludloff medial approach is commonly used, but poor results have been reported, with rates of the development of avascular necrosis (AVN) varying between 8% and 54%. This retrospective cohort study evaluates the long-term radiographic and clinical outcome of dislocated hips treated using this approach. Patients and Methods. Children with a dislocated hip, younger than one year of age at the time of surgery, who were treated using a medial approach were eligible for the study. Radiographs were evaluated for the degree of dislocation and the presence of an ossific nucleus preoperatively, and for the degree of AVN and residual dysplasia at one and five years and at a mean of 12.7 years (4.6 to 20.8) postoperatively. Radiographic outcome was assessed using the Severin classification, after five years of age. Further surgical procedures were recorded. Functional outcome was assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) or the Hip Disability and Osteoarthritis Outcome Score (HOOS), depending on the patient’s age. Results. A total of 52 children (58 hips) were included. At the latest follow-up, 11 hips (19%) showed signs of AVN. Further surgery was undertaken in 13 hips (22%). A total of 13 hips had a poor radiological outcome with Severin type III or higher. Of these, the age at the time of surgery was significantly higher (p < 0.05) than in those with a good Severin type (I or II). The patient-reported outcomes were significantly worse (p < 0.05) in children with a poor Severin classification. Conclusion. This retrospective long-term follow-up study shows that one in five children with DDH who undergo open reduction using a medial surgical approach has poor clinical and/or radiological outcome. The poor outcome is not related to the presence of AVN (19%), but due to residual dysplasia. Cite this article: Bone Joint J 2018;100-B:822–7

Aims. Magnetically controlled growing rod (MCGR) systems use non-invasive spinal lengthening for the surgical treatment of early-onset scoliosis (EOS). The primary aim of this study was to evaluate the performance of these devices in the prevention of progression of the deformity. A secondary aim was to record the rate of complications. Patients and Methods. An observational study of 31 consecutive children with EOS, of whom 15 were male, who were treated between December 2011 and October 2017 was undertaken. Their mean age was 7.7 years (2 to 14). The mean follow-up was 47 months (24 to 69). Distractions were completed using the tailgating technique. The primary outcome measure was correction of the radiographic deformity. Secondary outcomes were growth, functional outcomes and complication rates. Results. The mean Cobb angle was 54° (14° to 91°) preoperatively and 37° (11° to 69°) at the latest follow-up (p < 0.001). The mean thoracic kyphosis (TK) was 45° (10° to 89°) preoperatively and 42° (9° to 84°) at the latest follow-up. The mean T1–S1 height increased from 287 mm (209 to 378) to 338 mm (240 to 427) (p < 0.001) and the mean sagittal balance reduced from 68 mm (-76 to 1470) preoperatively to 18 mm (-32 to 166) at the latest follow-up. The mean coronal balance was 3 mm (-336 to 64) preoperatively and 8 mm (-144 to 64) at the latest follow-up. The mean increase in weight and sitting and standing height at the latest follow-up was 45%, 10% and 15%, respectively. The mean Activity Scale for Kids (ASKp) scores increased in all domains, with only personal care and standing skills being significant at the latest follow-up (p = 0.02, p = 0.03). The improvements in Cobb angle, TK and T1-S1 heights were not related to gender, the aetiology of the EOS, or whether the procedure was primary or conversion from a conventional growing rod system. A total of 21 children developed 23 complications at a rate of 0.23 per patient per year. Seven developed MCGR-specific complications. Complications developed at a mean of 38 months (3 to 67) after the initial surgery and required 22 further procedures. Children who developed a complication were more likely to be younger, have syndromic EOS, and have a single-rod construct (6.9 versus 9.3 years, p = 0.034). Conclusion. The progression of EOS can be controlled using MCGRs allowing growth and improved function. Younger and syndromic children are more likely to develop complications following surgery. Cite this article: Bone Joint J 2018;100-B:1187–1200

Aims. There are two techniques widely used to determine the rotational alignment of the components in total knee arthroplasty (TKA); gap balancing (GB) and measured resection (MR). Which technique is the best remains controversial. We aimed to investigate this in a systematic review and meta-analysis. Materials and Methods. In accordance with the methods of Cochrane, databases were searched for all randomised controlled trials in the literature between January 1986 and June 2015 comparing radiographic and clinical outcomes between the use of these two tecniques. Meta-analysis involved the use of the Revman5.3 software provided by Cochrane collaboration. Results. A total of 1464 papers were initially identified, and after the application of rigourous inclusion and exclusion critera, eight were included in the study. In total they inolved 980 TKAs. The meta-analysis showed that GB techniques resulted in statistically significant improvements in the restoration of mechanical and rotational alignment and mean Knee Society Scores and Knee Society Function scores two years post-operatively, but resulted in greater elevation of the position of the joint line. There is no significant difference in the other radiographic data. Conclusion. This study suggests that GB may provide better radiographic and clinical outcomes than MR when used to determine mechanical rotation in TKAs. Cite this article: Bone Joint J 2017;99-B:151–8

Aims. To investigate the longevity of uncemented fixation of a femoral component in total hip arthroplasty (THA) in patients with Dorr type C proximal femoral morphology. Patients and Methods. A total of 350 consecutive uncemented THA in 320 patients were performed between 1983 and 1987, by a single surgeon using the Taperloc femoral component. The 63 patients (68 hips) with Dorr type C proximal femoral morphology were the focus of this review. The mean age of the patients was 69 years (24 to 88) and mean follow-up was 16.6 years (ten to 29). Survival analysis included eight patients (eight hips) who died without undergoing revision surgery prior to obtaining ten years follow-up. All 55 surviving patients (60 hips) were available for clinical assessment and radiographic review. As a comparator group, the survival and implant fixation in the remaining 282 THAs (257 patients) with Dorr type A and B morphology were evaluated. The mean age of these patients was 52 years (20 to 82). Results. In the Dorr C patient group the mean Harris hip score improved from 51 points (21 to 69 points) pre-operatively to 89 (74 to 100) at final follow-up. No femoral component was loose by radiological criteria and osteolysis was only identified around two stems (3.3%). There was one revision (1.6%) of a well-fixed femoral component for sepsis at 11 years. The survival of the Taperloc femoral component at 20 years with revision for any reason as the endpoint was 98% (95% confidence interval; 87 to 99). A total of ten (3.5%) of the Dorr A and B patient group of 282 THAs required revision surgery. Only one (0.4%) for aseptic loosening. A total of two hips (1%) were loose by radiographic criteria and osteolysis occurred around 12 hips (4%). Conclusion. This study demonstrates that excellent fixation can be achieved using the Taperloc stem in patients with Dorr type A and B, and Dorr type C bone. Take home message: The Taperloc stem demonstrated equivalent results in Dorr type A and B and Dorr type C bone. Cite this article: Bone Joint J 2016;98-B:595–600

Objectives. The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method. Methods. In this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who underwent 19 Ilizarov tibial lengthenings were retrospectively matched to the LON group. Results. The mean external fixation time for the LON group was 2.6 months and for the matched case group was 7.6 months. The mean lengthening amounts for the LON and the matched case groups were 5.2 cm and 4.9 cm, respectively. The radiographic consolidation time in the LON group was 6.6 months and in the matched case group 7.6 months. Using a clinical and radiographic outcome score that was designed for this study, the outcome was determined to be excellent in 17 and good in two patients for the LON group. The outcome was excellent in 14 and good in five patients in the matched case group. The LON group had increased blood loss and increased cost. The LON group had four deep infections; the matched case group did not have any deep infections. Conclusions. The outcomes in the LON group were comparable with the outcomes in the matched case group. The LON group had a shorter external fixation time but experienced increased blood loss, increased cost, and four cases of deep infection. The advantage of reducing external fixation treatment time may outweigh these disadvantages in patients who have a healthy soft-tissue envelope. Cite this article: J. E. Herzenberg. Tibial lengthening over intramedullary nails: A matched case comparison with Ilizarov tibial lengthening. Bone Joint Res 2016;5:1–10. doi: 10.1302/2046-3758.51.2000577

Aims. The aims of this study were to describe the course of non-operatively managed, bilateral Perthes’ disease, and to determine specific prognostic factors for the radiographic and clinical outcome. . Patients and Methods. We identified 40 children with a mean age of 5.9 years (1.8 to 13.5), who were managed non-operatively for bilateral Perthes’ disease from our prospective, multicentre study of this condition, which included all children in Norway who were diagnosed with Perthes’ disease in the five-year period between 1996 and 2000. All children were followed up for five years. . The hips were classified according to the Catterall classification. A modified three-group Stulberg classification was used as an outcome measure, with a spherical femoral head being defined as a good outcome, an oval head as fair, and a flat femoral head as a poor outcome. . Results. Concurrent, simultaneous bilateral Perthes’ disease was seen in 23 children and 17 had the sequential onset of bilateral disease. The mean delay in onset for the second hip in the latter group was 1.9 years (0.3 to 5.5). . The five-year radiographic outcome was good in 30 (39%), fair in 25 (33%) and poor in 21 (28%) of the hips. The strongest predictors of poor outcome were > 50% necrosis of the femoral head, with odds ratio (OR) 19.6, and age at diagnosis > 6 years (OR 3.3). Other risk factors for poor outcome were the timing of the onset of disease, where children with the sequential onset of bilateral disease had a higher risk than those with the concurrent onset of bilateral disease (p = 0.021, chi-squared test). . Following a diagnosis of Perthes’ disease in one hip, there was a 5% chance of developing it in the contralateral hip. . Conclusion. These results imply that we need to distinguish between children with concurrent onset and those with sequential onset of bilateral Perthes’ disease, as the outcomes may be different. This has not been previously described. Children with concurrent onset of bilateral disease had a similar outcome to our previous series of those with unilateral disease, whereas children with sequential onset of bilateral disease had a worse prognosis. The increased risk of developing Perthes’ disease in the contralateral hip in those with unilateral disease is important information for the child and parents. . Cite this article: Bone Joint J 2016;98-B:569–75

Aims. The classical longitudinal incision used for the direct anterior approach (DAA) to the hip does not follow the tension lines of the skin and can lead to impaired wound healing and poor cosmesis. The purpose of this retrospective study was to determine the satisfaction with the scar, and functional and radiographic outcomes comparing the classic longitudinal incision with a modified skin crease ‘bikini’ when the DAA is used for total hip arthroplasty (THA). Patients and Methods. A total of 964 patients (51% female; 59% longitudinal, 41% ‘bikini’) completed a follow-up questionnaire between two and four years postoperatively, including the Oxford Hip Score (OHS), the University of North Carolina ‘4P’ scar scale (UNC4P) and two items for assessing the aesthetic appearance of the scar and symptoms of numbness. The positioning of the components, rates of heterotopic ossification (HO) and rates of revision were assessed. Results. The mean OHS was similar in both groups (p = 0.41). The mean UNC4P total score was slightly better (p = 0.01) and the proportion of patients who were very satisfied with the cosmetic aspects of the scar was higher in the ‘bikini’ group (p < 0.001). The proportion of patients reporting numbness in the scar was higher in the longitudinal group (14.5% vs 7.5%, respectively, p < 0.001). The abduction angle of the acetabular component, the position of the stem and rates of HO did not differ between the groups. There were no differences in the revision rates of both groups, being 2.3% in the longitudinal and 1.5% in the ‘bikini’ group (p = 0.911). Conclusion. We found that a short oblique ‘bikini’ skin crease incision is safe when used for the DAA at THA, without compromising the positioning of the components or increasing the rate of lateral femoral cutaneous nerve dysaesthesia. Although it leads to a superior scar satisfaction, as it is less extensile, it should be used after having gained experience with the classic longitudinal incision. Cite this article: Bone Joint J 2018;100-B:853–61

Aims

The aim of this study was to assess arthritis of the basal joint of the thumb quantitatively using bone single-photon emission CT/CT (SPECT/CT) and evaluate its relationship with patients’ pain and function.

Objectives. Normal sagittal spine-pelvis-lower extremity alignment is crucial in humans for maintaining an ergonomic upright standing posture, and pathogenesis in any segment leads to poor balance. The present study aimed to investigate how this sagittal alignment can be affected by severe knee osteoarthritis (KOA), and whether associated changes corresponded with symptoms of lower back pain (LBP) in this patient population. Methods. Lateral radiograph films in an upright standing position were obtained from 59 patients with severe KOA and 58 asymptomatic controls free from KOA. Sagittal alignment of the spine, pelvis, hip and proximal femur was quantified by measuring several radiographic parameters. Global balance was accessed according to the relative position of the C7 plumb line to the sacrum and femoral heads. The presence of chronic LBP was documented. Comparisons between the two groups were carried by independent samples t-tests or chi-squared test. Results. Patients with severe KOA showed significant backward femoral inclination (FI), hip flexion, forward spinal inclination, and higher prevalence of global imbalance (27.1% versus 3.4%, p < 0.001) compared with controls. In addition, patients with FI of 10° (n = 23) showed reduced lumbar lordosis and significant forward spinal inclination compared with controls, whereas those with FI > 10° (n = 36) presented with significant pelvic anteversion and hip flexion. A total of 39 patients with KOA (66.1%) suffered from LBP. There was no significant difference in sagittal alignment between KOA patients with and without LBP. Conclusions. The sagittal alignment of spine-pelvis-lower extremity axis was significantly influenced by severe KOA. The lumbar spine served as the primary source of compensation, while hip flexion and pelvic anteversion increased for further compensation. Changes in sagittal alignment may not be involved in the pathogenesis of LBP in this patient population. Cite this article: W. J. Wang, F. Liu, Y.W. Zhu, M.H. Sun, Y. Qiu, W. J. Weng. Sagittal alignment of the spine-pelvis-lower extremity axis in patients with severe knee osteoarthritis: A radiographic study. Bone Joint Res 2016;5:198–205. DOI:10.1302/2046-3758.55.2000538

Aims

One-stage revision hip arthroplasty for periprosthetic joint infection (PJI) has several advantages; however, resection of the proximal femur might be necessary to achieve higher success rates. We investigated the risk factors for resection and re-revisions, and assessed complications and subsequent re-revisions.

Aims. This study compared multiple sclerosis (MS) patients who underwent primary total hip arthroplasty (THA) with a matched cohort. Specifically, we evaluated: 1) implant survivorship; 2) functional outcomes (modified Harris Hip Scores (mHHS), Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR), and modified Multiple Sclerosis Impact Scale (mMSIS) scores (with the MS cohort also evaluated based on the disease phenotype)); 3) physical therapy duration and return to function; 4) radiographic outcomes; and 5) complications. Patients and Methods. We reviewed our institution’s database to identify MS patients who underwent THA between January 2008 and June 2016. A total of 34 MS patients (41 hips) were matched in a 1:2 ratio to a cohort of THA patients who did not have MS, based on age, body mass index (BMI), and Charlson/Deyo score. Patient records were reviewed for complications, and their functional outcomes and radiographs were reviewed at their most recent follow-up. Results. Compared with the matched cohort, MS patients had lower all-cause implant survivorship at eight years (91.5% (95% confidence interval (CI) 82.7 to 100) vs 98.7% (95% CI 96.2 to 100)) (p = 0.033), lower mHHS scores (66 vs 80, p < 0.001), and HOOS JR scores (79 vs 88, p = 0.009). Multiple sclerosis patients also required more physiotherapy (five weeks vs three weeks, p = 0.002) and took longer to return to baseline (seven weeks vs five weeks, p = 0.010) than the matched cohort. Furthermore, MS patients had more complications than the non-MS patients (six vs zero, p < 0.001). The worse outcomes of the MS group can potentially be explained by predisposition of these patients to mechanical complications and progression of their disease during the period of this study, as demonstrated by worsening of the mMSIS scores (2.9 vs 3.4; p = 0.008). Conclusion. MS patients had lower implant survivorship, lower functional outcome scores, and increased complication rates; in addition, MS patients took longer to return to their baseline functional level after THA. Cite this article: Bone Joint J 2018;100-B:875–81

Aims

The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking.

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: Bone Joint J 2015; 97-B:603–610

Aims

In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF.