The benefit of arthroscopy of the hip in the
treatment of femoroacetabular impingement (FAI) in terms of quality
of life (QoL) has not been reported. We prospectively collected
data on 612 patients (257 women (42%) and 355 men (58%)) with a
mean age at the time of surgery of 36.7 years (14 to 75) who underwent
arthroscopy of the hip for FAI under the care of a single surgeon.
The minimum follow-up was one year (mean 3.2 years (1 to 7)). The
responses to the modified Harris hip score were translated using
the Rosser Index Matrix in order to provide a QoL score. The mean
QoL score increased from 0.946 (-1.486 to 0.995) to 0.974 (0.7 to
1) at one year after surgery (p <
0.001). The mean QoL score
in men was significantly higher than in women, both before and one
year after surgery (both p <
0.001). However, the mean change
in the QoL score was not statistically different between men and
women (0.02 (-0.21 to 0.27) and 0.04 (-0.16 to 0.87), respectively;
p = 0.12). Linear regression analysis revealed that the significant predictors
of a change in QoL score were pre-operative QoL score (p <
0.001)
and gender (p = 0.04). The lower the pre-operative score, the higher
the gain in QoL post-operatively (ρ = -0.66; p <
0.001). One
year after surgery the QoL scores in the 612 patients had improved
in 469 (76.6%), remained unchanged in 88 (14.4%) and had deteriorated
in 55 (9.0%).
The current indications for functional restoration
of extension of the knee following quadriceps resection or loss require
reappraisal. The contribution of pedicled and free functional muscle
transfer is likely to be over-emphasised in many studies, with good
functional outcomes predominantly reported only in the context of
cases with residual quadriceps function. In cases with total quadriceps
resection or loss, all forms of reconstruction perform poorly. Furthermore,
in smaller resections with loss of two or fewer components of the
quadriceps, minimal impairment of function occurs in the absence
of functional reconstruction, suggesting that functional restoration
may not be warranted. Thus there is a paradox in the current approach
to quadriceps reconstruction, in that small resections are likely
to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and
rationale for reconstructing functional extension of the knee after
quadriceps resection or loss. A classification based on current
evidence is suggested that emphasises more clearly the indications
and rationale for functional transfers.
We studied bone-tendon healing using immunohistochemical methods in a rabbit model. Reconstruction of the anterior cruciate ligament was undertaken using semitendinosus tendon in 20 rabbits. Immunohistochemical evaluations were performed at one, two, four and eight weeks after the operation. The expression of CD31, RAM-11, VEGF, b-FGF, S-100 protein and collagen I, II and III in the bone-tendon interface was very similar to that in the endochondral ossification. Some of the type-III collagen in the outer layer of the graft, which was deposited at a very early phase after the operation, was believed to have matured into Sharpey-like fibres. However, remodelling of the tendon grafted into the bone tunnel was significantly delayed when compared with this ossification process. To promote healing, we believe that it is necessary to accelerate remodelling of the tendon, simultaneously with the augmentation of the ossification.
We reviewed the outcome of arthroscopic stabilisation of anterior glenohumeral instability in young adults using the transglenoid suture technique. A questionnaire was sent to 455 consecutive patients who had undergone this procedure between 1992 and 2000. Of these, 312 patients (68.5%) with 313 affected shoulders and a mean age of 20 years (18 to 28) responded. Outcome was determined by the number of re-dislocations or, in patients who had not re-dislocated, by the disease-specific quality of life as measured by the Western Ontario Shoulder Instability index. During a mean follow-up of 6.4 years (1 to 14), 177 patients (56%) sustained a re-dislocation, including 70 who required a further operation. In 136 patients (44%) who reported neither re-dislocation nor re-operation, the index scores were good (median 90.4%; 28.9% to 100%). No significant peri- or pre-operative predictors of re-dislocation or re-operation were found. We found a high rate of re-dislocation after transglenoid suture repair in young, physically active patients.
We retrospectively reviewed the operative treatment carried out between 1988 and 1994 of eight patients with habitual patellar dislocation. In four the condition was bilateral. All patients had recurrent dislocation with severe functional disability. The surgical technique involved distal advancement of the patella by complete mobilisation of the patellar tendon, lateral release and advancement of vastus medialis obliquus. The long-term results were assessed radiologically, clinically and functionally using the Lysholm knee score, by an independent observer. The mean age at operation was 10.3 years (7 to 14) with a mean follow-up of 13.5 years (11 to 16). One patient required revision. At the latest follow-up, all patellae were stable and knees functional with a mean Lysholm knee score of 98 points (95 to 100). In those aged younger than ten years at operation there was a statistically significant improvement in the sulcus angle at the latest follow-up (Student’s This technique offers a satisfactory treatment for the immature patient presenting with habitual patellar dislocation associated with patella alta. If performed early, we believe that remodelling of the shallow trochlea may occur, adding intrinsic patellofemoral stability.
We retrospectively reviewed the outcomes of 33
consecutive patients who had undergone an extra-articular, total or
partial scapulectomy for a malignant tumour of the shoulder girdle
between 1 July 2001 and 30 September 2013. Of these, 26 had tumours
which originated in the scapula or the adjacent soft tissue and
underwent a classic Tikhoff–Linberg procedure, while seven with
tumours arising from the proximal humerus were treated with a modified
Tikhoff-Linberg operation. We used a Ligament Advanced Reinforcement
System for soft-tissue reconstruction in nine patients, but not
in the other 24. The mean Musculoskeletal Tumor Society score (MSTS) was 17.6
(95% confidence interval (CI) 15.9 to 19.4); 17.6 (95% CI 15.5 to
19.6) after the classic Tikhoff–Linberg procedure and 18.1 (95%
CI 13.8 to 22.3) after the modified Tikhoff–Linberg procedure. Patients
who had undergone a LARS soft-tissue reconstruction had a mean score
of 18.6 (95% (CI) 13.9 to 22.4) compared with 17.2 (95% CI 15.5
to 19.0) for those who did not. The Tikhoff–Linberg procedure is a useful method for wide resection
of a malignant tumour of the shoulder girdle which helps to preserve
hand and elbow function. The method of soft-tissue reconstruction
has no effect on functional outcome. Cite this article:
Labral tears are commonly associated with femoroacetabular impingement. We reviewed 151 patients (156 hips) with femoroacetabular impingement and labral tears who had been treated arthroscopically. These were subdivided into those who had undergone a labral repair (group 1) and those who had undergone resection of the labrum (group 2). In order to ensure the groups were suitably matched for comparison of treatment effects, patients with advanced degenerative changes (Tönnis grade >
2, lateral sourcil height <
2 mm and Outerbridge grade 4 changes in the weight-bearing area of the femoral head) were excluded, leaving 96 patients (101 hips) in the study. At a mean follow-up of 2.44 years (2 to 4), the mean modified Harris hip score in the labral repair group (group 1, 69 hips) improved from 60.2 (24 to 85) pre-operatively to 93.6 (55 to 100), and in the labral resection group (group 2, 32 hips) from 62.8 (29 to 96) pre-operatively to 88.8 (35 to 100). The mean modified Harris hip score in the labral repair group was 7.3 points greater than in the resection group (p = 0.036, 95% confidence interval 0.51 to 14.09). Labral detachments were found more frequently in the labral repair group and labral flap tears in the resection group. No patient in our study group required a subsequent hip replacement during the period of follow-up. This study shows that patients without advanced degenerative changes in the hip can achieve significant improvement in their symptoms after arthroscopic treatment of femoroacetabular impingement. Where appropriate, labral repair provides a superior result to labral resection.
Tendinopathy is a debilitating musculoskeletal
condition which can cause significant pain and lead to complete rupture
of the tendon, which often requires surgical repair. Due in part
to the large spectrum of tendon pathologies, these disorders continue
to be a clinical challenge. Animal models are often used in this
field of research as they offer an attractive framework to examine
the cascade of processes that occur throughout both tendon pathology and
repair. This review discusses the structural, mechanical, and biological
changes that occur throughout tendon pathology in animal models,
as well as strategies for the improvement of tendon healing. Cite this article:
Bicondylar tibial plateau fractures result from
high-energy injuries. Fractures of the tibial plateau can involve
the tibial tubercle, which represents a disruption to the extensor
mechanism and logically must be stabilised. The purpose of this
study was to identify the incidence of an independent tibial tubercle
fracture in bicondylar tibial plateau fractures, and to report management
strategies and potential complications. We retrospectively reviewed
a prospectively collected orthopaedic trauma database for the period
January 2003 to December 2008, and identified 392 bicondylar fractures
of the tibial plateau, in which 85 tibial tubercle fractures (21.6%)
were identified in 84 patients. There were 60 men and 24 women in
our study group, with a mean age of 45.4 years (18 to 71). In 84 fractures
open reduction and internal fixation was undertaken, either with
screws alone (23 patients) or with a plate and screws (61 patients).
The remaining patient was treated non-operatively. In all, 52 fractures
were available for clinical and radiological assessment at a mean
follow-up of 58.5 weeks (24 to 94). All fractures of the tibial
tubercle united, but 24 of 54 fractures (46%) required a secondary
procedure for their tibial plateau fracture. Four patients reported
pain arising from prominent tubercle plates and screws, which in
one patient required removal. Tibial tubercle fractures occurred
in over one-fifth of the bicondylar tibial plateau fractures in
our series. Fixation is necessary and can be reliably performed
with screws alone or with a screw and plate, which restores the
extensor mechanism and facilitates early knee flexion. Cite this article:
We have compared three different methods of treating
symptomatic non-traumatic tears of the supraspinatus tendon in patients
above 55 years of age. A total of 180 shoulders (173 patients) with
supraspinatus tendon tears were randomly allocated into one of three
groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and
physiotherapy (group 2) and rotator cuff repair, acromioplasty and
physiotherapy (group 3). The Constant score was assessed and followed
up by an independent observer pre-operatively and at three, six
and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one
year (follow-up rate of 92.8%). There were 55 shoulders in group
1 (24 in males and 31 in females, mean age 65 years (55 to 79)),
57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79))
and 55 shoulders in group 3 (26 male and 29 female, mean age 65
years (55 to 81)). There were no between-group differences in the
Constant score at final follow-up: 74.1 ( 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.
Subtalar dislocation is a significant injury characterised by late complications, including subtalar arthritis. We describe a rare case of irreducible posterior subtalar dislocation due to incarceration of a fracture of the anterior process of the calcaneum in the subtalar joint, and discuss appropriate management.
Patients with transfemoral amputation (TFA) often
experience problems related to the use of socket-suspended prostheses.
The clinical development of osseointegrated percutaneous prostheses
for patients with a TFA started in 1990, based on the long-term
successful results of osseointegrated dental implants. Between1999 and 2007, 51 patients with 55 TFAs were consecutively
enrolled in a prospective, single-centre non-randomised study and
followed for two years. The indication for amputation was trauma
in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical
procedure was used to introduce a percutaneous implant to which
an external amputation prosthesis was attached. The assessment of
outcome included the use of two self-report questionnaires, the
Questionnaire for Persons with a Transfemoral Amputation (Q-TFA)
and the Short-Form (SF)-36. The cumulative survival at two years’ follow-up was 92%. The
Q-TFA showed improved prosthetic use, mobility, global situation
and fewer problems (all p <
0.001). The physical function SF-36
scores were also improved (p <
0.001). Superficial infection
was the most frequent complication, occurring 41 times in 28 patients
(rate of infection 54.9%). Most were treated effectively with oral
antibiotics. The implant was removed in four patients because of loosening
(three aseptic, one infection). Osseointegrated percutaneous implants constitute a novel form
of treatment for patients with TFA. The high cumulative survival
rate at two years (92%) combined with enhanced prosthetic use and
mobility, fewer problems and improved quality of life, supports
the ‘revolutionary change’ that patients with TFA have reported
following treatment with osseointegrated percutaneous prostheses. Cite this article:
This review discusses the pathogenesis and surgical treatment of tears of the rotator cuff.
The aim of this pilot study was to evaluate the accuracy of two different methods of navigated retrograde drilling of talar lesions. Artificial osteochondral talar lesions were created in 14 cadaver lower limbs. Two methods of navigated drilling were evaluated by one examiner. Navigated Iso-C3D was used in seven cadavers and 2D fluoroscopy-based navigation in the remaining seven. Of 14 talar lesions, 12 were successfully targeted by navigated drilling. In both cases of inaccurate targeting the 2D fluoroscopy-based navigation was used, missing lesions by 3 mm and 5 mm, respectively. The mean radiation time was increased using Iso-C3D navigation (23 s; 22 to 24) compared with 2D fluoroscopy-based navigation (14 s, 11 to 17).
Transarticular screw fixation with autograft
is an established procedure for the surgical treatment of atlantoaxial instability.
Removal of the posterior arch of C1 may affect the rate of fusion.
This study assessed the rate of atlantoaxial fusion using transarticular
screws with or without removal of the posterior arch of C1. We reviewed
30 consecutive patients who underwent atlantoaxial fusion with a
minimum follow-up of two years. In 25 patients (group A) the posterior
arch of C1 was not excised (group A) and in five it was (group B).
Fusion was assessed on static and dynamic radiographs. In selected
patients CT imaging was also used to assess fusion and the position
of the screws. There were 15 men and 15 women with a mean age of
51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6).
Stable union with a solid fusion or a stable fibrous union was achieved
in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid
fusion, four (16%) a stable fibrous union and one (4%) a nonunion.
In Group B, stable union was achieved in all patients, three having
a solid fusion and two a stable fibrous union. There was no statistically
significant difference between the status of fusion in the two groups.
Complications were noted in 12 patients (40%); these were mainly
related to the screws, and included malpositioning and breakage.
The presence of an intact or removed posterior arch of C1 did not
affect the rate of fusion in patients with atlantoaxial instability
undergoing C1/C2 fusion using transarticular screws and autograft. Cite this article:
Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again. The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply.
We describe the clinical outcome of a technique of surgical augmentation of chronic massive tears of the rotator cuff using a polyester ligament (Dacron) in 21 symptomatic patients (14 men, seven women) with a mean age of 66.5 years (55.0 to 85.0). All patients had MRI and arthroscopic evidence of chronic massive tears. The clinical outcome was assessed using the Constant and Murley and patient satisfaction scores at a mean follow-up of 36 months (30 to 46). The polyester ligament (500 mm × 10 mm) was passed into the joint via the portal of Neviaser, medial to the tear through healthy cuff. The two ends of the ligament holding the cuff were passed through tunnels made in the proximal humerus at the footprint of the insertion of the cuff. The ligament was tied with a triple knot over the humeral cortex. All the patients remained free from pain (p <
0.001) with improvement in function (p <
0.001) and range of movement (p <
0.001). The mean pre-operative and post-operative Constant scores were 46.7 (39.0 to 61.0) and 85.4 (52.0 to 96.0), respectively (p <
0.001). The mean patient satisfaction score was 90%. There were two failures, one due to a ruptured ligament after one year and the other due to deep-seated infection. The MR scan at the final follow-up confirmed intact and thickened bands in 15 of 17 patients. This technique of augmentation gives consistent relief from pain with improved shoulder movement in patients with symptomatic massive tears of the rotator cuff.
Because of the contradictory body of evidence related to the
potential benefits of helical blades in trochanteric fracture fixation,
we studied the effect of bone compaction resulting from the insertion
of a proximal femoral nail anti-rotation (PFNA). We developed a subject-specific computational model of a trochanteric
fracture (31-A2 in the AO classification) with lack of medial support
and varied the bone density to account for variability in bone properties
among hip fracture patients.Objectives
Methods