We compared the length of hospitalisation, rate
of infection, dislocation of the hip and revision, and mortality following
primary hip and knee arthroplasty for osteoarthritis in patients
with Alzheimer’s disease (n = 1064) and a matched control group
(n = 3192). The data were collected from nationwide Finnish health
registers. Patients with Alzheimer’s disease had a longer peri-operative
hospitalisation (median 13 days Cite this article:
We identified a group of patients from the Swedish
Arthroplasty Register who reported no relief of pain or worse pain
one year after a total knee replacement (TKR). A total of two different
patient-reported pain scores were used during this process. We then
evaluated how the instruments used to measure pain affected the
number of patients who reported no relief of pain or worse pain,
and the relative effect of potential risk factors. Between 2008 and 2010, 2883 TKRs were performed for osteoarthritis
in two Swedish arthroplasty units. After applying exclusion criteria,
2123 primary TKRs (2123 patients) were included in the study. The
Knee injury and Osteoarthritis Outcome Score (KOOS) and a Visual
Analogue Scale (VAS) for knee pain were used to assess patients pre-operatively
and one year post-operatively. Only 50 of the 220 patients (23%) who reported no pain relief
on either the KOOS pain subscale or the VAS for knee pain did so
with both of these instruments. Patients who reported no pain relief
on either measure tended to have less pain pre-operatively but a
higher degree of anxiety. Charnley category C was a predictor for
not gaining pain relief as measured on a VAS for knee pain. The number of patients who are not relieved of pain after a TKR
differs considerably depending on the instrument used to measure
pain. Cite this article:
This study assessed the effect of concomitant
back pain on the Oxford knee score (OKS), Short-Form (SF)-12 and patient
satisfaction after total knee replacement (TKR). It involved a prospectively
compiled database of demographics and outcome scores for 2392 patients
undergoing primary TKR, of whom 829 patients (35%) reported back
pain. Compared with those patients without back pain, those with
back pain were more likely to be female (odds ratio (OR) 1.5 (95%
confidence interval (CI) 1.3 to 1.8)), have a greater level of comorbidity,
a worse pre-operative OKS (2.3 points (95% CI 1.7 to 3.0)) and worse
SF-12 physical (2.0 points (95% CI 1.4 to 2.6)) and mental (3.3
points (95% CI 2.3 to 4.3)) components. One year post-operatively, those with back pain had significantly
worse outcome scores than those without with a mean difference in
the OKS of 5 points (95% CI 3.8 to 5.4), in the SF-12 physical component
of 6 points (95% CI 5.4 to 7.1) and in the mental component of
4 points (95% CI 3.1 to 4.9). Patients with back pain were less
likely to be satisfied (OR 0.62, 95% CI 0.5 to 0.78). After adjusting for confounding variables, concomitant back pain
was an independent predictor of a worse post-operative OKS, and
of dissatisfaction. Clinicians should be aware that patients suffering
concomitant back pain pre-operatively are at an increased risk of
being dissatisfied post-operatively. Cite this article:
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:
Although vertebroplasty is very effective for relieving acute pain from an osteoporotic vertebral compression fracture, not all patients who undergo vertebroplasty receive the same degree of benefit from the procedure. In order to identify the ideal candidate for vertebroplasty, pre-operative prognostic demographic or clinico-radiological factors need to be identified. The objective of this study was to identify the pre-operative prognostic factors related to the effect of vertebroplasty on acute pain control using a cohort of surgically and non-surgically managed patients. Patients with single-level acute osteoporotic vertebral compression fracture at thoracolumbar junction (T10 to L2) were followed. If the patients were not satisfied with acute pain reduction after a three-week conservative treatment, vertebroplasty was recommended. Pain assessment was carried out at the time of diagnosis, as well as three, four, six, and 12 weeks after the diagnosis. The effect of vertebroplasty, compared with conservative treatment, on back pain (visual analogue score, VAS) was analysed with the use of analysis-of-covariance models that adjusted for pre-operative VAS scores.Objectives
Patients and Methods
Hip fracture is a common injury associated with
high mortality, long-term disability and huge socio-economic burden.
Yet there has been relatively little research into best treatment,
and evidence that has been generated has often been criticised for
its poor quality. Here, we discuss the advances made towards overcoming
these criticisms and the future directions for hip fracture research:
how co-ordinating existing national infrastructures and use of now
established clinical research networks will likely go some way towards
overcoming the practical and financial challenges of conducting
large trials. We highlight the importance of large collaborative
pragmatic trials to inform decision/policy makers and the progress
made towards reaching a consensus on a core outcome set to facilitate data
pooling for evidence synthesis and meta-analysis. These advances and future directions are a priority in order
to establish the high-quality evidence base required for this important
group of patients. Cite this article:
Early and accurate prediction of hospital length-of-stay
(LOS) in patients undergoing knee replacement is important for economic
and operational reasons. Few studies have systematically developed
a multivariable model to predict LOS. We performed a retrospective
cohort study of 1609 patients aged ≥ 50 years who underwent elective,
primary total or unicompartmental knee replacements. Pre-operative
candidate predictors included patient demographics, knee function,
self-reported measures, surgical factors and discharge plans. In
order to develop the model, multivariable regression with bootstrap
internal validation was used. The median LOS for the sample was
four days (interquartile range 4 to 5). Statistically significant
predictors of longer stay included older age, greater number of comorbidities,
less knee flexion range of movement, frequent feelings of being
down and depressed, greater walking aid support required, total
( Cite this article:
The objective of this study was to validate the
efficacy of Takeuchi classification for lateral hinge fractures
(LHFs) in open wedge high tibial osteotomy (OWHTO). In all 74 osteoarthritic
knees (58 females, 16 males; mean age 62.9 years, standard deviation
7.5, 42 to 77) were treated with OWHTO using a TomoFix plate. The
knees were divided into non-fracture (59 knees) and LHF (15 knees)
groups, and the LHF group was further divided into Takeuchi types
I, II, and III (seven, two, and six knees, respectively). The outcomes
were assessed pre-operatively and one year after OWHTO. Pre-operative
characteristics (age, gender and body mass index) showed no significant
difference between the two groups. The mean Japanese Orthopaedic
Association score was significantly improved one year after operation
regardless of the presence or absence of LHF (p = 0.0015, p <
0.001, respectively). However, six of seven type I cases had no
LHF-related complications; both type II cases had delayed union;
and of six type III cases, two had delayed union with correction
loss and one had overcorrection. These results suggest that Takeuchi
type II and III LHFs are structurally unstable compared with type
I. Cite this article:
The June 2015 Children’s orthopaedics Roundup360 looks at: ACL reconstruction in paediatric knees; Hips, slips and cams; The adolescent clavicle; 3D fluoroscopy in DDH?; The psychiatric aspects of hip pain in adolescents; Adolescent bunions: dealer’s choice?; Medial epicondylar fractures revisited
The aims of this retrospective study were to
compare the mid-term outcomes following revision total knee replacement
(TKR) in 76 patients (81 knees) <
55 years of age with those
of a matched group of primary TKRs based on age, BMI, gender and
comorbid conditions. We report the activity levels, functional scores,
rates of revision and complications. Compared with patients undergoing
primary TKR, those undergoing revision TKR had less improvement
in the mean Knee Society function scores (8.14 (–55 to +60) Young patients undergoing revision TKR should be counselled that
they can expect somewhat less improvement and a higher risk of complications
than occur after primary TKR. Cite this article:
Patients who have limb amputation for musculoskeletal
tumours are a rare group of cancer survivors. This was a prospective
cross-sectional survey of patients from five specialist centres
for sarcoma surgery in England. Physical function, pain and quality
of life (QOL) outcomes were collected after lower extremity amputation
for bone or soft-tissue tumours to evaluate the survivorship experience
and inform service provision. Of 250 patients, 105 (42%) responded between September 2012 and
June 2013. From these, completed questionnaires were received from
100 patients with a mean age of 53.6 years (19 to 91). In total
60 (62%) were male and 37 (38%) were female (three not specified).
The diagnosis was primary bone sarcoma in 63 and soft-tissue tumour
in 37. A total of 20 tumours were located in the hip or pelvis,
31 above the knee, 32 between the knee and ankle and 17 in the ankle
or foot. In total 22 had hemipelvectomy, nine hip disarticulation,
35 transfemoral amputation, one knee disarticulation, 30 transtibial
amputation, two toe amputations and one rotationplasty. The Toronto
Extremity Salvage Score (TESS) differed by amputation level, with
poorer scores at higher levels (p <
0.001). Many reported significant
pain. In addition, TESS was negatively associated with increasing
age, and pain interference scores. QOL for Cancer Survivors was
significantly correlated with TESS (p <
0.001). This relationship appeared
driven by pain interference scores. This unprecedented national survey confirms amputation level
is linked to physical function, but not QOL or pain measures. Pain
and physical function significantly impact on QOL. These results
are helpful in managing the expectations of patients about treatment
and addressing their complex needs. Cite this article:
We assessed the effect of mental disability on
the outcome of total knee replacement (TKR) and investigated whether
mental health improves post-operatively. Outcome data were prospectively
recorded over a three-year period for 962 patients undergoing primary
TKR for osteoarthritis. Pre-operative and one year Short-Form (SF)-12 scores
and Oxford knee scores (OKS) were obtained. The mental component
of the SF-12 was stratified into four groups according to level
of mental disability (none ≥ 50, mild 40 to 49, moderate 30 to 39,
severe <
30). Patients with any degree of mental disability had
a significantly greater subjective physical disability according
to the SF-12 (p = 0.06) and OKS (p <
0.001). The improvement
in the disease-specific score (OKS) was not affected by a patient’s
mental health (p = 0.33). In contrast, patients with mental disability
had less of an improvement in their global physical health (SF-12)
(p <
0.001). However, patients with any degree of mental disability
had a significant improvement in their mental health post-operatively
(p <
0.001). Despite a similar improvement in their disease-specific scores
and improvement in their mental health, patients with mental disability
were significantly more likely to be dissatisfied with their TKR
at one year (p = 0.001). Patients with poor mental health do benefit
from improvements in their mental health and knee function after
TKR, but also have a higher rate of dissatisfaction. Cite this article:
The purpose of this study was to investigate the prevalence of
sarcopenia and to examine its impact on patients with degenerative
lumbar spinal stenosis (DLSS). This case-control study included two groups: one group consisting
of patients with DLSS and a second group of control subjects without
low back or neck pain and related leg pain. Five control cases were
randomly selected and matched by age and gender (n = 77 cases and
n = 385 controls) for each DLSS case. Appendicular muscle mass,
hand-grip strength, sit-to-stand test, timed up and go (TUG) test,
and clinical outcomes, including the Oswestry Disability Index (ODI)
scores and the EuroQol EQ-5D were compared between the two groups.Aims
Patients and Methods
Although infrequent, a fracture of the cuboid can lead to significant
disruption of the integrity of the midfoot and its function. The
purpose of this study was to classify the pattern of fractures of
the cuboid, relate them to the mechanism of injury and suggest methods
of managing them. We performed a retrospective review of patients with radiologically
reported cuboid fractures. Fractures were grouped according to commonly
occurring patterns of injury. A total of 192 fractures in 188 patients
were included. They were classified into five patterns of injury.Aims
Patients and Methods
Patient-reported outcome measures (PROMs) are
increasingly being used to assess functional outcome and patient satisfaction.
They provide a framework for comparisons between surgical units,
and individual surgeons for benchmarking and financial remuneration.
Better performance may bring the reward of more customers as patients and
commissioners seek out high performers for their elective procedures.
Using National Joint Registry (NJR) data linked to PROMs we identified
22 691 primary total knee replacements (TKRs) undertaken for osteoarthritis
in England and Wales between August 2008 and February 2011, and
identified the surgical factors that influenced the improvements
in the Oxford knee score (OKS) and EuroQol-5D (EQ-5D) assessment
using multiple regression analysis. After correction for patient
factors the only surgical factors that influenced PROMs were implant
brand and hospital type (both p <
0.001). However, the effects
of surgical factors upon the PROMs were modest compared with patient
factors. For both the OKS and the EQ-5D the most important factors
influencing the improvement in PROMs were the corresponding pre-operative
score and the patient’s general health status. Despite having only
a small effect on PROMs, this study has shown that both implant
brand and hospital type do influence reported subjective functional
scores following TKR. In the current climate of financial austerity,
proposed performance-based remuneration and wider patient choice,
it would seem unwise to ignore these effects and the influence of
a range of additional patient factors.
The April 2015 Wrist &
Hand Roundup360 looks at: Non-operative hand fracture management; From the sublime to the ridiculous?; A novel approach to carpal tunnel decompression; Osteoporosis and functional scores in the distal radius; Ulnar variance and force distribution; Tourniquets in carpal tunnel under the spotlight; Scaphoid fractures reclassified; Osteoporosis and distal radial fracture fixation; PROMISing results in the upper limb