A postal questionnaire was sent to 10 000 patients more than one year after their total knee replacement (TKR). They were assessed using the Oxford knee score and were asked whether they were satisfied, unsure or unsatisfied with their TKR. The response rate was 87.4% (8231 of 9417 eligible questionnaires) and a total of 81.8% (6625 of 8095) of patients were satisfied. Multivariable regression modelling showed that patients with higher scores relating to the pain and function elements of the Oxford knee score had a lower level of satisfaction (p <
0.001), and that ongoing pain was a stronger predictor of this. Female gender and a primary diagnosis of osteoarthritis were found to be predictors of lower levels of patient satisfaction. Differences in the rate of satisfaction were also observed in relation to age, the American Society of Anesthesiologists grade and the type of prosthesis. This study has provided data on the Oxford knee score and the expected levels of satisfaction at one year after TKR. The results should act as a benchmark of practice in the United Kingdom and provide a baseline for peer comparison between institutions.
In a prospective, randomised study on the repair of tears of the rotator cuff we compared the clinical results of two suture techniques for which different suture materials were used. We prospectively randomised 100 patients with tears of the rotator cuff into two groups. Group 1 had transosseous repair with No. 3 Ethibond using modified Mason-Allen sutures and group 2 had transosseous repair with 1.0 mm polydioxanone cord using modified Kessler sutures. After 24 to 30 months the patients were evaluated clinically using the Constant score and by ultrasonography. Of the 100 patients, 92 completed the study. No significant statistical difference was seen between the two groups: Constant score, 91% Overall, seven patients had complications which required revision surgery, in four for pain (two in each group) and in three for infection (two in group 1 and one in group 2).
We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192). Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both. The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern.
Autologous chondrocyte implantation (ACI) is used widely as a treatment for symptomatic chondral and osteochondral defects of the knee. Variations of the original periosteum-cover technique include the use of porcine-derived type I/type III collagen as a cover (ACI-C) and matrix-induced autologous chondrocyte implantation (MACI) using a collagen bilayer seeded with chondrocytes. We have performed a prospective, randomised comparison of ACI-C and MACI for the treatment of symptomatic chondral defects of the knee in 91 patients, of whom 44 received ACI-C and 47 MACI grafts. Both treatments resulted in improvement of the clinical score after one year. The mean modified Cincinnati knee score increased by 17.6 in the ACI-C group and 19.6 in the MACI group (p = 0.32). Arthroscopic assessments performed after one year showed a good to excellent International Cartilage Repair Society score in 79.2% of ACI-C and 66.6% of MACI grafts. Hyaline-like cartilage or hyaline-like cartilage with fibrocartilage was found in the biopsies of 43.9% of the ACI-C and 36.4% of the MACI grafts after one year. The rate of hypertrophy of the graft was 9% (4 of 44) in the ACI-C group and 6% (3 of 47) in the MACI group. The frequency of re-operation was 9% in each group. We conclude that the clinical, arthroscopic and histological outcomes are comparable for both ACI-C and MACI. While MACI is technically attractive, further long-term studies are required before the technique is widely adopted.
The optimal method for the management of neglected traumatic bifacetal dislocation of the subaxial cervical spine has not been established. We treated four patients in whom the mean delay between injury and presentation was four months (1 to 5). There were two dislocations at the C5-6 level and one each at C4-5 and C3-4. The mean age of the patients was 48.2 years (27 to 60). Each patient presented with neck pain and restricted movement of the cervical spine. Three of the four had a myelopathy. We carried out a two-stage procedure under the same anaesthetic. First, a posterior soft-tissue release and partial facetectomy were undertaken. This allowed partial reduction of the dislocation which was then supplemented by interspinous wiring and corticocancellous graft. Next, through an anterior approach, discectomy, tricortical bone grafting and anterior cervical plating were carried out. All the patients achieved a nearly anatomical reduction and sagittal alignment. The mean follow-up was 2.6 years (1 to 4). The myelopathy settled completely in the three patients who had a pre-operative neurological deficit. There was no graft dislodgement or graft-related problems. Bony fusion occurred in all patients and a satisfactory reduction was maintained. The posteroanterior procedure for neglected traumatic bifacetal dislocation of the subaxial cervical spine is a good method of achieving sagittal alignment with less risk of iatrogenic neurological injury, a reduced operating time, decreased blood loss, and a shorter hospital stay compared with other procedures.
Between March 1994 and June 2003, 80 patients with brachial plexus palsy underwent a trapezius transfer. There were 11 women and 69 men with a mean age of 31 years (18 to 69). Before operation a full evaluation of muscle function in the affected arm was carried out. A completely flail arm was found in 37 patients (46%). Some peripheral function in the elbow and hand was seen in 43 (54%). No patient had full active movement of the elbow in combination with adequate function of the hand. Patients were followed up for a mean of 2.4 years (0.8 to 8). We performed the operations according to Saha’s technique, with a modification in the last 22 cases. We demonstrated a difference in the results according to the pre-operative status of the muscles and the operative technique. The transfer resulted in an increase of function in all patients and in 74 (95%) a decrease in multidirectional instability of the shoulder. The mean increase in active abduction was from 6° (0 to 45) to 34° (5 to 90) at the last review. The mean forward flexion increased from 12° (0 to 85) to 30° (5 to 90). Abduction (41°) and especially forward flexion (43°) were greater when some residual function of the pectoralis major remained (n = 32). The best results were achieved in those patients with most pre-operative power of the biceps, coracobrachialis and triceps muscles (n = 7), with a mean of 42° of abduction and 56° of forward flexion. Active abduction (28°) and forward flexion (19°) were much less in completely flail shoulders (n = 34). Comparison of the 19 patients with the Saha technique and the 15 with the modified procedure, all with complete paralysis, showed the latter operation to be superior in improving shoulder stability. In all cases a decrease in instability was achieved and inferior subluxation was abolished. The results after trapezius transfer depend on the pre-operative pattern of paralysis and the operative technique. Better results can be achieved in patients who have some function of the biceps, coracobrachialis, pectoralis major and triceps muscles compared with those who have a complete palsy. A simple modification of the operation ensures a decrease in joint instability and an increase in function.
A review of the current literature shows that there is a lack of consensus regarding the treatment of spondylolysis and spondylolisthesis in children and adolescents. Most of the views and recommendations provided in various reports are weakly supported by evidence. There is a limited amount of information about the natural history of the condition, making it difficult to compare the effectiveness of various conservative and operative treatments. This systematic review summarises the current knowledge on spondylolysis and spondylolisthesis and attempts to present a rational approach to the evaluation and management of this condition in children and adolescents.
A 48-year old man presented with back pain that was resistant to treatment. An MR scan showed spondylolisthesis at L4-5 and narrowing of the exit foraminae. He had a posterior fusion which did not relieve his symptoms. He continued to have back pain and developed subcutaneous nodules in both forearms. Biopsy from the skin revealed cutaneous sarcoidosis, and one from the lumbar spine showed sarcoidosis granuloma between the bone trabeculae. A CT scan of the abdomen and chest revealed axillary lymphadenopathy, mediastinal enlarged nodes, apical nodular nodes and splenomegaly. The patient was started on large doses of methotrexate and steroids. His angiotensin-converting enzyme and calcium levels returned to normal and the back pain resolved.
We have examined the outcome in 19 professional rugby union players who underwent anterior cervical discectomy and fusion between 1998 and 2003. Through a retrospective review of the medical records and telephone interviews of all 19 players, we have attempted to determine the likelihood of improvement, return to professional sport and the long-term consequences. We have also attempted to relate the probability of symptoms in the neck and radicular pain in the arm to the position of play. Neck and radicular pain were improved in 17 patients, with 13 returning to rugby, the majority by six months after operation. Of these, 13 returned to their pre-operative standard of play, one to a lower level and five have not played rugby again. Two of those who returned to the game have subsequently suffered further symptoms in the neck, one of whom was obliged to retire. The majority of the players with problems in the neck were front row forwards. A return to playing rugby union after surgery and fusion of the anterior cervical spine is both likely and safe and need not end a career in the game.
Giant-cell tumour of the synovium is known to affect the fingers or toes of adults. It has seldom been described in the spine and rarely in the thoracic vertebrae or in a child. The lesions of giant-cell tumour of the synovium have a classical radiological appearance, but require a high index of suspicion for correct recognition. Unlike giant-cell tumour of the synovium at other well-known sites, spinal lesions lack the characteristic papillary architecture, thereby raising other diagnostic possibilities. We describe a giant-cell tumour of the synovium of the left facet joint of a thoracic vertebra in a nine-year-old girl. The tumour was treated successfully by surgical excision.
We report 79 cases of bone and joint tuberculosis between 1988 and 2005, eight of which were in the Caucasian population and 71 in the non-white population. The diagnosis was made in the majority (73.4%) by positive bacteriology and/or histology. The mean age at the time of diagnosis was higher in the Caucasian group at 51.5 years (28 to 66) than in the South Asian group at 36.85 years (12 to 93). Only one patient had previous BCG immunisation. The spine was the site most commonly affected (44.3%). Surgical stabilisation and/or decompression was performed in 23% of these cases because of cord compression on imaging or the presence of neurological signs. A six-month course of chemotherapy comprising of an initial two months of rifampicin, isoniazide, pyrazinamide and sometimes ethambutol followed by four months treatment with rifampicin and isoniazide, was successful in all cases without proven drug resistance.
Kienböck’s disease is a form of osteonecrosis affecting the lunate. Its aetiology remains unknown. Morphological variations, such as negative ulnar variance, high uncovering of the lunate, abnormal radial inclination and/or a trapezoidal shape of the lunate and the particular pattern of its vascularity may be predisposing factors. A history of trauma is common. The diagnosis is made on plain radiographs, but MRI can be helpful early in the disease. A CT scan is useful to demonstrate fracture or fragmentation of the lunate. Lichtman classified Kienböck disease into five stages. The natural history of the condition is not well known, and the symptoms do not correlate well with the changes in shape of the lunate and the degree of carpal collapse. There is no strong evidence to support any particular form of treatment. Many patients are improved by temporary immobilisation of the wrist, which does not stop the progression of carpal collapse. Radial shortening may be the treatment of choice in young symptomatic patients presenting with stages I to III-A of Kienböck’s disease and negative ulnar variance. Many other forms of surgical treatment have been described.
A total of 47 non-walking patients (52 hips) with severe cerebral palsy and with a mean age of 14 years, (9 to 27) underwent a Dega-type pelvic osteotomy after closure of the triradiate cartilage, together with a derotation varus-shortening femoral osteotomy and soft-tissue correction for hip displacement which caused pain and/or difficulties in sitting. The mean follow-up was 48 months (12 to 153). The migration percentage improved from a pre-operative mean of 70% (26% to 100%) to 10% (0% to 100%) post-operatively. In five hips the post-operative migration percentage was greater than 25%, which was associated with continuing pain in two patients. Three patients had persistent hip pain and a migration percentage less than 25%. In five hips a fracture through the acetabulum occurred, and in another there was avascular necrosis of the superior acetabular segment, but these had no adverse effect on functional outcome. We conclude that it is possible to perform a satisfactory pelvic osteotomy of this type in these patients after the triradiate cartilage has been closed.
There are few reports of the treatment of lumbar tuberculous spondylitis using the posterior approach. Between January 1999 and February 2004, 16 patients underwent posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation. Their mean age at surgery was 51 years (28 to 66). The mean follow-up period was 33 months (24 to 48). The clinical outcome was assessed using the Frankel neurological classification and the Kirkaldy-Willis criteria. On the Frankel classification, one patient improved by two grades (C to E), seven by one grade, and eight showed no change. The Kirkaldy-Willis functional outcome was classified as excellent in eight patients, good in five, fair in two and poor in one. Bony union was achieved within one year in 15 patients. The mean pre-operative lordotic angle was 27.8° (9° to 45°) which improved by the final follow-up to 35.8° (28° to 48°). Post-operative complications occurred in four patients, transient root injury in two, a superficial wound infection in one and a deep wound infection in one, in whom the implant was removed. Our results show that a posterior lumbar interbody fusion with autogenous iliac-bone grafting and pedicle screw instrumentation for tuberculous spondylitis through the posterior approach can give satisfactory results.
Fractures of the occipital condyle are rare. Their prompt diagnosis is crucial since there may be associated cranial nerve palsies and cervical spinal instability. The fracture is often not visible on a plain radiograph. We report the case of a 21-year-old man who sustained an occipital condylar fracture without any associated cranial nerve palsy or further injuries. We have also reviewed the literature on this type of injury, in order to assess the incidence, the mechanism and the association with head and cervical spinal injuries as well as classification systems, options for treatment and outcome.
Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure. Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective.
Osteonecrosis of the knee comprises two separate disorders, primary spontaneous osteonecrosis which is often a self-limiting condition and secondary osteonecrosis which is associated with risk factors and a poor prognosis. In a series of 61 knees (38 patients) we analysed secondary osteonecrosis of the knee treated by a new technique using multiple small percutaneous 3 mm drillings. Total knee replacement was avoided in 59 knees (97%) at a mean follow-up of 3 years (2 to 4). Of the 61 knees, 56 (92%) had a successful clinical outcome, defined as a Knee Society score greater than 80 points. The procedure was successful in all 24 knees with small lesions compared with 32 of 37 knees (86%) with large lesions. All the procedures were performed as day cases and there were no complications. This technique appears to have a low morbidity, relieves symptoms and delays more invasive surgery.
Between 1998 and 2002, 37 neuropathies in 32 patients with a displaced supracondylar fracture of the humerus who were referred to a nerve injury unit were identified. There were 19 boys and 13 girls with a mean age of 7.9 years (3.6 to 11.3). A retrospective review of these injuries was performed. The ulnar nerve was injured in 19, the median nerve in ten and the radial nerve in eight cases. Fourteen neuropathies were noted at the initial presentation and 23 were diagnosed after treatment of the fracture. After referral, exploration of the nerve was planned for 13 patients. Surgery was later cancelled in three because of clinical recovery. Six patients underwent neurolysis alone. Excision of neuroma and nerve grafting were performed in four. At follow-up, 26 patients had an excellent, five a good and one a fair outcome.
