To study the measurement properties of a joint specific patient
reported outcome measure, a measure of capability and a general
health-related quality of life (HRQOL) tool in a large cohort of
patients with a hip fracture. Responsiveness and associations between the Oxford Hip Score
(a hip specific measure: OHS), ICEpop CAPability (a measure of capability
in older people: ICECAP-O) and EuroQol EQ-5D (general health-related
quality of life measure: EQ-5D) were assessed using data available
from two large prospective studies. The three outcome measures were assessed
concurrently at a number of fixed follow-up time-points in a consecutive
sequence of patients, allowing direct assessment of change from
baseline, inter-measure associations and validity using a range
of statistical methods.Objectives
Methods
Supination-external rotation (SER) fractures of the ankle may present with a medial ligamentous injury that is not apparent on the initial radiographs. A cadaver gravity-stress view has been described, but the manual-stress view is considered to be the examination of choice for the diagnosis of medial injuries. We prospectively compared the efficacy of these two examinations. We undertook both examinations in 29 patients with SER fractures. Of these, 16 (55%) were stress-positive, i.e. and had widening of the medial clear space of >
4 mm with a mean medial clear space of 6.09 mm (4.4 to 8.1) on gravity-stress and 5.81 mm (4.0 to 8.2) on manual-stress examination, and 13 patients (45%) were stress-negative with a mean medial clear space of 3.91 mm (3.3 to 5.1) and 3.61 mm (2.6 to 4.5) on examination of gravity- and manual-stress respectively. The mean absolute visual analgoue scale score for discomfort in the examination of gravity stress was 3.45 (1 to 6) and in the manual-stress procedure 6.14 (3 to 10). We have shown that examination of gravity-stress is as reliable and perceived as more comfortable than that of manual stress. We recommend using it as the initial diagnostic screening examination for the detection of occult medial ligamentous injuries in SER fractures of the ankle.
We determined the short-term clinical outcome
and migration within the bone of the humeral cementless component
of the Instrumented Bone Preserving (IBP) total elbow replacement
in a series of 16 patients. There were four men and 12 women with
a mean age at operation of 63 years (40 to 81). Migration was calculated
using radiostereometric analysis. There were no intra-operative
complications and no revisions. At two-year follow-up, all patients
showed a significant reduction in pain and functional improvement
of the elbow (both p <
0.001). Although ten components (63%)
showed movement or micromovement during the first six weeks, 14
(88%) were stable at one year post-operatively. Translation was
primarily found in the proximal direction (median 0.3 mm (interquartile range
(IQR) -0.09 to 0.8); the major rotational movement was an anterior
tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component
continued to migrate during the second year, and one component could
not be followed beyond three months because migration had caused
the markers to break off the prosthesis. This study shows promising early results for the cementless humeral
component of the IBP total elbow replacement. All patients had a
good clinical outcome, and most components stabilised within six
months of the operation. Cite this article:
The June 2013 Foot &
Ankle Roundup360 looks at: soft-tissue pain following arthroplasty; pigmented villonodular synovitis of the foot and ankle; ankles, allograft and arthritis; open calcaneal fracture; osteochondral lesions in the longer term; severe infections in diabetic feet; absorbable first ray fixation; and showering after foot surgery.
The aim of this study was to determine the effect
of radial extracorporeal shock-wave therapy (rESWT) on patients with
chronic tendinitis of the rotator cuff. This was a randomised controlled
trial in which 82 patients (mean age 47 years (24 to 67)) with chronic
tendinitis diagnosed clinically were randomly allocated to a treatment
group who received low-dose rESWT (three sessions at an interval
10 to 14 days, 2000 pulses, 0.11 mJ/mm2, 8 Hz) or to
a placebo group, with a follow-up of six months. The patients and
the treating orthopaedic surgeon, who were both blinded to the treatment,
evaluated the results. A total of 44 patients were allocated to
the rESWT group and 38 patients to the placebo group. A visual analogue
scale (VAS) score for pain, a Constant–Murley (CMS) score and a simple
shoulder test (SST) score significantly improved in both groups
at three and six months compared with baseline (all p ≤ 0.012).
The mean VAS was similar in both groups at three (p = 0.43) and
six months (p = 0.262). Also, the mean CMS and SST scores were similar
in both groups at six months (p = 0.815 and p = 0.834, respectively). It would thus seem that low-dose rESWT does not reduce pain or
improve function in patients chronic rotator cuff tendinitis compared
with placebo treatment. Cite this article:
We have performed a prospective double-blind, randomised controlled trial over two years to evaluate the efficacy and safety of an intra-operative peri-articular injection of triamcinolone acetonide in patients undergoing medial unicondylar knee replacement. We randomised 90 patients into two equal groups. The study group received an injection of triamcinolone acetonide, bupivacaine, and epinephrine into the peri-articular tissues at the end of the operation. The control group received the same injection mixture but without the addition of triamcinolone. The peri-operative analgesic regimen was standardised. The study group reported a significant reduction in pain (p = 0.014 at 12 hours, p = 0.031 at 18 hours and p = 0.031 at 24 hours) and had a better range of movement (p = 0.023 at three months). There was no significant difference in the rate of infection and no incidence of tendon rupture in either group. The addition of corticosteroid to the peri-articular injection after unicondylar knee replacement had both immediate and short-term benefits in terms of relief from pain, and rehabilitation with no increased risk of infection.
We investigated whether, in the management of
stable paediatric fractures of the forearm, flexible casts that
can be removed at home are as clinically effective Cite this article:
In a retrospective cohort study we compared the
clinical outcome and complications, including dysphagia, following
anterior cervical fusion for the treatment of cervical spondylosis
using either a zero-profile (Zero-P; Synthes) implant or an anterior
cervical plate and cage. A total of 83 patients underwent fusion
using a Zero-P and 107 patients underwent fusion using a plate and
cage. The mean follow-up was 18.6 months ( When compared with the traditional anterior cervical plate and
cage, the Zero-P implant is a safe and convenient procedure giving
good results in patients with symptomatic cervical spondylosis with
a reduced incidence of dysphagia post-operatively. Cite this article:
We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were randomised after stabilisation of the fracture into two equal groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device. All other aspects of their rehabilitation were the same. The treatment was continued for ten days after operation. Outcome measurements included the use of a visual analogue scale for pain, the brief pain inventory and Ketorolac for post-operative control of pain, and an overall assessment of outcome by the surgeon. There were significantly better results for the patients receiving treatment by active electrical stimulation (repeated measures analysis of variance, p <
0.001). The findings of this pilot trial justify a larger study to determine if these results are more generally applicable.
We aimed to examine the characteristics of deep venous flow in
the leg in a cast and the effects of a wearable neuromuscular stimulator
(geko; FirstKind Ltd) and also to explore the participants’ tolerance
of the stimulator. This is an open-label physiological study on ten healthy volunteers.
Duplex ultrasonography of the superficial femoral vein measured
normal flow and cross-sectional area in the standing and supine
positions (with the lower limb initially horizontal and then elevated).
Flow measurements were repeated during activation of the geko stimulator
placed over the peroneal nerve. The process was repeated after the
application of a below-knee cast. Participants evaluated discomfort
using a questionnaire (verbal rating score) and a scoring index
(visual analogue scale).Objectives
Methods
We have reviewed the current literature to compare
the results of surgery aimed to repair or debride a damaged acetabular
labrum. We identified 28 studies to be included in the review containing
a total of 1631 hips in 1609 patients. Of these studies 12 reported
a mean rate of good results of 82% (from 67% to 100%) for labral debridement.
Of the 16 studies that reported a combination of debridement and
re-attachment, five reported a comparative outcome for the two methods,
four reported better results with re-attachment and one study did
not find any significant difference in outcomes. Due to the heterogeneity
of the studies it was not possible to perform a meta-analysis or
draw accurate conclusions. Confounding factors in the studies include
selection bias, use of historical controls and high rates of loss
of follow-up. It seems logical to repair an unstable tear in a good quality
labrum with good potential to heal in order potentially to preserve
its physiological function. A degenerative labrum on the other hand
may be the source of discomfort and its preservation may result
in persistent pain and the added risk of failure of re-attachment.
The results of the present study do not support routine refixation
for all labral tears. Cite this article:
Whether to combine spinal decompression with
fusion in patients with symptomatic lumbar spinal stenosis remains
controversial. We performed a cohort study to determine the effect
of the addition of fusion in terms of patient satisfaction after
decompressive spinal surgery in patients with and without a degenerative spondylolisthesis. The National Swedish Register for Spine Surgery (Swespine) was
used for the study. Data were obtained for all patients in the register
who underwent surgery for stenosis on one or two adjacent lumbar
levels. A total of 5390 patients fulfilled the inclusion criteria
and completed a two-year follow-up. Using multivariable models the
results of 4259 patients who underwent decompression alone were
compared with those of 1131 who underwent decompression and fusion.
The consequence of having an associated spondylolisthesis in the
operated segments pre-operatively was also considered. At two years there was no significant difference in patient satisfaction
between the two treatment groups for any of the outcome measures,
regardless of the presence of a pre-operative spondylolisthesis.
Moreover, the proportion of patients who required subsequent further
lumbar surgery was also similar in the two groups. In this large cohort the addition of fusion to decompression
was not associated with an improved outcome. Cite this article:
We present the extended follow-up (≥ 20 years)
of a series of fully hydroxyapatite-coated femoral components used in
72 primary total hip replacements (THRs). Earlier results of this
cohort have been previously published. All procedures were performed
between 1986 and 1991. The series involved 45 women and 15 men with
12 bilateral procedures. Their mean age at the time of surgery was
60 years (46 to 80) and the mean duration of follow-up was 22.5
years (20 to 25). At final follow-up, the mean Merle d’Aubigné and
Postel hip scores were 5.5 (4.5 to 6), 3.8 (3.5 to 5) and 3.3 (3.0
to 5.0) for pain, mobility and function, respectively. Of the patients
92% were very satisfied at the time of final follow-up. There were seven revisions: six of the acetabular component for
aseptic loosening and one of both the stem and the acetabular component
for loosening due to deep infection. The survival of this prosthesis
at 22.5 years with revision for any reason as the endpoint was 91.7%
(95% confidence interval (CI) 84 to 99). Survival with aseptic loosening
of the stem as the endpoint was 100% (95% CI 90 to 100). This prosthesis provides pain relief in the long term. Survival
of this component is comparable to the best results for primary
THR with any means of fixation. Cite this article:
We report the clinical and radiological results of a two- to three-year prospective randomised study which was designed to compare a minimally-invasive technique with a standard technique in total knee replacement and was undertaken between January 2004 and May 2007. The mini-midvastus approach was used on 50 patients (group A) and a standard approach on 50 patients (group B). The mean follow-up in both groups was 23 months (24 to 35). The functional outcome was better in group A up to nine months after operation, as shown by statistically significant differences in the mean function score, mean total score and the mean Oxford knee score (all, p = 0.05). Patients in group A had statistically significant greater early flexion (p = 0.04) and reached their greatest mean knee flexion of 126.5° (95° to 135°) 21 days after operation. However, at final follow-up there was no significant difference in the mean maximum flexion between the groups (p = 0.08). Technical errors were identified in six patients from group A (12%) on radiological evaluation. Based on these results, the authors currently use minimally-invasive techniques in total knee replacement in selected cases only.
We report the use of the reverse shoulder prosthesis in the revision of a failed shoulder hemiarthroplasty in 19 shoulders in 18 patients (7 men, 11 women) with severe pain and loss of function. The primary procedure had been undertaken for glenohumeral arthritis associated with severe rotator cuff deficiency. Statistically significant improvements were seen in pain and functional outcome. After a mean follow-up of 44 months (24 to 89), mean forward flexion improved by 26.4° and mean abduction improved by 35°. There were six prosthesis-related complications in six shoulders (32%), five of which had severe bone loss of the glenoid, proximal humerus or both. Three shoulders (16%) had non-prosthesis related complications. The use of the reverse shoulder prosthesis provides improvement in pain and function for patients with failure of a hemiarthroplasty for glenohumeral arthritis and rotator cuff deficiency. However, high rates of complications were associated with glenoid and proximal humeral bone loss.
We conducted a randomised controlled trial to
determine whether active intense pulsed light (IPL) is an effective treatment
for patients with chronic mid-body Achilles tendinopathy. A total
of 47 patients were randomly assigned to three weekly therapeutic
or placebo IPL treatments. The primary outcome measure was the Victorian
Institute of Sport Assessment – Achilles (VISA-A) score. Secondary
outcomes were a visual analogue scale for pain (VAS) and the Lower
Extremity Functional Scale (LEFS). Outcomes were recorded at baseline,
six weeks and 12 weeks following treatment. Ultrasound assessment
of the thickness of the tendon and neovascularisation were also
recorded before and after treatment. There was no significant difference between the groups for any
of the outcome scores or ultrasound measurements by 12 weeks, showing
no measurable benefit from treatment with IPL in patients with Achilles tendinopathy. Cite this article:
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.
It has been suggested that extracorporeal shockwave
therapy is a safe and effective treatment for pain relief from recalcitrant
plantar fasciopathy (PF). However, the changes in gait and associated
biomechanical parameters have not been well characterised. We recruited
12 female patients with recalcitrant PF who had a mean age of 59
years (50 to 70) and mean body mass index of 25 kg/m2 (22
to 30). The patients reported a mean duration of symptoms of 9.3
months (6 to 15). Shockwave therapy consisting of 1500 impulses
(energy flux density 0.26 mJ/mm2) was applied for three
sessions, each three weeks apart. A pain visual analogue scale (VAS)
rating, plantar pressure assessment and motion analysis were carried
out before and nine weeks after first shock wave therapy. It was demonstrated
that patients increased their walking velocity and cadence as well
indicating a decrease in pain after shockwave therapy. In the symptomatic
foot, the peak contact pressure over the forefoot increased and
the contact area over the digits decreased. The total foot impulse
also decreased as did stance duration. The duration the centre of
pressure remained in the hindfoot increased in the symptomatic foot
after shockwave therapy. The differences in centre of pressure trajectory
at baseline decreased at final follow-up. In conclusion, shockwave
therapy not only decreased the pain VAS rating but also improved
the gait parameters of the symptomatic foot in PF patients. Cite this article:
Despite the worldwide usage of the cemented Contemporary
acetabular component (Stryker), no published data are available
regarding its use in patients aged <
50 years. We undertook a
mid- to long-term follow-up study, including all consecutive patients
aged
<
50 years who underwent a primary total hip replacement using
the Contemporary acetabular component with the Exeter cemented stem
between January 1999 and January 2006. There were 152 hips in 126
patients, 61 men and 65 women, mean age at surgery 37.6 years (16
to 49 yrs). One patient was lost to follow-up. Mean clinical follow-up of all implants was 7.6 years (0.9 to
12.0). All clinical questionnaire scores, including Harris hip score,
Oxford hip score and several visual analogue scales, were found
to have improved. The eight year survivorship of all acetabular
components for the endpoints revision for any reason or revision
for aseptic loosening was 94.4% (95% confidence interval (CI) 89.2
to 97.2) and 96.4% (95% CI 91.6 to 98.5), respectively. Radiological follow-up
was complete for 146 implants. The eight year survival for the endpoint
radiological loosening was 93.1% (95% CI 86.2 to 96.6). Three surviving
implants were considered radiologically loose but were asymptomatic.
The presence of acetabular osteolysis (n = 17, 11.8%) and radiolucent
lines (n = 20, 13.9%) in the 144 surviving cups indicates a need
for continued observation in the second decade of follow-up in order
to observe their influence on long-term survival. The clinical and radiological data resulting in a ten-year survival
rate >
90% in young patients support the use of the Contemporary
acetabular component in this specific patient group. Cite this article:
The April 2013 Knee Roundup360 looks at: graft tension and outcome; chondrocytes at the midterm; pre-operative deformity and failure; the designer effect; whether chondroitin sulphate really does work; whether ACL reconstruction is really required; analgesia after TKR; and degenerative meniscus.