Vascularised fibular grafts (VFGs ) are a valuable
surgical technique in limb salvage after resection of a tumour.
The primary objective of this multicentre study was to assess the
risk factors for failure and complications for using a VFG after
resection of a tumour. The study involved 74 consecutive patients (45 men and 29 women
with mean age of 23 years (1 to 64) from four tertiary centres for
orthopaedic oncology who underwent reconstruction using a VFG after
resection of a tumour between 1996 and 2011. There were 52 primary
and 22 secondary reconstructions. The mean follow-up was 77 months
(10 to 195). In all, 69 patients (93%) had successful limb salvage; all of
these united and 65 (88%) showed hypertrophy of the graft. The mean
time to union differed between those involving the upper (28 weeks;
12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred
in 11 (15%), and nonunion in 14 (19%) patients. In 35 patients (47%) at least one complication arose, with a
greater proportion in lower limb reconstructions, non-bridging osteosynthesis,
and in children. These complications resulted in revision surgery
in 26 patients (35%). VFG is a successful and durable technique for reconstruction
of a defect in bone after resection of a tumour, but is accompanied
by a significant risk of complications, that often require revision
surgery. Union was not markedly influenced by the need for chemo-
or radiotherapy, but should not be expected during chemotherapy.
Therefore, restricted weight-bearing within this period is advocated. Cite this article:
It has previously been suggested that among unstable
ankle fractures, the presence of a malleolar fracture is associated
with a worse outcome than a corresponding ligamentous injury. However,
previous studies have included heterogeneous groups of injury. The
purpose of this study was to determine whether any specific pattern of
bony and/or ligamentous injury among a series of supination-external
rotation type IV (SER IV) ankle fractures treated with anatomical
fixation was associated with a worse outcome. We analysed a prospective cohort of 108 SER IV ankle fractures
with a follow-up of one year. Pre-operative radiographs and MRIs
were undertaken to characterise precisely the pattern of injury.
Operative treatment included fixation of all malleolar fractures.
Post-operative CT was used to assess reduction. The primary and
secondary outcome measures were the Foot and Ankle Outcome Score
(FAOS) and the range of movement of the ankle. There were no clinically relevant differences between the four
possible SER IV fracture pattern groups with regard to the FAOS
or range of movement. In this population of strictly defined SER
IV ankle injuries, the presence of a malleolar fracture was not
associated with a significantly worse clinical outcome than its
ligamentous injury counterpart. Other factors inherent to the injury
and treatment may play a more important role in predicting outcome.
The August 2013 Spine Roundup360 looks at: SPECT CT and facet joints; a difficult conversation: scoliosis and complications; time for a paradigm shift? complications under the microscope; minor trauma and cervical injury: a predictable phenomenon?; more costly all round: incentivising more complex operations?; minimally invasive surgery = minimal scarring; and symptomatic lumbar spine stenosis.
The August 2013 Shoulder &
Elbow Roundup360 looks at: the sternoclavicular joint revisited; surgical simulators: more than just a fancy idea?; arthroscopic tennis elbow release; costly clavicle stabilisation; a better treatment for tennis elbow?; shock news: surgeons and radiologists agree; overhead athletes and SLAP repair; and total shoulder arthroplasty more effective than hemiarthroplasty
The December 2014 Spine Roundup360 looks at: surgeon outcomes; complications and scoliosis surgery; is sequestrectomy enough in lumbar disc prolapse?; predicting outcomes in lumbar disc herniation; sympathectomy has a direct effect on the dorsal root ganglion; and distal extensions of fusion in adolescent idiopathic scoliosis.
The treatment of osteochondral lesions is of
great interest to orthopaedic surgeons because most lesions do not heal
spontaneously. We present the short-term clinical outcome and MRI
findings of a cell-free scaffold used for the treatment of these
lesions in the knee. A total of 38 patients were prospectively evaluated
clinically for two years following treatment with an osteochondral
nanostructured biomimetic scaffold. There were 23 men and 15 women; the
mean age of the patients was 30.5 years (15 to 64). Clinical outcome
was assessed using the Knee Injury and Osteoarthritis Outcome Score
(KOOS), the Tegner activity scale and a Visual Analgue scale for
pain. MRI data were analysed based on the Magnetic Resonance Observation
of Cartilage Repair Tissue (MOCART) scoring system at three, 12
and 24 months post-operatively. There was a continuous significant
clinical improvement after surgery. In two patients, the scaffold
treatment failed (5.3%) There was a statistically significant improvement
in the MOCART precentage scores. The repair tissue filled most of
the defect sufficiently. We found subchondral laminar changes in all
patients. Intralesional osteophytes were found in two patients (5.3%).
We conclude that this one-step scaffold-based technique can be used
for osteochondral repair. The surgical technique is straightforward,
and the clinical results are promising. The MRI aspects of the repair
tissue continue to evolve during the first two years after surgery.
However, the subchondral laminar and bone changes are a concern. Cite this article:
The June 2013 Hip &
Pelvis Roundup360 looks at: failure in metal-on-metal arthroplasty; minimal hip approaches; whether bisphosphonates improve femoral bone stock following arthroplasty; whether more fat means more operative time; surgical infection; vascularised fibular graft for osteonecrosis; subclinical SUFE; and dentists, hips and antibiotics.
The indications for reverse shoulder arthroplasty
(RSA) continue to be expanded. Associated impairment of the deltoid
muscle has been considered a contraindication to its use, as function
of the RSA depends on the deltoid and impairment of the deltoid
may increase the risk of dislocation. The aim of this retrospective
study was to determine the functional outcome and risk of dislocation
following the use of an RSA in patients with impaired deltoid function.
Between 1999 and 2010, 49 patients (49 shoulders) with impairment
of the deltoid underwent RSA and were reviewed at a mean of 38 months
(12 to 142) post-operatively. There were nine post-operative complications (18%),
including two dislocations. The mean forward elevation improved
from 50° ( These results suggest that pre-operative deltoid impairment,
in certain circumstances, is not an absolute contraindication to
RSA. This form of treatment can yield reliable improvement in function
without excessive risk of post-operative dislocation. Cite this article:
The December 2014 Shoulder &
Elbow Roundup360 looks at: cuff tears and plexus injury; corticosteroids and physiotherapy in SAI; diabetes and elbow arthroplasty; distal biceps tendon repairs; shockwave therapy in frozen shoulder; hydrodilation and steroids for adhesive capsulitis; just what do our patients read?; and what happens to that stable radial head fracture?
Large-head metal-on-metal total hip replacement has a failure rate of almost 8% at five years, three times the revision rate of conventional hip replacement. Unexplained pain remains a feature of this type of arthroplasty. All designs of the femoral component of large-head metal-on-metal total hip replacements share a unique characteristic: a subtended angle of 120° defining the proportion of a sphere that the head represents. Using MRI, we measured the contact area of the iliopsoas tendon on the femoral head in sagittal reconstruction of 20 hips of patients with symptomatic femoroacetabular impingement. We also measured the articular extent of the femoral head on 40 normal hips and ten with cam-type deformities. Finally, we performed virtual hip resurfacing on normal and cam-type hips, avoiding overhang of the metal rim inferomedially. The articular surface of the femoral head has a subtended angle of 120° anteriorly and posteriorly, but only 100° medially. Virtual surgery in a normally shaped femoral head showed a 20° skirt of metal protruding medially where iliopsoas articulates. The excessive extent of the large-diameter femoral components may cause iliopsoas impingement independently of the acetabular component. This may be the cause of postoperative pain with these implants.
The June 2013 Knee Roundup360 looks at: knee arthroplasty in diabetic patients; whether TKR is a timebomb; the use of antidepressants for knee OA; trochleoplasty; articulated spacers; mental health and joint replacement; and the use of physiotherapy for meniscal tear.
We investigated the incidence and risk factors
for the development of avascular necrosis (AVN) of the femoral head in
the course of treatment of children with cerebral palsy (CP) and
dislocation of the hip. All underwent open reduction, proximal femoral
and Dega pelvic osteotomy. The inclusion criteria were: a predominantly
spastic form of CP, dislocation of the hip (migration percentage,
MP >
80%), Gross Motor Function Classification System, (GMFCS) grade
IV to V, a primary surgical procedure and follow-up of >
one year. There were 81 consecutive children (40 girls and 41 boys) in
the study. Their mean age was nine years (3.5 to 13.8) and mean
follow-up was 5.5 years (1.6 to 15.1). Radiological evaluation included
measurement of the MP, the acetabular index (AI), the epiphyseal
shaft angle (ESA) and the pelvic femoral angle (PFA). The presence
and grade of AVN were assessed radiologically according to the Kruczynski
classification. Signs of AVN (grades I to V) were seen in 79 hips (68.7%). A
total of 23 hips (18%) were classified between grades III and V. Although open reduction of the hip combined with femoral and
Dega osteotomy is an effective form of treatment for children with
CP and dislocation of the hip, there were signs of avascular necrosis
in about two-thirds of the children. There was a strong correlation
between post-operative pain and the severity of the grade of AVN. Cite this article:
A poor response to chemotherapy (≤ 90% necrosis)
for osteosarcomas leads to poorer survival and an increased risk of
local recurrence, particularly if there is a close margin of excision.
We evaluated whether amputation confers any survival benefit over
limb salvage surgery (LSS) with narrow margins in patients who respond
poorly to chemotherapy. We only analysed patients with an osteosarcoma of the limb, a
poor response to chemotherapy and close margins on LSS (marginal/intralesional)
or primary amputation: 360 patients (36 LSS (intralesional margins),
197 LSS (marginal margins) and 127 amputations) were included. Local
recurrence developed in 13 (36%) following LSS with intralesional
margins, and 39 (20%) following LSS with marginal margins. There
was no local recurrence in patients who underwent amputation. The
five-year survival for all patients was 41% (95% confidence interval
(CI) 35 to 46), but for those treated by LSS with marginal margins
was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated
by amputation, and 28% (95 CI 14 to 44) for those treated by LSS
with intralesional margins. Patients who had LSS and then developed
local recurrence as a first event had the same survival as those
who had primary amputation without local recurrence. Prophylactic
adjuvant radiotherapy was used in 40 patients but had no discernible
effect in preventing local recurrence. Although amputation offered better local control, it conferred
no clear survival benefit over LSS with marginal margins in these
patients with a poor overall prognosis. Cite this article:
In 11 paediatric patients (seven girls and four
boys, from 12 to 15 years old) with unilateral obligatory patellar dislocation
and ligamentous laxity vastus medialis advancement, lateral release,
partial patellar ligament transposition and Galeazzi semitendinosus
tenodesis was undertaken to stabilise the patella. The diagnostic criterion
for ligamentous laxity was based on the Beighton scale. Outcomes
were evaluated radiologically and functionally by measurement of
the range of knee movement and isokinetic testing. The evaluation
also included the Lysholm knee scale. Follow-up studies took place
at a mean of 8.1 years (5 to 15) post-operatively. Normal patellar tracking without any recurrence of dislocation
was obtained in ten out of 11 patients. Pain related to vigorous
activity was reported by nine patients. Compared with the opposite
normal side, the isokinetic tests revealed a statistically significant
decrease in the maximal torque values for the affected quadriceps
muscle (p = 0.003 and p = 0.004), but no difference between the
knee flexors (for angular velocities of 60°/s and 180°/s) (p = 0.858
and p = 0.79). The applied surgical technique generally prevents the recurrence
of the disorder in children with habitual patellar dislocation and
ligamentous laxity. Quadriceps muscle weakness can be expected to
occur post-operatively, Cite this article:
The April 2013 Hip &
Pelvis Roundup360 looks at: hip cartilage and magnets; labral repair or resection; who benefits from injection; rotational osteotomy for osteonecrosis; whether ceramic implants risk fracture; dual articulation; and hydroxyapatite.
A suspected fracture of the scaphoid remains difficult to manage despite advances in knowledge and imaging methods. Immobilisation and restriction of activities in a young and active patient must be balanced against the risks of nonunion associated with an undiagnosed and undertreated fracture of the scaphoid. The assessment of diagnostic tests for a suspected fracture of the scaphoid must take into account two important factors. First, the prevalence of true fractures among suspected fractures is low, which greatly reduces the probability that a positive test will correspond with a true fracture, as false positives are nearly as common as true positives. This situation is accounted for by Bayesian statistics. Secondly, there is no agreed reference standard for a true fracture, which necessitates the need for an alternative method of calculating diagnostic performance characteristics, based upon a statistical method which identifies clinical factors tending to associate (latent classes) in patients with a high probability of fracture. The most successful diagnostic test to date is MRI, but in low-prevalence situations the positive predictive value of MRI is only 88%, and new data have documented the potential for false positive scans. The best strategy for improving the diagnosis of true fractures among suspected fractures of the scaphoid may well be to develop a clinical prediction rule incorporating a set of demographic and clinical factors which together increase the pre-test probability of a fracture of the scaphoid, in addition to developing increasingly sophisticated radiological tests.
The April 2013 Trauma Roundup360 looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction.
Cancellous allograft bone chips are commonly
used in the reconstruction of defects in bone after removal of benign tumours.
We investigated the MRI features of grafted bone chips and their
change over time, and compared them with those with recurrent tumour.
We retrospectively reviewed 66 post-operative MRIs from 34 patients
who had undergone curettage and grafting with cancellous bone chips
to fill the defect after excision of a tumour. All grafts showed
consistent features at least six months after grafting: homogeneous
intermediate or low signal intensities with or without scattered
hyperintense foci (speckled hyperintensities) on T1 images; high
signal intensities with scattered hypointense foci (speckled hypointensities)
on T2 images, and peripheral rim enhancement with or without central
heterogeneous enhancements on enhanced images. Incorporation of
the graft occurred from the periphery to the centre, and was completed
within three years. Recurrent lesions consistently showed the same signal
intensities as those of pre-operative MRIs of the primary lesions.
There were four misdiagnoses, three of which were chondroid tumours. We identified typical MRI features and clarified the incorporation
process of grafted cancellous allograft bone chips. The most important
characteristics of recurrent tumours were that they showed the same
signal intensities as the primary tumours. It might sometimes be
difficult to differentiate grafted cancellous allograft bone chips
from a recurrent chondroid tumour. Cite this article:
Treatment for osteoarthritis (OA) has traditionally
focused on joint replacement for end-stage disease. An increasing number
of surgical and pharmaceutical strategies for disease prevention
have now been proposed. However, these require the ability to identify
OA at a stage when it is potentially reversible, and detect small
changes in cartilage structure and function to enable treatment
efficacy to be evaluated within an acceptable timeframe. This has
not been possible using conventional imaging techniques but recent
advances in musculoskeletal imaging have been significant. In this
review we discuss the role of different imaging modalities in the
diagnosis of the earliest changes of OA. The increasing number of
MRI sequences that are able to non-invasively detect biochemical
changes in cartilage that precede structural damage may offer a
great advance in the diagnosis and treatment of this debilitating
condition. Cite this article: