Aims

For paediatric and adolescent patients with growth potential, preservation of the physiological joint by transepiphyseal resection (TER) of the femur confers definite advantages over arthroplasty procedures. We hypothesized that the extent of the tumour and changes in its extent after neoadjuvant chemotherapy are essential factors in the selection of this procedure, and can be assessed with MRI. The oncological and functional outcomes of the procedure were reviewed to confirm its safety and efficacy.

Between 1978 and 1986, 59 patients received a GSB III elbow prosthesis, six of them in both elbows. Rheumatoid arthritis (RA) was the underlying cause in 51 of the patients and post-traumatic osteoarthritis (PTOA) in eight. Of these, 24 patients (28 prostheses) have since died; two, both operated on bilaterally, had had their implants for more than ten years and had already been assessed for inclusion in the long-term follow-up. Two patients, each with one elbow prosthesis, have been lost to follow-up and three males who are still living (two with PTOA, one with juvenile RA) had their prosthesis removed before ten years had elapsed. The remaining 32 patients (28 RA, 4 PTOA) with 36 GSB III elbows were examined clinically and radiologically after a mean period of 13.5 years. Pain was considerably reduced in 91.6%. Mobility was increased by 37° in those with RA and by 67° in those with PTOA. There were three cases of aseptic loosening and three of deep infection. The main complication was disassembly of the prosthetic component in nine elbows (13.8%). This last group included two patients with postoperative fractures unrelated to the operative technique and one with neuropathic arthritis. Ulnar neuritis occurred in two patients. Since 87.7% of all the GSB III prostheses implanted in this period remained in situ, our results are comparable with those for hip and knee arthroplasty

We reviewed 264 consecutive primary total hip replacements in 244 patients in which the Harris-Galante I porous-coated acetabular component had been used. The mean follow-up was 95 months (69 to 132). In 221 arthroplasties a 32 mm ceramic head had been used, and in the other 43 one of cobalt-chrome alloy. There were 124 women and 120 men with a mean age at operation of 56.8 years (21 to 83). Survival analysis of the acetabular components was performed using the following definitions of failure: 1) infection; 2) removal because of aseptic loosening; 3) removal for any cause; and 4) a worst-case analysis including removal of the cup or infection or loss to follow-up. Two well-fixed cups had been removed because of deep infection and three, similarly sound cups had been exchanged at the time of femoral revision. None of the acetabular components had required revision for aseptic loosening. After 11 years survival was 97.7% using the worst-case criterion. Radiological analysis of 187 acetabular components at a mean of 82 months (41 to 132) revealed no case of aseptic loosening. Pelvic osteolysis was seen in only one patient, but was not progressive and showed signs of regression. The results using these acetabular components are encouraging but the need for regular follow-up remains since complications such as significant wear of the liner, massive osteolysis of the pelvis, aseptic loosening and late infection may increase in the second decade

After an allogenic bone-marrow transplant, a vascular necrosis of the femoral head may affect young adults, producing destructive lesions which require hip replacement. We have reviewed 27 consecutive such total hip arthroplasties (THA) at a minimal follow-up of two years. Of these, 20 were primary operations for Ficat (1985) stage-III and stage-IV lesions, and seven were revisions after the failure of previous surgery. The median age at operation was 30 years (17.5 to 44). The prostheses had a cemented, collared titanium-alloy stem, an alumina-alumina joint, and a press-fit socket. Seven had a titanium-alloy metal back and 20 had all-alumina cups of which six had to be cemented. At an average follow-up of five years, no patient had been lost to follow-up. One had died from septicaemia after two years and another with chronic graft-versus-host disease developed a deep infection 2.5 years postoperatively and had a successful revision. There were no revisions for aseptic loosening. The clinical results on the Merle d’Aubigné and Postel (1954) scale were very good or excellent in 23 hips (88%), good in one and fair in two. Ten hips showed incomplete acetabular radiolucencies less than 1 mm thick, but there were no radiolucent lines around the stems. We conclude that for these difficult patients THA with ceramic joints and careful technique provides the best short- and medium-term option after the failure of medical treatment

We investigated the capacity of patient warming devices to disrupt the ultra-clean airflow system. We compared the effects of two patient warming technologies, forced-air and conductive fabric, on operating theatre ventilation during simulated hip replacement and lumbar spinal procedures using a mannequin as a patient. Infection data were reviewed to determine whether joint infection rates were associated with the type of patient warming device that was used. Neutral-buoyancy detergent bubbles were released adjacent to the mannequin’s head and at floor level to assess the movement of non-sterile air into the clean airflow over the surgical site. During simulated hip replacement, bubble counts over the surgical site were greater for forced-air than for conductive fabric warming when the anaesthesia/surgery drape was laid down (p = 0.010) and at half-height (p < 0.001). For lumbar surgery, forced-air warming generated convection currents that mobilised floor air into the surgical site area. Conductive fabric warming had no such effect. A significant increase in deep joint infection, as demonstrated by an elevated infection odds ratio (3.8, p = 0.024), was identified during a period when forced-air warming was used compared to a period when conductive fabric warming was used. Air-free warming is, therefore, recommended over forced-air warming for orthopaedic procedures

1. Eighty consecutive open fractures of the tibial shaft were treated by primary internal fixation and wound closure. Wound healing was complicated by deep infection in eight patients (10 per cent) and by skin loss of varying degree in ten (l2·5 per cent). 2. Careful selection of patients on the basis of associated soft-tissue injuries is urged. A simple method of grading open fractures by the appearance of the wound and adjacent skin and the effectiveness of wound closure is suggested. If internal fixation is indicated on mechanical grounds, the nature of the soft-tissue injury should be the deciding factor in the choice of the method of treatment. In the less severe (Grade 1) fractures internal fixation and wound closure may be safely employed. In the severe (Grade 3) injuries, primary wound closure with or without internal fixation should be avoided. Moderately severe (Grade 2) fractures should be carefully assessed and treated by internal fixation and wound closure only if primary wound healing is confidently expected. 3. Wound healing by first intention requires, in addition to adequate debridement of the deep layers of the wound, careful approximation of healthy wound edges without excessive tension. An adequate knowledge of skin-plastic procedures is essential to achieve this. 4. A combination of systemic penicillin and streptomycin in adequate doses is a safe and effective prophylactic antibiotic for use in the treatment of open fractures

Aims

The purpose of this study was to: review the efficacy of the induced membrane technique (IMT), also known as the Masquelet technique; and investigate the relationship between patient factors and technique variations on the outcomes of the IMT.

We studied the outcome and functional status of 33 patients with 34 severe open tibial fractures (Gustilo grade IIIb and IIIc). The treatment regime consisted of radical debridement, immediate bony stabilisation and early soft-tissue cover using a muscle flap (free or rotational). The review included standardised assessments of health-related quality of life (SF-36 and Euroqol) and measurement of the following parameters: gait, the use of walking aids, limb-length discrepancy, knee and ankle joint function, muscle wasting and the cosmetic appearance of the limb. Personal comments and overall patient satisfaction were also recorded. The mean follow-up was 46 months (15 to 80). There were 30 Gustilo grade IIIb fractures and and four grade IIIc fractures. Of the 33 patients, 29 had primary internal fixation and four, external fixation; 11 (34%) later required further surgery to achieve union and two needed bone transport procedures to reconstruct large segmental defects. The mean time to union was 41 weeks (12 to 104). Two patients (6.1%) developed deep infection; both resolved with treatment. The mean SF-36 physical and mental scores were 49 and 62 respectively. The mean state of health score for the Euroqol was 68. Patients with isolated tibial fractures had a better outcome than those with other associated injuries on both scoring systems. Knee stiffness was noted in seven patients (21%) and ankle stiffness in 19 (56%); 12 patients (41%) returned to work. Our results compare favourably with previous outcome measurements published for both limb salvage and amputation. All patients were pleased to have retained their limbs

Aims

Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery.

Eighty elbows in 65 patients with an average age of 57 years have had two-part non-constrained Liverpool elbow arthroplasties performed since 1974. Fifty-five had rheumatoid arthritis, eight osteoarthritis or ankylosis secondary to injury, one osteochondritis dissecans and one pyknodysostosis. The average preoperative range of movement was 42 degrees to 112 degrees with 47 degrees of pronation and 42 degrees of supination. There was significant gain in the arc of movements at follow-up: 32 degrees in the extension-flexion range (average range 32 degrees to 134 degrees of flexion) and 42 degrees in forearm rotation (average pronation 69 degrees and supination 62 degrees). Before operation severe pain was the predominating symptom in 43 elbows (53.8%) but after replacement there was only moderate pain in five elbows (6.2%). The results were excellent in 42 (52.5%), good in 15 (18.7%), fair in 9 (11.3%) and unsatisfactory or poor in 14 (17.5%). Eight elbows required revision of the arthroplasty: three were post-traumatic, disorganised or osteoarthritic joints, three rheumatoid and both elbows in the patient with pyknodysostosis. Loosening of the prosthesis (particularly the humeral component) was the common factor necessitating revision. Of six rheumatoid elbows needing removal of the implant, four had deep infection, one had a dislodged humeral component as a result of injury and in one a divided olecranon had developed non-union. Rheumatoid elbows benefited more than post-traumatic arthritic elbows from the operation. (ABSTRACT TRUNCATED AT 250 WORDS)

Aims

Dislocation is the most common indication for further surgery following total hip arthroplasty (THA) when undertaken in patients with a femoral neck fracture. This study aimed to assess the complication rates of THA with dual mobility components (THA-DMC) following a femoral neck fracture and to compare outcomes between THA-DMC, conventional THA, and hemiarthroplasty (HA).

Aims. The aim of this study is to introduce and investigate the efficacy and feasibility of a new vertebral osteotomy technique, vertebral column decancellation (VCD), for rigid thoracolumbar kyphotic deformity (TLKD) secondary to ankylosing spondylitis (AS). . Patients and Methods. We took 39 patients from between January 2009 and January 2013 (26 male, 13 female, mean age 37.4 years, 28 to 54) with AS and a TLKD who underwent VCD (VCD group) and compared their outcome with 45 patients (31 male, 14 female, mean age 34.8 years, 23 to 47) with AS and TLKD, who underwent pedicle subtraction osteotomy (PSO group), according to the same selection criteria. The technique of VCD was performed at single vertebral level in the thoracolumbar region of AS patients according to classification of AS kyphotic deformity. Pre- and post-operative chin-brow vertical angle (CBVA), sagittal vertical axis (SVA) and sagittal Cobb angle in the thoracolumbar region were reviewed in the VCD and PSO groups. Intra- , post-operative and general complications were analysed in both group. Results. lf patients could lie on their backs and walk with horizontal vision and sagittal profile, radiographic parameters improved significantly post-operatively in both groups. No major acute complications such as death or complete paralysis occurred in either group. In the VCD group, five patients (12.8%) experienced complications such as severe CSF leak (n = 4), deep wound infection (n = 1) and in one patient a transient neurological deficit occurred. In the PSO group, eight patients (17.8%) suffered conditions such as severe CSF leak (n = 5), infections (n = 2) and sagittal translation at osteotomy site (n = 1). Scoliosis Research Society outcomes instrument (SRS-22) improved significantly in both groups. All patients achieved solid fusion at latest follow-up and no implant failures were noted in either group. Take home message: The VCD technique is a new, safe and effective strategy for correction of rigid TLKD in AS patients. The main advantage of the new correction mechanism is that it achieved a satisfactory correction by controlled anterior column opening and posterior column closing, avoiding the occurrence of sagittal translation. Cite this article: Bone Joint J 2016;98-B:672–8

Aims. We present the results of correcting a double or triple curve adolescent idiopathic scoliosis using a convex segmental pedicle screw technique. Patients and Methods. We reviewed 191 patients with a mean age at surgery of 15 years (11 to 23.3). Pedicle screws were placed at the convexity of each curve. Concave screws were inserted at one or two cephalad levels and two caudal levels. The mean operating time was 183 minutes (132 to 276) and the mean blood loss 0.22% of the total blood volume (0.08% to 0.4%). Multimodal monitoring remained stable throughout the operation. The mean hospital stay was 6.8 days (5 to 15). Results. The mean post-operative follow-up was 5.8 years (2.5 to 9.5). There were no neurological complications, deep wound infection, obvious nonunion or need for revision surgery. Upper thoracic scoliosis was corrected by a mean 68.2% (38% to 48%, p < 0.001). Main thoracic scoliosis was corrected by a mean 71% (43.5% to 8.9%, p < 0.001). Lumbar scoliosis was corrected by a mean 72.3% (41% to 90%, p < 0.001). No patient lost more than 3° of correction at follow-up. The thoracic kyphosis improved by 13.1° (-21° to 49°, p < 0.001); the lumbar lordosis remained unchanged (p = 0.58). Coronal imbalance was corrected by a mean 98% (0% to 100%, p < 0.001). Sagittal imbalance was corrected by a mean 96% (20% to 100%, p < 0.001). The Scoliosis Research Society Outcomes Questionnaire score improved from a mean 3.6 to 4.6 (2.4 to 4, p < 0.001); patient satisfaction was a mean 4.9 (4.8 to 5). . Conclusions. This technique carries low neurological and vascular risks because the screws are placed in the pedicles of the convex side of the curve, away from the spinal cord, cauda equina and the aorta. A low implant density (pedicle screw density 1.2, when a density of 2 represents placement of pedicle screws bilaterally at every instrumented segment) achieved satisfactory correction of the scoliosis, an improved thoracic kyphosis and normal global sagittal balance. Both patient satisfaction and functional outcomes were excellent. Cite this article: Bone Joint J 2017;99-B:1080–7

Internal hemipelvectomy is a standard treatment for malignant tumours of the pelvis. Reconstruction using a non-vascularised fibular graft is relatively straightforward compared to other techniques. We describe the surgical and functional outcomes for a series of ten patients who underwent an internal hemipelvectomy (type I or I/IV) with reconstruction by a non-vascularised fibular graft between 1996 and 2009. A key prerequisite for this procedure was a preserved sciatic notch, confirmed pre-operatively on MRI. Graft-host union was achieved in all patients with a single fibular graft, and in the lower graft where two grafts had been used. The mean time to union was 7.3 months (3 to 12). The upper graft did not unite in four of six cases where two grafts had been used. Seven patients were eventually able to walk without a stick. The mean post-operative Musculoskeletal Tumour Society score was 75.4% (16.7 to 96.7). There were no cases of deep post-operative infection. The mean pelvic shortening was 0.9 cm (0.2 to 3.4). Recurrent tumour occurred in three cases, and death from tumour-related disease occured in one. Patients who need an internal hemipelvectomy will do well if their pelvic ring is reconstructed with a non-vascularised fibular graft. The complication rate is low, and they attain a good functional outcome

A total of 370 consecutive primary total knee replacements performed for osteoarthritis were followed up prospectively at 6, 18, 36 and 60 months. The Knee Society score and complications (perioperative mortality, superficial and deep wound infection, deep-vein thrombosis and revision rate) were recorded. By dividing the study sample into subgroups based on the body mass index overall, the body mass index in female patients and the absolute body-weight. The outcome in obese and non-obese patients was compared. A repeated measures analysis of variance showed no difference in the Knee Society score between the subgroups. There was no statistically-significant difference in the complication rates for the subgroups studied. Obesity did not influence the clinical outcome five years after total knee replacement

We describe the results of treatment of open tibial fractures in 92 children; 22 fractures were Gustilo type I, 51 type II and 19 type III. All children received tetanus prophylaxis, systemic antibiotics for 48 hours and thorough debridement and irrigation of the wound. Fifty-one wounds with minimal soft-tissue injury were closed primarily. The other 41 were initially left open; of these, 18 small wounds were allowed to heal secondarily and 23 larger wounds required split skin grafts or soft-tissue local or microvascular free flaps. Stable fractures were reduced and immobilised in an above-knee plaster cast (71%) and external fixation (28%) was used for unstable fractures, extensive soft-tissue injury and multiple injuries. Short-term complications included compartment syndrome (4%), superficial infection (8%), deep infection (3%), delayed union (16%), nonunion (7.5%) and malunion (6.5%): these incidences are similar to those reported in adults. Selective primary closure of wounds did not increase the incidence of infection. External fixation was associated with a greater occurrence of delayed and nonunion than plaster immobilisation, but this technique was used most often for the more severe injuries. Late review, at 1.5 to 9.8 years, showed a high incidence of continuing morbidity including pain at the healed fracture site (50%), restriction of sporting activity (23%), joint stiffness (23%), cosmetic defects (23%) and minor leg-length discrepancies (64%). Open tibial fractures in children are associated with a high incidence of early and late complications, which are more frequent in children with Gustilo type III injuries. The Gustilo classification was a useful guide for predicting the outcome and planning treatment