This study sought to determine the medium-term
patient-reported and radiographic outcomes in patients undergoing
surgery for hallux valgus. A total of 118 patients (162 feet) underwent
surgery for hallux valgus between January 2008 and June 2009. The
Manchester-Oxford Foot Questionnaire (MOXFQ), a validated tool for
the assessment of outcome after surgery for hallux valgus, was used
and patient satisfaction was sought. The medical records and radiographs
were reviewed retrospectively. At a mean of 5.2 years (4.7 to 6.0)
post-operatively, the median combined MOXFQ score was 7.8 (IQR:0
to 32.8). The median domain scores for pain, walking/standing, and social
interaction were 10 (IQR: 0 to 45), 0 (IQR: 0 to 32.1) and 6.3 (IQR:
0 to 25) respectively. A total of 119 procedures (73.9%, in 90 patients)
were reported as satisfactory but only 53 feet (32.7%, in 43 patients)
were completely asymptomatic. The mean (SD) correction of hallux
valgus, intermetatarsal, and distal metatarsal articular angles was
18.5° (8.8°), 5.7° (3.3°), and 16.6° (8.8°), respectively. Multivariable
regression analysis identified that an American Association of Anesthesiologists
grade of >
1 (Incident Rate Ratio (IRR) = 1.67, p-value = 0.011)
and recurrent deformity (IRR = 1.77, p-value = 0.003) were associated
with significantly worse MOXFQ scores. No correlation was found
between the severity of deformity, the type, or degree of surgical
correction and the outcome. When using a validated outcome score
for the assessment of outcome after surgery for hallux valgus, the
long-term results are worse than expected when compared with the
short- and mid-term outcomes, with 25.9% of patients dissatisfied
at a mean follow-up of 5.2 years. Cite this article:
To assess the sustainability of our institutional
bone bank, we calculated the final product cost of fresh-frozen femoral
head allografts and compared these costs with the use of commercial
alternatives. Between 2007 and 2010 all quantifiable costs associated
with allograft donor screening, harvesting, storage, and administration
of femoral head allografts retrieved from patients undergoing elective
hip replacement were analysed. From 290 femoral head allografts harvested and stored as full
(complete) head specimens or as two halves, 101 had to be withdrawn.
In total, 104 full and 75 half heads were implanted in 152 recipients.
The calculated final product costs were €1367 per full head. Compared
with the use of commercially available processed allografts, a saving
of at least €43 119 was realised over four-years (€10 780 per year)
resulting in a cost-effective intervention at our institution. Assuming
a price of between €1672 and €2149 per commercially purchased allograft,
breakeven analysis revealed that implanting between 34 and 63 allografts
per year equated to the total cost of bone banking. Cite this article:
Our aim was to compare the one-year post-operative
outcomes following retention or removal of syndesmotic screws in
adult patients with a fracture of the ankle that was treated surgically.
A total of 51 patients (35 males, 16 females), with a mean age of
33.5 years (16 to 62), undergoing fibular osteosynthesis and syndesmotic
screw fixation, were randomly allocated to retention of the syndesmotic
screw or removal at three months post-operatively. The two groups
were comparable at baseline. One year post-operatively, there was no significant difference
in the mean Olerud–Molander ankle score (82.4 retention We conclude that removal of a syndesmotic screw produces no significant
functional, clinical or radiological benefit in adult patients who
are treated surgically for a fracture of the ankle. Cite this article:
The aim of this study was to define return to
theatre (RTT) rates for elective hip and knee replacement (HR and
KR), to describe the predictors and to show the variations in risk-adjusted
rates by surgical team and hospital using national English hospital
administrative data. We examined information on 260 206 HRs and 315 249 KRs undertaken
between April 2007 and March 2012. The 90-day RTT rates were 2.1%
for HR and 1.8% for KR. Male gender, obesity, diabetes and several
other comorbidities were associated with higher odds for both index
procedures. For HR, hip resurfacing had half the odds of cement fixation
(OR = 0.58, 95% confidence intervals (CI) 0.47 to 0.71). For KR,
unicondylar KR had half the odds of total replacement (OR = 0.49,
95% CI 0.42 to 0.56), and younger ages had higher odds (OR = 2.23,
95% CI 1.65 to 3.01) for ages <
40 years compared with ages 60
to 69 years). There were more funnel plot outliers at three standard deviations
than would be expected if variation occurred on a random basis. Hierarchical modelling showed that three-quarters of the variation
between surgeons for HR and over half the variation between surgeons
for KR are not explained by the hospital they operated at or by
available patient factors. We conclude that 90-day RTT rate may
be a useful quality indicator for orthopaedics. Cite this article:
We report our early experience with the use of
a new prosthesis, the Modular Hemipelvic Prosthesis II, for reconstruction
of the hemipelvis after resection of a primary malignant peri-acetabular
tumour involving the sacroiliac joint. We retrospectively reviewed the outcome of 17 patients who had
undergone resection of a pelvic tumour and reconstruction with this
prosthesis between July 2002 and July 2010. One patient had a type I+II+III+IV resection (ilium + peri-acetabulum
+ pubis/ischium + sacrum) and 16 had a type I+II+IV resection (ilium
+ acetabulum + sacrum). The outcome was assessed at a mean follow-up
of 33 months (15 to 59). One patient was alive with disease, 11
were alive without disease and five had died of disease. The overall
five-year survival rate was 62.4%. Six patients had a local recurrence.
The mean Musculoskeletal Tumour Society score was 58% (33 to 77).
Deep infection occurred in two patients, problems with wound healing
in five and dislocation in one. For patients with a primary malignant peri-acetabular sarcoma
involving the sacroiliac joint, we believe that this new prosthesis
is a viable option for reconstruction of the bony defect left following
resection of the tumour. It results in a satisfactory functional
outcome with an acceptable rate of complications. Cite this article:
In a decidedly upper limb themed series of reviews this edition of Cochrane Corner summarises four new and updated reviews published by the Cochrane Bone, Joint and Muscle Trauma Group over the last few months. The tenacious reviewers at the Cochrane collaboration have turned their beady eyes to conservative treatments for shoulder dislocations and clavicle fractures along with evaluation of femoral nerve blocks in knee replacement and how to best manage entrapment injuries in children.
We prospectively followed 171 patients who underwent
bilateral unicompartmental knee replacement (UKR) over a period
of two years. Of these, 124 (72.5%) underwent a simultaneous bilateral
procedure and 47 (27.5%) underwent a staged procedure. The mean
cumulative operating time and length of hospital stay were both
shorter in the simultaneous group, by 22.5 minutes (p <
0.001)
and three days (p <
0.001), respectively. The mean reduction
in haemoglobin level post-operatively was greater by 0.15 g/dl in
the simultaneous group (p = 0.023), but this did not translate into
a significant increase in the number of patients requiring blood
transfusion (p = 1.000). The mean hospital cost was lower by $8892
in the simultaneous group (p <
0.001). There was no significant
difference in the rate of complications between the groups, and
at two-year follow-up there was no difference in the outcomes between
the two groups. We conclude that simultaneous bilateral UKR can be recommended
as an appropriate treatment for patients with bilateral medial compartment
osteoarthritis of the knee. Cite this article:
The aim of this study was to examine the functional
outcome at ten years following lateral closing wedge high tibial osteotomy
for medial compartment osteoarthritis of the knee and to define
pre-operative predictors of survival and determinants of functional
outcome. 164 consecutive patients underwent high tibial osteotomy between
2000 and 2002. A total of 100 patients (100 knees) met the inclusion
criteria and 95 were available for review at ten years. Data were
collected prospectively and included patient demographics, surgical
details, long leg alignment radiographs, Western Ontario and McMaster Universities
osteoarthritis index (WOMAC) and Knee Society scores (KSS) pre-operatively
and at five and ten years follow-up. At ten years, 21 patients had been revised at a mean of five
years. Overall Kaplan–Meier survival was 87% (95% confidence interval
(CI) 81 to 94) and 79% (95% CI 71 to 87) at five and ten years,
respectively. When compared with unrevised patients, those who had
been revised had significantly lower mean pre-operative WOMAC Scores
(47 (21 to 85) This study has shown that improved survival is associated with
age <
55 years, pre-operative WOMAC scores >
45 and, a BMI <
30. In patients over 55 years of age with adequate pre-operative
functional scores, survival can be good and functional outcomes
can be significantly better than their younger counterparts. We
recommend the routine use of pre-operative functional outcome scores
to guide decision-making when considering suitability for high tibial osteotomy. Cite this article:
Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. However, trials supporting its use have not fully evaluated the risks of wound complications. This study of 1048 total hip/knee replacements records the rates of return to theatre and infection before and after the change from a low molecular weight heparin (tinzaparin) to rivaroxaban as the agent of chemical thromboprophylaxis in patients undergoing lower-limb arthroplasty. During a period of 13 months, 489 consecutive patients undergoing lower-limb arthroplasty received tinzaparin and the next 559 consecutive patients received rivaroxaban as thromboprophylaxis. Nine patients in the control (tinzaparin) group (1.8%, 95% confidence interval 0.9 to 3.5) returned to theatre with wound complications within 30 days, compared with 22 patients in the rivaroxaban group (3.94%, 95% confidence interval 2.6 to 5.9). This increase was statistically significant (p = 0.046). The proportion of patients who returned to theatre and became infected remained similar (p = 0.10). Our study demonstrates the need for further randomised controlled clinical trials to be conducted to assess the safety and efficacy of rivaroxaban in clinical practice, focusing on the surgical complications as well as the potential prevention of venous thromboembolism.
The April 2013 Research Roundup360 looks at: when the ‘residency cake’ is done; steroids, stem cells and tendons; what exactly is osteoarthritis; platelet-rich plasma; CRPS; d-Dimer for DVT; reducing bacterial adhesion; and fin or limb?
In March 2012, an algorithm for the treatment
of intertrochanteric fractures of the hip was introduced in our academic
department of Orthopaedic Surgery. It included the use of specified
implants for particular patterns of fracture. In this cohort study,
102 consecutive patients presenting with an intertrochanteric fracture
were followed prospectively (post-algorithm group). Another 117
consecutive patients who had been treated immediately prior to the
implementation of the algorithm were identified retrospectively
as a control group (pre-algorithm group). The total cost of the
implants prior to implementation of the algorithm was $357 457 (mean:
$3055 (1947 to 4133)); compared with $255 120 (mean: $2501 (1052
to 4133)) after its implementation. There was a trend toward fewer complications
in patients who were treated using the algorithm (33% pre- The implementation of an evidence-based algorithm for the treatment
of intertrochanteric fractures reduced costs while maintaining quality
of care with a lower rate of complications and re-admissions. Cite this article:
Nanotechnology is the study, production and controlled
manipulation of materials with a grain size <
100 nm. At this
level, the laws of classical mechanics fall away and those of quantum
mechanics take over, resulting in unique behaviour of matter in
terms of melting point, conductivity and reactivity. Additionally,
and likely more significant, as grain size decreases, the ratio
of surface area to volume drastically increases, allowing for greater interaction
between implants and the surrounding cellular environment. This
favourable increase in surface area plays an important role in mesenchymal
cell differentiation and ultimately bone–implant interactions. Basic science and translational research have revealed important
potential applications for nanotechnology in orthopaedic surgery,
particularly with regard to improving the interaction between implants
and host bone. Nanophase materials more closely match the architecture
of native trabecular bone, thereby greatly improving the osseo-integration
of orthopaedic implants. Nanophase-coated prostheses can also reduce
bacterial adhesion more than conventionally surfaced prostheses.
Nanophase selenium has shown great promise when used for tumour
reconstructions, as has nanophase silver in the management of traumatic
wounds. Nanophase silver may significantly improve healing of peripheral
nerve injuries, and nanophase gold has powerful anti-inflammatory
effects on tendon inflammation. Considerable advances must be made in our understanding of the
potential health risks of production, implantation and wear patterns
of nanophase devices before they are approved for clinical use.
Their potential, however, is considerable, and is likely to benefit
us all in the future. Cite this article:
Arthroscopy of the knee is one of the most commonly
performed orthopaedic procedures worldwide. Large-volume outcome
data have not previously been available for English NHS patients.
Prospectively collected admissions data, routinely collected on
every English NHS patient, were analysed to determine the rates
of complications within 30 days (including re-operation and re-admission),
90-day symptomatic venous thromboembolism and all-cause mortality.
There were 301 701 operations performed between 2005 and 2010 –
an annual incidence of 9.9 per 10 000 English population. Of these,
16 552 (6%) underwent ligament reconstruction and 106 793 (35%)
underwent meniscal surgery. The 30-day re-admission rate was 0.64%
(1662) and 30-day wound complication rate was 0.26% (677). The overall
30-day re-operation rate was 0.40% (1033) and the 90-day pulmonary embolism
rate was 0.08% (230), of which six patients died. 90-day mortality
was 0.02% (47). Age <
40 years, male gender and ligament reconstruction
were significantly associated with an increased rate of 30-day re-admission
and unplanned re-operation. In addition, a significant increase
in 30-day admission rates were seen with Charlson comorbidity scores
of 1 (p = 0.037) and ≥ 2 (p <
0.001) compared with scores of
0, and medium volume units compared with high volume units (p <
0.001). Complications following arthroscopy of the knee are rare. It
is a safe procedure, which in the majority of cases is performed
as day case surgery. These data can be used for quality benchmarking,
in terms of consent, consultant re-validation and individual unit
performance.
We compared a new fixation system, the Targon
Femoral Neck (TFN) hip screw, with the current standard treatment of
cannulated screw fixation. This was a single-centre, participant-blinded,
randomised controlled trial. Patients aged 65 years and over with
either a displaced or undisplaced intracapsular fracture of the
hip were eligible. The primary outcome was the risk of revision
surgery within one year of fixation. A total of 174 participants were included in the trial. The absolute
reduction in risk of revision was of 4.7% (95% CI 14.2 to 22.5)
in favour of the TFN hip screw (chi-squared test, p = 0.741), which
was less than the pre-specified level of minimum clinically important
difference. There were no significant differences in any of the
secondary outcome measures. We found no evidence of a clinical difference in the risk of
revision surgery between the TFN hip screw and cannulated screw
fixation for patients with an intracapsular fracture of the hip. Cite this article:
The June 2014 Trauma Roundup360 looks at: BMP use increasing wound complication rates in trauma surgery; can we predict re-admission in trauma?; humeral bundle nailing; how best to treat high-angle femoral neck fractures?; hyperglycaemia and infection; simultaneous soft-tissue and bony repair in terrible triad injuries; metaphyseal malunion in the forearm leading to function restrictions; delayed fixation of the distal radius: not a bad option; and fasciotomies better with shoelaces
Metatarsus primus varus deformity correction
is one of the main objectives in hallux valgus surgery. A ‘syndesmosis’
procedure may be used to correct hallux valgus. An osteotomy is
not involved. The aim is to realign the first metatarsal using soft
tissues and a cerclage wire around the necks of the first and second
metatarsals. We have retrospectively assessed 27 patients (54 feet) using
the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs
and measurements of the plantar pressures after bilateral syndesmosis
procedures. There were 26 women. The mean age of the patients was
46 years (18 to 70) and the mean follow-up was 26.4 months (24 to
33.4). Matched-pair comparisons of the AOFAS scores, the radiological
parameters and the plantar pressure measurements were conducted
pre- and post-operatively, with the mean of the left and right feet.
The mean AOFAS score improved from 62.8 to 94.4 points (p <
0.001).
Significant differences were found on all radiological parameters
(p <
0.001). The mean hallux valgus and first intermetatarsal
angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1°
to 45.3°) (p <
0.001) and from 15.0° (10.2° to 18.6°) to 7.2°
(4.2° to 11.4°) (p <
0.001) respectively. The mean medial sesamoid
position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p <
0.001)
according to the Hardy’s scale (0 to 7). The mean maximum force
and the force–time integral under the hallux region were significantly
increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63
to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70
(1.28 to 19.23)) respectively. The occurrence of the maximum force
under the hallux region was delayed by 11% (p = 0.02), (87.3% stance
(36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data
reflected the restoration of the function of the hallux. Three patients
suffered a stress fracture of the neck of the second metatarsal.
The short-term results of this surgical procedure for the treatment
of hallux valgus are satisfactory. Cite this article:
Most animal studies indicate that early irrigation
and debridement reduce infection after an open fracture. Unfortunately,
these studies often do not involve antibiotics. Clinical studies
indicate that the timing of initial debridement does not affect
the rate of infection but these studies are observational and fraught
with confounding variables. The purpose of this study was to control
these variables using an animal model incorporating systemic antibiotics
and surgical treatment. We used a rat femur model with a defect which was contaminated
with No animal that received antibiotics and surgery two hours after
injury had detectable bacteria. When antibiotics were started at
two hours, a delay in surgical treatment from two to six hours significantly
increased the development of infection (p = 0.047). However, delaying
surgery to 24 hours increase the rate of infection, but not significantly
(p = 0.054). The timing of antibiotics had a more significant effect
on the proportion of positive samples than earlier surgery. Delaying
antibiotics to six or 24 hours had a profoundly detrimental effect
on the infection rate regardless of the timing of surgery. These
findings are consistent with the concept that bacteria progress
from a vulnerable planktonic form to a treatment-resistant biofilm.
The April 2014 Trauma Roundup360 looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture.
Proximal femoral resection (PFR) is a proven
pain-relieving procedure for the management of patients with severe cerebral
palsy and a painful displaced hip. Previous authors have recommended
post-operative traction or immobilisation to prevent a recurrence
of pain due to proximal migration of the femoral stump. We present
a series of 79 PFRs in 63 patients, age 14.7 years (10 to 26; 35
male, 28 female), none of whom had post-operative traction or immobilisation. A total of 71 hips (89.6%) were reported to be pain free or to
have mild pain following surgery. Four children underwent further
resection for persistent pain; of these, three had successful resolution
of pain and one had no benefit. A total of 16 hips (20.2%) showed
radiographic evidence of heterotopic ossification, all of which
had formed within one year of surgery. Four patients had a wound
infection, one of which needed debridement; all recovered fully.
A total of 59 patients (94%) reported improvements in seating and
hygiene. The results are as good as or better than the historical results
of using traction or immobilisation. We recommend that following
PFR, children can be managed without traction or immobilisation,
and can be discharged earlier and with fewer complications. However,
care should be taken with severely dystonic patients, in whom more
extensive femoral resection should be considered in combination
with management of the increased tone. Cite this article:
Using human cadaver specimens, we investigated
the role of supplementary fibular plating in the treatment of distal
tibial fractures using an intramedullary nail. Fibular plating is
thought to improve stability in these situations, but has been reported
to have increased soft-tissue complications and to impair union
of the fracture. We proposed that multidirectional locking screws
provide adequate stability, making additional fibular plating unnecessary.
A distal tibiofibular osteotomy model performed on matched fresh-frozen
lower limb specimens was stabilised with reamed nails using conventional
biplanar distal locking (CDL) or multidirectional distal locking
(MDL) options with and without fibular plating. Rotational stiffness
was assessed under a constant axial force of 150 N and a superimposed
torque of ± 5 Nm. Total movement, and neutral zone and fracture
gap movement were analysed. In the CDL group, fibular plating improved stiffness at the tibial
fracture site, albeit to a small degree (p = 0.013). In the MDL
group additional fibular plating did not increase the stiffness.
The MDL nail without fibular plating was significantly more stable
than the CDL nail with an additional fibular plate (p = 0.008). These findings suggest that additional fibular plating does not
improve stability if a multidirectional distal locking intramedullary
nail is used, and is therefore unnecessary if not needed to aid
reduction. Cite this article: