The June 2014 Foot & Ankle Roundup³⁶⁰ looks at: peroneal tendon tears associated with calcaneal fractures; syndesmosis procedure for first ray deformities; thromboprophylaxis not necessary in elective Ilizarov surgery; ankle replacement gaining traction in academic centres; some evidence for PRP and; fusion nailing and osteotomy an effective treatment for symptomatic tibial malunion

Our aim was to determine the effect of the initial pattern of fracture and the displacement of fragments on the outcome of proximal humeral fractures treated conservatively. We followed 93 consecutive patients prospectively for one year. Final movement and strength were compared with those of the contralateral side. The final American Shoulder and Elbow Society score and the Disabilities of Arm, Shoulder and Hand and Short-Form 36 questionnaires were compared with those provided by the patient on the day of the injury. Radiographs and CT scans with three-dimensional reconstruction were obtained in all patients. The pattern of the fracture and the displacement of individual fragments were analysed and correlated with the final outcome. There were two cases of nonunion and six of avascular necrosis. The majority of the fractures (84 patients; 90%) followed one of the following four patterns: posteromedial (varus) impaction in 50 patients (54%), lateral (valgus) impaction in 13 (14%), isolated greater tuberosity in 15 (16%), and anteromedial impaction fracture in six (6%). Head orientation, impaction of the surgical neck and displacement of the tuberosity correlated strongly with the outcome.

In fractures with posteromedial impaction, a poor outcome was noted as the articular surface displaced inferiorly increasing its distance from the acromion. A poorer outcome was noted as a fractured greater tuberosity displaced medially overlapping with the posterior articular surface. Lateral impaction fractures had a worse outcome than other patterns of fracture.

The purpose of this study was to compare the clinical and radiological outcome of patients with intact, broken and removed syndesmosis screws after Weber B or C ankle fracture with an associated injury to the syndesmosis. We hypothesised that there would be no difference. Of a possible 142 patients who fulfilled our inclusion criteria, 52 returned for clinical and radiological assessment at least one year after surgery. Of these, 27 had intact syndesmosis screws, ten had broken screws, and 15 had undergone elective removal of the screw. The mean American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 83.07 (sd 13.59) in the intact screw group, 92.40 (sd 12.69) in the broken screw group, and 85.80 (sd 11.33) in the removed screw group (p = 0.0466).

There was no difference in clinical outcome of patients with intact or removed syndesmotic screws. Paradoxically, patients with a broken syndesmosis screw had the best clinical outcome. Our data do not support the removal of intact or broken syndesmosis screws, and we caution against attributing post-operative ankle pain to breakage of the syndesmosis screw.

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities.

We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D).

There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation.

We describe a modified technique of micro-decompression of the lumbar spine involving the use of an operating microscope, a malleable retractor and a high-speed burr, which allows decompression to be performed on both sides of the spine through a unilateral, hemi-laminectomy approach. The first 100 patients to be treated with this technique have been evaluated prospectively using a visual analogue score for sciatica and back pain, the MacNab criteria for patient satisfaction, and functional assessment with the Oswestry Disability Index.

After a period of follow-up from 12 months to six years and four months, sciatica had improved in 90 patients and back pain in 84 patients. Their result was graded as good or excellent by 82 patients according to the MacNab criteria, and 75 patients had subjective improvement in their walking distance. Late instability developed in four patients.

Lumbar micro-decompression has proved to be safe, with few complications. Postoperative instability requiring fusion was uncommon, and less than using traditional approaches in published series.

The Motec cementless modular metal-on-metal ball-and-socket wrist arthroplasty was implanted in 16 wrists with scaphoid nonunion advanced collapse (SNAC; grades 3 or 4) and 14 wrists with scapholunate advanced collapse (SLAC) in 30 patients (20 men) with severe (grades 3 or 4) post-traumatic osteoarthritis of the wrist. The mean age of the patients was 52 years (31 to 71). All prostheses integrated well radiologically. At a mean follow-up of 3.2 years (1.1 to 6.1) no luxation or implant breakage occurred. Two wrists were converted to an arthrodesis for persistent pain. Loosening occurred in one further wrist at five years post-operatively. The remainder demonstrated close bone–implant contact. The clinical results were good, with markedly decreased Disabilities of the Arm Shoulder and Hand (DASH) and pain scores, and increased movement and grip strength. No patient used analgesics and most had returned to work.

Good short-term function was achieved using this wrist arthroplasty in a high-demand group of patients with post-traumatic osteoarthritis.

Malunion is the most common complication of the distal radius with many modalities of treatment available for such a problem. The use of bone grafting after an osteotomy is still recommended by most authors. We hypothesised that bone grafting is not required; fixing the corrected construct with a volar locked plate helps maintain the alignment, while metaphyseal defect fills by itself. Prospectively, we performed the procedure on 30 malunited dorsally-angulated radii using fixed angle volar locked plates without bone grafting. At the final follow-up, 22 wrists were available. Radiological evidence of union, correction of the deformity, clinical and functional improvement was achieved in all cases. Without the use of bone grafting, corrective open wedge osteotomy fixed by a volar locked plate provides a high rate of union and satisfactory functional outcomes.

The purpose of this study was to determine whether patients with a burst fracture of the thoracolumbar spine treated by short segment pedicle screw fixation fared better clinically and radiologically if the affected segment was fused at the same time. A total of 50 patients were enrolled in a prospective study and assigned to one of two groups. After the exclusion of three patients, there were 23 patients in the fusion group and 24 in the non-fusion group. Follow-up was at a mean of 23.9 months (18 to 30). Functional outcome was evaluated using the Greenough Low Back Outcome Score. Neurological function was graded using the American Spinal Injury Association Impairment Scale. Radiological outcome was assessed on the basis of the angle of kyphosis.

Peri-operative blood transfusion requirements and duration of surgery were significantly higher in the fusion group (p = 0.029 and p < 0.001, respectively). There were no clinical or radiological differences in outcome between the groups (all outcomes p > 0.05). The results of this study suggest that adjunctive fusion is unnecessary when managing patients with a burst fracture of the thoracolumbar spine with short segment pedicle screw fixation.

The purpose of this study was to evaluate whether concerns about the release of metal ions in metal-on-metal total hip replacements (THR) should be extended to patients with metal-bearing total disc replacements (TDR).

Cobalt and chromium levels in whole blood and serum were measured in ten patients with a single-level TDR after a mean follow-up of 34.5 months (13 to 61) using inductively-coupled plasma mass spectrometry. These metal ion levels were compared with pre-operative control levels in 81 patients and with metal ion levels 12 months after metal-on-metal THR (n = 21) and resurfacing hip replacement (n = 36). Flexion-extension radiographs were used to verify movement of the TDR.

Cobalt levels in whole blood and serum were significantly lower in the TDR group than in either the THR (p = 0.007) or the resurfacing group (p < 0.001). Both chromium levels were also significantly lower after TDR versus hip resurfacing (p < 0.001), whereas compared with THR this difference was only significant for serum levels (p = 0.008). All metal ion levels in the THR and resurfacing groups were significantly higher than in the control group (p < 0.001). In the TDR group only cobalt in whole blood appeared to be significantly higher (p < 0.001). The median range of movement of the TDR was 15.5° (10° to 22°).

These results suggest that there is minimal cause for concern about high metal ion concentrations after TDR, as the levels appear to be only moderately elevated. However, spinal surgeons using a metal-on-metal TDR should still be aware of concerns expressed in the hip replacement literature about toxicity from elevated metal ion levels, and inform their patients appropriately.

Linburg-Comstock syndrome is characterised by an anomalous tendon slip from the flexor pollicis longus to the flexor digitorum profundus, usually of the index finger. An incidence as high as 60% to 70% has been reported. Post-traumatic inflammation of inter-tendinous connections between the flexor pollicis longus and flexor digitorum profundus, usually of the index finger, may cause unexplained chronic pain in the distal forearm. A total of 11 patients (eight females, three males), mean age 29.1 years (14 to 47) with a clinical diagnosis of Linburg-Comstock syndrome underwent surgical release of the inter-tendinous connection. The mean follow-up was for 27 months (2 to 48).

Ten patients reported excellent relief of pain in the forearm, with independent flexion of flexor pollicis longus and flexor digitorum profundus to the index finger. Surgical release was an effective treatment for the Linburg-Comstock syndrome in this series.

Cartilage repair in terms of replacement, or regeneration of damaged or diseased articular cartilage with functional tissue, is the ‘holy grail’ of joint surgery. A wide spectrum of strategies for cartilage repair currently exists and several of these techniques have been reported to be associated with successful clinical outcomes for appropriately selected indications. However, based on respective advantages, disadvantages, and limitations, no single strategy, or even combination of strategies, provides surgeons with viable options for attaining successful long-term outcomes in the majority of patients. As such, development of novel techniques and optimisation of current techniques need to be, and are, the focus of a great deal of research from the basic science level to clinical trials. Translational research that bridges scientific discoveries to clinical application involves the use of animal models in order to assess safety and efficacy for regulatory approval for human use. This review article provides an overview of animal models for cartilage repair.

Cite this article: Bone Joint Res 2014;4:89–94.

We systematically reviewed all the evidence published in the English language on proximal interphalangeal joint (PIPJ) replacement, to determine its effectiveness on the function of the hand and the associated post-operative complications.

Original studies were selected if they reported clinical outcome with a minimum of one year’s follow-up. Quality was assessed using the Cowley systematic review criteria modified for finger-joint replacements. Of 319 articles identified, only five were adequately reported according to our quality criteria; there were no randomised controlled trials. PIPJ replacements had a substantial effect size on hand pain of -23.2 (95% confidence interval (CI) -27.3 to -19.1) and grip strength 1.2 (95% CI -10.7 to 13.1), and a small effect on range of movement 0.2 (95% CI -0.4 to 0.8). A dorsal approach was most successful. Post-operative loosening occurred in 10% (95% CI 3 to 30) of ceramic and 12.5% (95% CI 7 to 21) of pyrocarbon replacements. Post-operative complications occurred in 27.8% (95% CI 20 to 37).

We conclude that the effectiveness of PIPJ replacement has not been established. Small observational case studies and short-term follow-up, together with insufficient reporting of patient data, functional outcomes and complications, limit the value of current evidence.

We recommend that a defined core set of patients, surgical and outcome data for this intervention be routinely and systematically collected within the framework of a joint registry.

A total of 159 patients (84 women and 75 men, mean age of 53 (20 to 87)) with subacromial impingement were randomised to treatment with subacromial injections using lidocaine with one of hyaluronic acid (51 patients), corticosteroid (53 patients) or placebo (55 patients). Patients were followed up for 26 weeks. The primary outcome was pain on a visual analogue score (VAS), and secondary outcomes included the Constant Murley score, shoulder pain score, functional mobility score, shoulder disability questionnaire and pain-specific disability score. The different outcome measures showed similar results. After three, six and 12 weeks corticosteroid injections were superior to hyaluronic acid injections and only at six weeks significantly better than placebo injections. The mean short-term reduction in pain on the VAS score at 12 weeks was 7% (sd 2.7; 97.5% confidence interval (CI) 0.207 to 1.55; p = 0.084) in the hyaluronic acid group, 28% (sd 2.8; 97.5% CI 1.86 to 3.65; p < 0.001) in the corticosteroid group and 23% (sd 3.23; 97.5% CI 1.25 to 3.26; p < 0.001) in the placebo group. At 26 weeks there was a reduction in pain in 63% (32 of 51) of patients in the hyaluronic acid group, 72% (38 of 53) of those in the corticosteroid group and 69% (38 of 55) of those in the placebo group.

We were not able to show a convincing benefit from hyaluronic acid injections compared with corticosteroid or placebo injections. Corticosteroid injections produced a significant reduction in pain in the short term (three to 12 weeks), but in the long term the placebo injection produced the best results.

We investigated the pre-operative and one-year post-operative health-related quality of life (HRQoL) outcome by using a Euroqol (EQ-5D) questionnaire in 230 patients who underwent surgery for lumbar spinal stenosis. Data were obtained from the National Swedish Registry for operations on the lumbar spine between 2001 and 2002. We analysed the pre- and postoperative quality of life data, age, gender, smoking habits, pain and walking ability. The relative differences were compared to a Swedish EQ-5D population survey.

The mean age of the patients was 66 years, and there were 123 females (53%). Before the operation 62 (27%) of the patients could walk more than 500 m. One year after the operation 150 (65%) were able to walk 500 m or more.

The mean EQ-5D score improved from 0.36 to 0.64, and the HRQoL improved in 184 (80%) of the patients. However, they did not reach the level reported by a matched population sample (mean difference 0.18). Women had lower pre- and post-operative EQ-5D scores than men. Severe low back pain was a predictor for a poor outcome.

The Bologna–Oxford (BOX) total ankle replacement (TAR) was developed with the aim of achieving satisfactory pain-free movement of the ankle. To date, only one single multicentre study has reported its clinical results. The aim of this study was to conduct an independent review of its mid-term results.

We retrospectively reviewed a total of 60 prospectively followed patients in whom 62 BOX TARs had been implanted between 2004 and 2008. We used the American Orthopedic Foot and Ankle Society (AOFAS) score to assess the clinical results. Standardised radiographs taken at the time of final follow-up were analysed by two observers. The overall survival was 91.9% at a mean follow-up of 42.5 months (24 to 71). The mean AOFAS score had improved from 35.1 points (sd 16.6; 4 to 73) pre-operatively to 78.0 (sd 10.7; 57 to 100) at final follow-up (p < 0.01). Tibial radiolucencies < 2 mm in width were seen around 16 TARs. Talar radiolucencies < 2 mm were seen around four TARs. A total of 47 patients (78.3%) were very satisfied or satisfied with the outcome. Five patients required revision for functional limitation or continuing pain.

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment.

Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p − 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8°, p = 0.003) and for reduction in pain (difference on a visual analogue scale −1.7 cm, p < 0.0005).

The December 2013 Wrist & Hand Roundup³⁶⁰ looks at: Scapholunate instability; three-ligament tenodesis; Pronator quadratus; Proximal row carpectomy; FPL dysfunction after volar plate fixation; Locating the thenar branch of the median nerve; Metallosis CMCJ arthroplasties; and timing of flap reconstruction

We undertook a prospective pilot study to determine whether arthroscopic surgery through the central compartment of the hip was effective in the management of a snapping iliopsoas tendon. Seven patients were assessed pre-operatively and at three, six, 12 and 24 months after operation. This included the assessment of pain on a visual analogue scale (VAS) and function using the modified Harris hip score.

All the patients had resolution of snapping post-operatively and this persisted at follow-up at two years. The mean VAS score for pain fell from 7.7 (6 to 10) pre-operatively to 4.3 (0 to 10) by three months (p = 0.051), and to 3.6 (1 to 8) (p = 0.015), 2.4 (0 to 8) (p = 0.011) and 2.4 (0 to 8) (p = 0.011) by six, 12 and 24 months, respectively. The mean modified Harris hip score increased from 56.1 (13.2 to 84.7) pre-operatively to 88.4 (57.2 to 100) at one year (p = 0.018) and to 87.9 (49.5 to 100) at two years (p = 0.02). There were no complications and no weakness occurred in the musculature around the hip.

Our findings suggest that this treatment is effective and would support the undertaking of a larger study comparing this procedure with other methods of treatment.

The lateral subvastus approach combined with an osteotomy of the tibial tubercle is a recognised, but rarely used approach for total knee replacement (TKR). A total of 32 patients undergoing primary TKR was randomised into two groups, in one of which the lateral subvastus approach combined with a tibial tubercle osteotomy and in the other the medial parapatellar approach were used. The patients were assessed radiologically and clinically using measurement of the range of movement, a visual analogue patient satisfaction score, the Western Ontario McMasters University Osteoarthritis Index and the American Knee Society score. Four patients were lost to the complete follow-up at two years.

At two years there were no significant differences between the groups in any of the parameters for clinical outcome. In the lateral approach group there was one complication due to displacement of the tibial tubercle osteotomy and two osteotomies took more than six months to unite. In the medial approach group, one patient had a partial tear of the quadriceps. There was a significantly greater incidence of lateral patellar subluxation in the medial approach group (3 of 12) compared with the lateral approach group (0 of 16) (p = 0.034), but without any apparent clinical detriment.

We conclude that the lateral approach with tibial tubercle osteotomy is a safe technique with an outcome comparable with that of the medial parapatellar approach for TKR, but the increased surgical time and its specific complications do not support its routine use. It would seem to be more appropriate to reserve this technique for patients in whom problems with patellar tracking are anticipated.

The February 2014 Knee Roundup³⁶⁰ looks at: whether sham surgery is as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether trans-tibial tunnel placement increases the risk of graft failure in ACL surgery; whether joint replacements prevent cardiac events; the size of the pulmonary embolism problem; tranexamic acid and knee replacement haemostasis; matching the demand for knee replacement and follow-up; predicting the length of stay after knee replacement; and popliteal artery injury in TKR.