Pigmented villonodular synovitis (PVNS) is a
rare proliferative process of the synovium which most commonly affects
the knee and occurs in either a localised (LPVNS) or a diffuse form
(DPVNS). The effect of different methods of surgical synovectomy
and adjuvant radiotherapy on the rate of recurrence is unclear.
We conducted a systematic review and identified 35 observational
studies in English which reported the use of surgical synovectomy
to treat PVNS of the knee. A meta-analysis included 630 patients, 137 (21.8%) of whom had
a recurrence after synovectomy. For patients with DPVNS, low-quality
evidence found that the rate of recurrence was reduced by both open
synovectomy (odds ration (OR) = 0.47; 95% CI 0.25 to 0.90; p = 0.024)
and combined open and arthroscopic synovectomy (OR = 0.19, 95% CI
= 0.06 to 0.58; p = 0.003) compared with arthroscopic surgery. Very
low-quality evidence found that the rate of recurrence of DPVNS
was reduced by peri-operative radiotherapy (OR = 0.31, 95% CI 0.14
to 0.70; p = 0.01). Very low-quality evidence suggested that the
rate of recurrence of LPVNS was not related to the surgical approach. This meta-analysis suggests that open synovectomy or synovectomy
combined with peri-operative radiotherapy for DPVNS is associated
with a reduced rate of recurrence. Large long-term prospective multicentre
observational studies, with a focus on both rate of recurrence and
function, are required to confirm these findings. Cite this article:
The use of hinged implants in primary total knee
replacement (TKR) should be restricted to selected indications and mainly
for elderly patients. Potential indications for a rotating hinge
or pure hinge implant in primary TKR include: collateral ligament
insufficiency, severe varus or valgus deformity (>
20°) with necessary
relevant soft-tissue release, relevant bone loss including insertions
of collateral ligaments, gross flexion-extension gap imbalance,
ankylosis, or hyperlaxity. Although data reported in the literature
are inconsistent, clinical results depend on implant design, proper
technical use, and adequate indications. We present our experience
with a specific implant type that we have used for over 30 years
and which has given our elderly patients good mid-term results.
Because revision of implants with long cemented stems can be very
challenging, an effort should be made in the future to use shorter stems
in modular versions of hinged implants. Cite this article:
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:
This review examines the future of total hip arthroplasty, aiming to avoid past mistakes
Osteoarthritis (OA) is an important cause of
pain, disability and economic loss in humans, and is similarly important in
the horse. Recent knowledge on post-traumatic OA has suggested opportunities
for early intervention, but it is difficult to identify the appropriate
time of these interventions. The horse provides two useful mechanisms
to answer these questions: 1) extensive experience with clinical
OA in horses; and 2) use of a consistently predictable model of
OA that can help study early pathobiological events, define targets
for therapeutic intervention and then test these putative therapies.
This paper summarises the syndromes of clinical OA in horses including
pathogenesis, diagnosis and treatment, and details controlled studies
of various treatment options using an equine model of clinical OA.
The purpose of this study was to evaluate the
natural history of rheumatoid disease of the shoulder over an eight-year
period. Our hypothesis was that progression of the disease is associated
with a decrease in function with time. A total of 22 patients (44 shoulders; 17 women, 5 men, (mean
age 63)) with rheumatoid arthritis were followed for eight years.
All shoulders were assessed using the Constant score, anteroposterior
radiographs (Larsen score, Upward-Migration-Index (UMI)) and ultrasound
(US). At final follow-up, the Short Form-36, disabilities of the
arm, shoulder and hand (DASH) Score, erythrocyte sedimentation rate
and use of anti-rheumatic medication were determined. The mean Constant score was 72 points (50 to 88) at baseline
and 69 points (25 to 100) at final follow-up. Radiological evaluation
showed progressive destruction of the peri-articular structures
with time. This progression of joint and rotator cuff destruction
was significantly associated with the Constant score. However, at
baseline only the extent of rotator cuff disease and the UMI could
predict the Constant score at final follow-up. A plain anteroposterior radiograph of the shoulder is sufficient
to assess any progression of rheumatoid disease and to predict functional
outcome in the long term by using the UMI as an indicator of rotator
cuff degeneration. Cite this article:
We report our experience with glenohumeral arthrodesis
as a salvage procedure for epilepsy-related recurrent shoulder instability.
A total of six patients with epilepsy underwent shoulder fusion
for recurrent instability and were followed up for a mean of 39 months
(12 to 79). The mean age at the time of surgery was 31 years (22
to 38). Arthrodesis was performed after a mean of four previous
stabilisation attempts (0 to 11) in all but one patient in whom
the procedure was used as a primary treatment. All patients achieved
bony union, with a mean time to fusion of 2.8 months (2 to 7). There
were no cases of re-dislocation. One revision was undertaken for
loosening of the metalwork, and then healed satisfactorily. An increase
was noted in the mean subjective shoulder value, which improved
from 37 (5 to 50) pre-operatively to 42 (20 to 70) post-operatively
although it decreased in two patients. The mean Oxford shoulder
instability score improved from 13 pre-operatively (7 to 21) to
24 post-operatively (13 to 36). In our series, glenohumeral arthrodesis
eliminated recurrent instability and improved functional outcome. Fusion
surgery should therefore be considered in this patient population.
However, since the majority of patients are young and active, they
should be comprehensively counselled pre-operatively given the functional
deficit that results from the procedure. Cite this article:
A rigorous approach to developing, delivering and documenting
rehabilitation within randomised controlled trials of surgical interventions
is required to underpin the generation of reliable and usable evidence.
This article describes the key processes used to ensure provision
of good quality and comparable rehabilitation to all participants
of a multi-centre randomised controlled trial comparing surgery
with conservative treatment of proximal humeral fractures in adults. These processes included the development of a patient information
leaflet on self-care during sling immobilisation, the development
of a basic treatment physiotherapy protocol that received input
and endorsement by specialist physiotherapists providing patient
care, and establishing an expectation for the provision of home
exercises. Specially designed forms were also developed to facilitate
reliable reporting of the physiotherapy care that patients received.Objectives
Methods
The October 2014 Wrist &
Hand Roundup360 looks at: pulsed electromagnetic field of no use in acute scaphoid fractures; proximal interphalangeal joint replacement: one at a time or both at once; trapeziometacarpal arthrodesis in the young patient; Tamoxifen and Dupytren’s disease; and endoscopic or open for de Quervain’s syndrome?
In this study we randomised 140 patients who
were due to undergo primary total knee arthroplasty (TKA) to have the
procedure performed using either patient-specific cutting guides
(PSCG) or conventional instrumentation (CI). The primary outcome measure was the mechanical axis, as measured
at three months on a standing long-leg radiograph by the hip–knee–ankle
(HKA) angle. This was undertaken by an independent observer who
was blinded to the instrumentation. Secondary outcome measures were
component positioning, operating time, Knee Society and Oxford knee
scores, blood loss and length of hospital stay. A total of 126 patients (67 in the CI group and 59 in the PSCG
group) had complete clinical and radiological data. There were 88
females and 52 males with a mean age of 69.3 years (47 to 84) and
a mean BMI of 28.6 kg/m2 (20.2 to 40.8). The mean HKA
angle was 178.9° (172.5 to 183.4) in the CI group and 178.2° (172.4
to 183.4) in the PSCG group (p = 0.34). Outliers were identified
in 22 of 67 knees (32.8%) in the CI group and 19 of 59 knees (32.2%)
in the PSCG group (p = 0.99). There was no significant difference
in the clinical results (p = 0.95 and 0.59, respectively). Operating time,
blood loss and length of hospital stay were not significantly reduced
(p = 0.09, 0.58 and 0.50, respectively) when using PSCG. The use of PSCG in primary TKA did not reduce the proportion
of outliers as measured by post-operative coronal alignment. Cite this article:
We describe the clinical and radiological results
of cementless primary total hip replacement (THR) in 25 patients
(18 women and seven men; 30 THRs) with severe developmental dysplasia
of the hip (DDH). Their mean age at surgery was 47 years (23 to
89). In all, 21 hips had Crowe type III dysplasia and nine had Crowe
type IV. Cementless acetabular components with standard polyethylene
liners were introduced as close to the level of the true acetabulum
as possible. The modular cementless S-ROM femoral component was
used with a low resection of the femoral neck. A total of 21 patients (25 THRs) were available for review at
a mean follow-up of 18.7 years (15.8 to 21.8). The mean modified
Harris hip score improved from 46 points pre-operatively to 90 at
final follow up (p <
0.001). A total of 15 patients (17 THRs; 57%) underwent revision of the
acetabular component at a mean of 14.6 years (7 to 20.8), all for
osteolysis. Two patients (two THRs) had symptomatic loosening. No
patient underwent femoral revision. Survival with revision of either
component for any indication was 81% at 15 years (95% CI 60.1 to
92.3), with 21 patients at risk. This technique may reduce the need for femoral osteotomy in severe
DDH, while providing a good long-term functional result. Cite this article:
Femoroacetabular Junction Impingement (FAI) describes abnormalities
in the shape of the femoral head–neck junction, or abnormalities
in the orientation of the acetabulum. In the short term, FAI can
give rise to pain and disability, and in the long-term it significantly increases
the risk of developing osteoarthritis. The Femoroacetabular Impingement
Trial (FAIT) aims to determine whether operative or non-operative
intervention is more effective at improving symptoms and preventing
the development and progression of osteoarthritis. FAIT is a multicentre superiority parallel two-arm randomised
controlled trial comparing physiotherapy and activity modification
with arthroscopic surgery for the treatment of symptomatic FAI.
Patients aged 18 to 60 with clinical and radiological evidence of
FAI are eligible. Principal exclusion criteria include previous
surgery to the index hip, established osteoarthritis (Kellgren–Lawrence
≥ 2), hip dysplasia (centre-edge angle <
20°), and completion
of a physiotherapy programme targeting FAI within the previous 12
months. Recruitment will take place over 24 months and 120 patients
will be randomised in a 1:1 ratio and followed up for three years.
The two primary outcome measures are change in hip outcome score
eight months post-randomisation (approximately six-months post-intervention
initiation) and change in radiographic minimum joint space width
38 months post-randomisation. ClinicalTrials.gov: NCT01893034. Cite this article: Aims
Methods
We report the outcome of 39 patients who underwent
a modified Pauwels’ intertrochanteric osteotomy for nonunion of
a femoral neck fracture following failed osteosynthesis. There were
31 men and eight women with a mean age of 47.2 years (34 to 59).
By Pauwels’ classification, there were 11 Type II fractures and
28 Type III fractures. The mean follow-up was 7.9 years (2 to 19).
In the 11 patients whose initial treatment had been osteotomy, union was
achieved in nine (81.8%). In 28 patients whose initial treatment
had been with a lag screw or a dynamic hip screw, union was achieved
in 27 (96.4%). Limb lengths were equalised in 14 of 16 patients
(87.5%) with pre-operative shortening. The mean neck-shaft angle
improved significantly from 100.5° (80° to 120°) to 131.6° (120°
to 155°) (p = 0.004). The mean modified Harris hip score was 85.6
points (70 to 97) and the mean modified Merle d’Aubigné score was
14.3 (11 to 18). Good to excellent functional outcomes were achieved
in 32 patients (88.8%). A modified Pauwels’ intertrochanteric osteotomy
is a reliable method of treating ununited fractures of the femoral neck
following failed osteosynthesis: coxa vara and shortening can also
simultaneously be addressed. Cite this article
There are many reasons why a total knee replacement
(TKR) may fail and qualify for revision. Successful revision surgery
depends as much on accurate assessment of the problem TKR as it
does on revision implant design and surgical technique. Specific
modes of failure require specific surgical solutions. Causes of
failure are often presented as a list or catalogue, without a system
or process for making a decision. In addition, strict definitions
and consensus on modes of failure are lacking in published series
and registry data. How we approach the problem TKR is an essential
but neglected aspect of understanding knee replacement surgery.
It must be carried out systematically, comprehensively and efficiently.
Eight modes of failure are described: 1) sepsis; 2) extensor discontinuity;
3) stiffness; 4) tibial- femoral instability; 5) patellar tracking;
6) aseptic loosening and osteolysis; 7) periprosthetic fracture
and 8) component breakage. A ninth ‘category’, unexplained pain
is an indication for further investigation but not surgery. Cite this article:
The August 2014 Wrist &
Hand Roundup360 looks at: Trapeziectomy superior to arthrodesis;
The June 2014 Knee Roundup360 looks at: acute repair preferable in hamstring ruptures; osteoarthritis a given in ACL injury, even with reconstruction?; chicken and egg: patellofemoral dysfunction and hip weakness; meniscal root tears as bad as we thought; outcomes in the meniscus; topical NSAIDs have a measurable effect on synovitis; nailing for tibial peri-prosthetic fracture.
Wear of polyethylene inserts plays an important role in failure
of total knee replacement and can be monitored Before revision, the minimum joint space width values and their
locations on the insert were measured in 15 fully weight-bearing
radiographs. These measurements were compared with the actual minimum
thickness values and locations of the retrieved tibial inserts after
revision. Introduction
Method
This systematic review and meta-analysis was conducted to determine
the mid- to long-term clinical outcomes for a medial-pivot total
knee replacement (TKR) system. The objectives were to synthesise
available survivorship, Knee Society Scores (KSS), and reasons for
revision for this system. A systematic search was conducted of two online databases to
identify sources of survivorship, KSS, and reasons for revision.
Survivorship results were compared with values in the National Joint
Registry of England, Wales, and Northern Ireland (NJR).Objectives
Methods
Back pain is a common symptom in children and
adolescents. Here we review the important causes, of which defects
and stress reactions of the pars interarticularis are the most common
identifiable problems. More serious pathology, including malignancy
and infection, needs to be excluded when there is associated systemic
illness. Clinical evaluation and management may be difficult and
always requires a thorough history and physical examination. Diagnostic
imaging is obtained when symptoms are persistent or severe. Imaging
is used to reassure the patient, relatives and carers, and to guide
management. Cite this article:
