The aim of this retrospective cohort study was
to identify any difference in femoral offset as measured on pre-operative
anteroposterior (AP) radiographs of the pelvis, AP radiographs of
the hip and corresponding CT scans in a consecutive series of 100
patients with primary end-stage osteoarthritis of the hip (43 men
and 57 women with a mean age of 61 years (45 to 74) and a mean body
mass index of 28 kg/m2 (20 to 45)). Patients were positioned according to a standardised protocol
to achieve reproducible projection and all images were calibrated.
Inter- and intra-observer reliability was evaluated and agreement
between methods was assessed using Bland-Altman plots. In the entire cohort, the mean femoral offset was 39.0 mm (95%
confidence interval (CI) 37.4 to 40.6) on radiographs of the pelvis,
44.0 mm (95% CI 42.4 to 45.6) on radiographs of the hip and 44.7
mm (95% CI 43.5 to 45.9) on CT scans. AP radiographs of the pelvis
underestimated femoral offset by 13% when compared with CT (p <
0.001).
No difference in mean femoral offset was seen between AP radiographs
of the hip and CT (p = 0.191). Our results suggest that femoral offset is significantly underestimated
on AP radiographs of the pelvis but can be reliably and accurately
assessed on AP radiographs of the hip in patients with primary end-stage
hip osteoarthritis. We, therefore, recommend that additional AP radiographs of the
hip are obtained routinely for the pre-operative assessment of femoral
offset when templating before total hip replacement.
We performed a retrospective examination of the
anteroposterior pelvic CT scout views of 419 randomly selected patients between
April 2004 and August 2009 in order to determine the prevalence
of cam-type femoroacetabular deformity in the asymptomatic population.
The CT scans had all been undertaken for conditions unrelated to
disorders of the hip. The frequency of cam-type femoroacetabular
deformity was assessed by measuring the α-angle of each hip on the
anteroposterior images. The α-angles were classified according to
the Copenhagen Osteoarthritis Study. Among 215 male hips (108 patients)
the mean α-angle was 59.12° (37.75° to 103.50°). Of these, a total
of 30 hips (13.95%) were defined as pathological, 32 (14.88%) as
borderline and 153 (71.16%) as normal. Among 540 female hips (272
patients) the mean α-angle was 45.47° (34.75° to 87.00°), with 30
hips (5.56%) defined as pathological, 33 (6.11%) as borderline and
477 (88.33%) as normal. It appears that the cam-type femoroacetabular
deformity is not rare among the asymptomatic population. These anatomical
abnormalities, as determined by an increased α-angle, appear to
be twice as frequent in men as in women. Although an association
between osteoarthritis and femoroacetabular impingement is believed
to exist, a long-term epidemiological study is needed to determine
the natural history of these anatomical abnormalities.
Recent events have highlighted the importance
of implant design for survival and wear-related complications following
metal-on-metal hip resurfacing arthroplasty. The mid-term survival
of the most widely used implant, the Birmingham Hip Resurfacing
(BHR), has been described by its designers. The aim of this study
was to report the ten-year survival and patient-reported functional
outcome of the BHR from an independent centre. In this cohort of 554 patients (646 BHRs) with a mean age of
51.9 years (16.5 to 81.5) followed for a mean of eight years (1
to 12), the survival and patient-reported functional outcome depended
on gender and the size of the implant. In female hips (n = 267)
the ten-year survival was 74% (95% confidence interval (CI) 83 to
91), the ten-year revision rate for pseudotumour was 7%, the mean
Oxford hip score (OHS) was 43 ( This study supports the ongoing use of resurfacing in young active
men, who are a subgroup of patients who tend to have problems with
conventional THR. In contrast, the results in women have been poor
and we do not recommend metal-on-metal resurfacing in women. Continuous
follow-up is recommended because of the increasing incidence of
pseudotumour with the passage of time.
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.
We obtained information from the Elective Orthopaedic
Centre on 1523 patients with baseline and six-month Oxford hip scores
(OHS) after undergoing primary hip replacement (THR) and 1784 patients
with Oxford knee scores (OKS) for primary knee replacement (TKR)
who completed a six-month satisfaction questionnaire. Receiver operating characteristic curves identified an absolute
change in OHS of 14 points or more as the point that discriminates
best between patients’ satisfaction levels and an 11-point change
for the OKS. Satisfaction is highest (97.6%) in patients with an
absolute change in OHS of 14 points or more, compared with lower
levels of satisfaction (81.8%) below this threshold. Similarly,
an 11-point absolute change in OKS was associated with 95.4% satisfaction
compared with 76.5% below this threshold. For the six-month OHS
a score of 35 points or more distinguished patients with the highest
satisfaction level, and for the six-month OKS 30 points or more identified
the highest level of satisfaction. The thresholds varied according
to patients’ pre-operative score, where those with severe pre-operative
pain/function required a lower six-month score to achieve the highest
levels of satisfaction. Our data suggest that the choice of a six-month follow-up to
assess patient-reported outcomes of THR/TKR is acceptable. The thresholds
help to differentiate between patients with different levels of
satisfaction, but external validation will be required prior to
general implementation in clinical practice.
The purpose of this study was to report the outcome
of ‘isolated’ anterior cruciate ligament (ACL) ruptures treated with
anatomical endoscopic reconstruction using hamstring tendon autograft
at a mean of 15 years (14.25 to 16.9). A total of 100 consecutive
men and 100 consecutive women with ‘isolated’ ACL rupture underwent
four-strand hamstring tendon reconstruction with anteromedial portal
femoral tunnel drilling and interference screw fixation by a single
surgeon. Details were recorded pre-operatively and at one, two,
seven and 15 years post-operatively. Outcomes included clinical
examination, subjective and objective scoring systems, and radiological
assessment. At 15 years only eight of 118 patients (7%) had moderate
or severe osteo-arthritic changes (International Knee Documentation
Committee Grades C and D), and 79 of 152 patients (52%) still performed
very strenuous activities. Overall graft survival at 15 years was
83% (1.1% failure per year). Patients aged <
18 years at the
time of surgery and patients with >
2 mm of laxity at one year had
a threefold increase in the risk of suffering a rupture of the graft
(p = 0.002 and p = 0.001, respectively). There was no increase in
laxity of the graft over time. ACL reconstructive surgery in patients with an ‘isolated’ rupture
using this technique shows good results 15 years post-operatively
with respect to ligamentous stability, objective and subjective
outcomes, and does not appear to cause osteoarthritis.
We investigated factors that were thought to be associated with an increased incidence of squeaking of ceramic-on-ceramic total hip replacements. Between June 1997 and December 2008 the three senior authors implanted 2406 primary total hip replacements with a ceramic-on-ceramic bearing surface. The mean follow-up was 10.6 years. The diagnosis was primary osteoarthritis in each case, and no patient had undergone previous surgery to the hip. We identified 74 squeaking hips (73 patients) giving an incidence of 3.1% at a mean follow-up of 9.5 years (4.1 to 13.3). Taller, heavier and younger patients were significantly more likely to have hips that squeaked. Squeaking hips had a significantly higher range of post-operative internal (p = 0.001) and external rotation (p = 0.003) compared with silent hips. Patients with squeaking hips had significantly higher activity levels (p = 0.009). A squeaking hip was not associated with a significant difference in patient satisfaction (p = 0.24) or Harris hip score (p = 0.34). Four implant position factors enabled good prediction of squeaking. These were high acetabular component inclination, high femoral offset, lateralisation of the hip centre and either high or low acetabular component anteversion. This is the largest study to date to examine patient factors and implant position factors that predispose to squeaking of a ceramic-on-ceramic hip. The results suggest that factors which increase the mechanical forces across the hip joint and factors which increase the risk of neck-to-rim impingement, and therefore edge-loading, are those that predispose to squeaking.
It is probable that both genetic and environmental
factors play some part in the aetiology of most cases of degenerative
hip disease. Geneticists have identified some single gene disorders
of the hip, but have had difficulty in identifying the genetics
of many of the common causes of degenerative hip disease. The heterogeneity
of the phenotypes studied is part of the problem. A detailed classification
of phenotypes is proposed. This study is based on careful documentation
of 2003 consecutive total hip replacements performed by a single
surgeon between 1972 and 2000. The concept that developmental problems
may initiate degenerative hip disease is supported. The influences
of gender, age and body mass index are outlined. Biomechanical explanations
for some of the radiological appearances encountered are suggested.
The body weight lever, which is larger than the abductor lever, causes
the abductor power to be more important than body weight. The possibility
that a deficiency in joint lubrication is a cause of degenerative
hip disease is discussed. Identifying the phenotypes may help geneticists
to identify genes responsible for degenerative hip disease, and
eventually lead to a definitive classification.
This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4). Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved. This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow.
Given the growing prevalence of obesity around
the world and its association with osteoarthritis of the knee, orthopaedic
surgeons need to be familiar with the management of the obese patient
with degenerative knee pain. The precise mechanism by which obesity
leads to osteoarthritis remains unknown, but is likely to be due
to a combination of mechanical, humoral and genetic factors. Weight loss has clear medical benefits for the obese patient
and seems to be a logical way of relieving joint pain associated
with degenerative arthritis. There are a variety of ways in which
this may be done including diet and exercise, and treatment with
drugs and bariatric surgery. Whether substantial weight loss can
delay or even reverse the symptoms associated with osteoarthritis
remains to be seen. Surgery for osteoarthritis in the obese patient can be technically
more challenging and carries a risk of additional complications.
Substantial weight loss before undertaking total knee replacement
is advisable. More prospective studies that evaluate the effect
of significant weight loss on the evolution of symptomatic osteoarthritis
of the knee are needed so that orthopaedic surgeons can treat this
patient group appropriately.
Modern metal-on-metal hip resurfacing has been
widely performed in the United Kingdom for over a decade. However,
the literature reports conflicting views of the benefits: excellent
medium- to long-term results with some brands in specific subgroups,
but high failure rates and local soft-tissue reactions in others.
The National Joint Registry for England and Wales (NJR) has collected
data on all hip resurfacings performed since 2003. This retrospective
cohort study recorded survival time to revision from a resurfacing
procedure, exploring risk factors independently associated with
failure. All patients with a primary diagnosis of osteoarthritis
who underwent resurfacing between 2003 and 2010 were included in
the analyses. Cox’s proportional hazard models were used to analyse
the extent to which the risk of revision was related to patient,
surgeon and implant covariates. A total of 27 971 hip resurfacings were performed during the
study period, of which 1003 (3.59%) underwent revision surgery.
In the final adjusted model, we found that women were at greater
risk of revision than men (hazard ratio (HR) = 1.30, p = 0.007),
but the risk of revision was independent of age. Of the implant-specific
predictors, five brands had a significantly greater risk of revision
than the Birmingham Hip Resurfacing (BHR) (ASR: HR = 2.82, p <
0.001,
Conserve: HR = 2.03, p <
0.001, Cormet: HR = 1.43, p = 0.001,
Durom: HR = 1.67, p <
0.001, Recap: HR = 1.58, p = 0.007). Smaller
femoral head components were also significantly more likely to require
revision (≤ 44 mm: HR = 2.14, p <
0.001, 45 to 47 mm: HR = 1.48,
p = 0.001) than medium or large heads, as were operations performed
by low-volume surgeons (HR = 1.36, p <
0.001). Once these influences
had been removed, in 4873 male patients <
60 years old undergoing
resurfacing with a BHR, the five-year estimated risk of revision
was 1.59%. In summary, after adjustment for a range of covariates we found
that there were significant differences in the rate of failure between
brands and component sizes. Younger male patients had good five-year
implant survival when the BHR was used.
In order to clarify how intra-articular lesions
influence the survival of a periacetabular osteotomy in patients
with dysplasia of the hip, we performed an observational study of
121 patients (121 hips) who underwent a transposition osteotomy
of the acetabulum combined with an arthroscopy. Their mean age was
40.2 years (13 to 64) and the mean follow-up was 9.9 years (2 to
18). Labral and cartilage degeneration tended to originate from
the anterosuperior part of the acetabulum, followed by the femoral
side. In all, eight hips (6.6%) had post-operative progression to
Kellgren–Lawrence grade 4 changes, and these hips were associated
with the following factors: moderate osteoarthritis, decreased width
of the joint space, joint incongruity, and advanced intra-articular
lesions (subchondral bone exposure in the cartilage and a full-thickness
labral tear). Multivariate analysis indicated subchondral bone exposure
on the femoral head as an independent risk factor for progression
of osteoarthritis (p = 0.003). In hips with early stage osteoarthritis,
femoral subchondral bone exposure was a risk factor for progression of
the grade of osteoarthritis. Although the outcome of transposition osteotomy of the acetabulum
was satisfactory, post-operative progression of osteoarthritis occurred
at a high rate in hips with advanced intra-articular lesions, particularly
in those where the degenerative process had reached the point of
femoral subchondral bone exposure.
The patellofemoral joint is an important source of symptoms in osteoarthritis of the knee. We have used a newly designed surgical model of patellar strengthening to induce osteoarthritis in BALB/c mice and to establish markers by investigating the relationship between osteoarthritis and synovial levels of matrix metalloproteinases (MMPs). Osteoarthritis was induced by using this microsurgical technique under direct vision without involving the cavity of the knee. Degeneration of cartilage was assessed by the Mankin score and synovial tissue was used to determine the mRNA expression levels of MMPs. Irrigation fluid from the knee was used to measure the concentrations of MMP-3 and MMP-9. Analysis of cartilage degeneration was correlated with the levels of expression of MMP. After operation the patellofemoral joint showed evidence of mild osteoarthritis at eight weeks and further degenerative changes by 12 weeks. The level of synovial MMP-9 mRNA correlated with the Mankin score at eight weeks, but not at 12 weeks. The levels of MMP-2, MMP-3 and MMP-14 mRNA correlated with the Mankin score at 12 weeks. An increase in MMP-3 was observed from four weeks up to 16 weeks. MMP-9 was notably increased at eight weeks, but the concentration at 16 weeks had decreased to the level observed at four weeks. Our observations suggest that MMP-2, MMP-3 and MMP-14 could be used as markers of the progression of osteoarthritic change.
We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001). We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.
Autologous chondrocyte implantation is an option in the treatment of full-thickness chondral or osteochondral injuries which are symptomatic. The goal of surgery and rehabilitation is the replacement of damaged cartilage with hyaline or hyaline-like cartilage, producing improved levels of function and preventing early osteoarthritis. The intermediate results have been promising in terms of functional and clinical improvement. Our aim was to explore the hypothesis that the histological quality of the repair tissue formed after autologous chondrocyte implantation improved with increasing time after implantation. In all, 248 patients who had undergone autologous chondrocyte implantation had biopsies taken of the repair tissue which then underwent histological grading. Statistical analysis suggested that with doubling of the time after implantation the likelihood of a favourable histological outcome was increased by more than fourfold (p <
0.001).
We measured the plasma 25-hydroxyvitamin D3 (25(OH)D3) levels in 62 consecutive Caucasian patients undergoing total hip replacement for osteoarthritis. The patients were divided into two groups based on whether they were vitamin D sufficient or deficient. The groups were matched for age, gender and the American Society of Anaesthesiologists (ASA) grade. The prevalence of vitamin D deficiency in our patients was comparable with recent population-based studies performed in the United Kingdom. Patients with vitamin D deficiency had lower pre-operative Harris hip scores (Mann-Whitney test, p = 0.018) and were significantly less likely to attain an excellent outcome from total hip replacement (chi-squared test, p = 0.038). Vitamin D levels were found to positively correlate with both pre- and post-operative Harris hip scores. These results warrant further study of vitamin D deficiency in patients undergoing joint replacement as it is a risk factor for a suboptimal outcome which is relatively simple and cheap to correct.
We present the outcomes in 38 consecutive patients who had total ankle replacement using the Ankle Evolution System with a minimum follow-up of four years. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and regular standardised anteroposterior and lateral weight-bearing radiographs were obtained. Patient satisfaction and complications were recorded and the survival of the implants was demonstrated by the Kaplan-Meier method. The mean follow-up was for 57.8 months (48 to 80). The cumulative survival rate at six years was 94.7% (95% confidence interval 80.3 to 98.7). The mean total AOFAS score was 88.1 (53 to 100). The mean score for pain was 35.8 (20 to 40). Ten patients presented with edge-loading of whom nine had corrective surgery. Two ankles were revised, one to an arthrodesis and the other to replace the tibial component. Nine patients showed radiological evidence of osteolysis. They had minimal non-progressive symptoms and further surgery was not undertaken. Nevertheless, the concerns about osteolysis led to the implant being withdrawn by the manufacturer. The medium-term results of the ankle evolution system ankle replacement are satisfactory with high patient satisfaction, but the rate of osteolysis is of some concern. The long-term benefit of this procedure has yet to be determined.
This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p <
0.001) and movement improved in active elevation and both external and internal rotation (p <
0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery. Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives.
In order to evaluate the relationship between acetabular and proximal femoral alignment in the initiation and evolution of osteoarthritis of the dysplastic hip, the acetabular and femoral angles were calculated geometrically from radiographs of 62 patients with pre-arthrosis and early osteoarthritis. The sum of the lateral opening angle of the acetabulum and the neck-shaft angle was defined as the lateral instability index (LII), and the sum of the anterior opening angle of the acetabulum and the anteversion angle of the femoral neck as the anterior instability index (AII). These two indices were compared in dysplastic and unaffected hips. A total of 22 unilateral hips with pre-arthrosis were followed for at least 15 years to determine whether the two indices were associated with the progression of osteoarthritis. The LII of the affected hips (197.4 (