The October 2014 Research Roundup360 looks at: unpicking syndesmotic injuries: CT scans evaluated; surgical scrub suits and sterility in theatre; continuous passive motion and knee injuries; whether pain at night is melatonin related;
A small proportion of children with Gartland
type III supracondylar humeral fracture (SCHF) experience troubling limited
or delayed recovery after operative treatment. We hypothesised that
the fracture level relative to the isthmus of the humerus would
affect the outcome. We retrospectively reviewed 230 children who underwent closed
reduction and percutaneous pinning (CRPP) for their Gartland type
III SCHFs between March 2003 and December 2012. There were 144 boys
and 86 girls, with the mean age of six years (1.1 to 15.2). The
clinico-radiological characteristics and surgical outcomes (recovery
of the elbow range of movement, post-operative angulation, and the
final Flynn grade) were recorded. Multivariate analysis was employed
to identify prognostic factors that influenced outcome, including
fracture level. Multivariate analysis revealed that a fracture below
the humeral isthmus was significantly associated with poor prognosis
in terms of the range of elbow movement (p <
0.001), angulation
(p = 0.001) and Flynn grade (p = 0.003). Age over ten years was also
a poor prognostic factor for recovery of the range of elbow movement (p
= 0.027). This is the first study demonstrating a subclassification system
of Gartland III fractures with prognostic significance. This will
guide surgeons in peri-operative planning and counselling as well
as directing future research aimed at improving outcomes. Cite this article:
Our study was designed to compare the effect of indometacin with that of a placebo in reducing the incidence of heterotopic ossification in a prospective, randomised trial. A total of 121 patients with displaced fractures of the acetabulum treated by operation through a Kocher-Langenbeck approach was randomised to receive either indometacin (75 mg) sustained release, or a placebo once daily for six weeks. The extent of heterotopic ossification was evaluated on plain radiographs three months after operation. Significant ossification of Brooker grade III to IV occurred in nine of 59 patients (15.2%) in the indometacin group and 12 of 62 (19.4%) receiving the placebo. We were unable to demonstrate a statistically significant reduction in the incidence of severe heterotopic ossification with the use of indometacin when compared with a placebo (p = 0.722). Based on these results we cannot recommend the routine use of indometacin for prophylaxis against heterotopic ossification after isolated fractures of the acetabulum.
Hand function was evaluated in 105 patients who had been operated on in early infancy for brachial plexus birth palsy. The mean follow-up after surgery was for 13.4 years (5.0 to 31.5). Fine sensation, stereognosis, grip and pinch strength and the Raimondi scale were recorded. Fine sensation was normal in 34 of 49 patients (69%) with C5–6 injury, 15 of 31 (48%) with C5–7 and in 8 of 25 (32%) with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand in 12 of 105 patients (11%). Normal stereognosis was recorded in 88 of the 105 patients (84%), whereas only 9 of the 105 (9%) had normal grip strength. The mean Raimondi scale scores were 4.57 (3 to 5) (C5–6), 4.26 (1 to 5) (C5–7) and 2.16 (0 to 5) in patients with total injury. The location of impaired sensation was related to the distribution of the root injury. Avulsion type of injury correlated with poor recovery of hand function.
Diabetes mellitus is considered an indicator of poor prognosis for acute ankle fractures, but this risk may be specific to an identifiable subpopulation. We retrospectively reviewed 42 patients with both diabetes mellitus and an acute, closed, rotational ankle fracture. Patients were individually matched to controls by age, gender, fracture type, and surgical
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:
Two types of fracture, early and late, have been
reported following limb lengthening in patients with achondroplasia (ACH)
and hypochondroplasia (HCH). We reviewed 25 patients with these conditions who underwent 72
segmental limb lengthening procedures involving the femur and/or
tibia, between 2003 and 2011. Gender, age at surgery, lengthened
segment, body mass index, the shape of the callus, the amount and
percentage of lengthening and the healing index were evaluated to determine
predictive factors for the occurrence of early (within three weeks
after removal of the fixation pins) and late fracture (>
three weeks
after removal of the pins). The Mann‑Whitney U test and Pearson’s
chi-squared test for univariate analysis and stepwise regression
model for multivariate analysis were used to identify the predictive factor
for each fracture. Only one patient (two tibiae) was excluded from
the analysis due to excessively slow formation of the regenerate,
which required supplementary measures. A total of 24 patients with
70 limbs were included in the study. There were 11 early fractures in eight patients. The shape of
the callus (lateral or central callus) was the only statistical
variable related to the occurrence of early fracture in univariate
and multivariate analyses. Late fracture was observed in six limbs
and the mean time between removal of the fixation pins and fracture
was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing
index, and lateral or central callus were related to the occurrence
of a late fracture in univariate analysis. A multivariate analysis
demonstrated that the shape of the callus was the strongest predictor
for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91
to 128). Lateral or central callus had a significantly larger risk
of fracture than fusiform, cylindrical, or concave callus. Radiological monitoring of the shape of the callus during distraction
is important to prevent early and late fracture of lengthened limbs
in patients with ACH or HCH. In patients with thin callus formation,
some measures to stimulate bone formation should be considered as
early as possible. Cite this article:
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.
The June 2014 Oncology Roundup360 looks at: Infection still a problem in endoprosthetic reconstruction; massive allografts not as successful as we perhaps think; curopsy for aneurysmal bone cysts?; lengthening prosthesis: days are numbered; new WHO classification in brief; proximal tumours and fluid levels: bad news; infection is predictable in orthopaedic oncology; psychosocial support key in oncological outcomes.
The optimal timing of percutaneous vertebroplasty
as treatment for painful osteoporotic vertebral compression fractures
(OVCFs) is still unclear. With the position of vertebroplasty having
been challenged by recent placebo-controlled studies, appropriate
timing gains importance. We investigated the relationship between the onset of symptoms
– the time from fracture – and the efficacy of vertebroplasty in
115 patients with 216 painful subacute or chronic OVCFs (mean time
from fracture 6.0 months ( It was found that there was an immediate and sustainable improvement
in the level of back pain and HRQoL after vertebroplasty, which
was independent of the time from fracture. Greater time from fracture
was associated with neither worse pre-operative conditions nor increased
vertebral deformity, nor with the presence of an intravertebral cleft. We conclude that vertebroplasty can be safely undertaken at an
appropriate moment between two and 12 months following the onset
of symptoms of an OVCF.
Our aim was to determine the pre-operative sporting profiles of patients undergoing primary joint replacement and to establish if they were able to return to sport after surgery. A postal survey was completed by 2085 patients between one and three years after operation. They had undergone one of five operations, namely total hip replacement, hip resurfacing, total knee replacement, unicompartmental knee replacement or patellar resurfacing. In the three years before operation 726 (34.8%) patients were participating in sport, the most common being swimming, walking and golf. A total of 446 (61.4%) had returned to their sporting activities by one to three years after operation and 192 (26.4%) were unable to do so because of their joint replacement, with the most common reason being pain. The largest decline was in high-impact sports including badminton, tennis and dancing. After controlling for the influence of age and gender, there was no significant difference in the rate of return to sport according to the type of operation.
Monostotic fibrous dysplasia of the proximal
femur has a variable clinical course, despite its reported limited tendency
to progress. We investigated the natural history and predisposing factors
for progression of dysplasia in a group of 76 patients with a mean
follow-up of 8.5 years (2.0 to 15.2). Of these, 31 (41%) presented
with an asymptomatic incidental lesion while 45 (59%) presented
with pain or a pathological fracture. A group of 23 patients (30%)
underwent early operative treatment for pain (19: 25%) or pathological
fracture (4: 5%). Of the 53 patients who were initially treated non-operatively,
45 (85%) remained asymptomatic but eight (15%) needed surgery because
of pain or fracture. The progression-free survival of the observation
group was 81% ( The risk of experiencing pain or pathological fracture is considerable
in monostotic fibrous dysplasia of the proximal femur. Patients
presenting with pain, a limp or radiological evidence of microfracture
have a high chance of needing surgical treatment. Cite this article:
Severe acute respiratory syndrome (SARS) is a newly described infectious disease caused by the SARS coronavirus which attacks the immune system and pulmonary epithelium. It is treated with regular high doses of corticosteroids. Our aim was to determine the relationship between the dosage of steroids and the number and distribution of osteonecrotic lesions in patients treated with steroids during the SARS epidemic in Beijing, China in 2003. We identified 114 patients for inclusion in the study. Of these, 43 with osteonecrosis received a significantly higher cumulative and peak methylprednisolone-equivalent dose than 71 patients with no osteonecrosis identified by MRI. We confirmed that the number of osteonecrotic lesions was directly related to the dosage of steroids and that a very high dose, a peak dose of more than 200 mg or a cumulative methylprednisolone-equivalent dose of more than 4000 mg, is a significant risk factor for multifocal osteonecrosis with both epiphyseal and diaphyseal lesions. Patients with diaphyseal osteonecrosis received a significantly higher cumulative methylprednisolone-equivalent dose than those with epiphyseal osteonecrosis. Multifocal osteonecrosis should be suspected if a patient is diagnosed with osteonecrosis in the shaft of a long bone.
The June 2014 Hip &
Pelvis Roundup360 looks at: Modular femoral necks: early signs are not good; is corrosion to blame for modular neck failures; metal-on-metal is not quite a closed book; no excess failures in fixation of displaced femoral neck fractures; noise no problem in hip replacement; heterotopic ossification after hip arthroscopy: are NSAIDs the answer?; thrombotic and bleeding events surprisingly low in total joint replacement; and the elephant in the room: complications and surgical volume.
The April 2014 Spine Roundup360 looks at: medical treatment for ankylosing spondylitis; unilateral TLIF effective; peg fractures akin to neck of femur fractures; sleep apnoea and spinal surgery; scoliosis in osteogenesis imperfect; paediatric atlanto-occipital dislocation; back pain and obesity: chicken or egg?; BMP associated with lumbar plexus deficit; and just how common is back pain?
The February 2014 Spine Roundup360 looks at: single posterior approach for severe kyphosis; risk factors for recurrent disc herniation; dysphagia and cervical disc replacement or fusion; hang on to your topical antibiotics; cost-effective lumbar disc replacement; anxiolytics no role to play in acute lumbar back pain; and surgery best for lumbar disc herniation.
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
Death during the first year after hip fracture may be influenced by the type of hospital in which patients are treated as well as the time spent awaiting surgery. We studied 57 315 hip fracture patients who were admitted to hospital in Ontario, Canada. Patients treated in teaching hospitals had a decreased risk of in-hospital mortality (odds ratio (OR) 0.89; 95% confidence interval (CI) 0.83 to 0.97) compared with those treated in urban community institutions. There was a trend toward increased mortality in rural rather than urban community hospitals. In-hospital mortality increased as the surgical delay increased (OR 1.13; 95% CI 1.10 to 1.16) for a one-day delay and higher (OR 1.60; 95% CI 1.42 to 1.80) for delays of more than two days. This relationship was strongest for patients younger than 70 years of age and with no comorbidities but was independent of hospital status. Similar relationships were seen at three months and one year after surgery. This suggests that any delay to surgery for non-medical reasons is detrimental to a patient’s outcome.
We have previously reported the short-term radiological
results of a randomised controlled trial comparing kinematically
aligned total knee replacement (TKR) and mechanically aligned TKR,
along with early pain and function scores. In this study we report
the two-year clinical results from this trial. A total of 88 patients
(88 knees) were randomly allocated to undergo either kinematically
aligned TKR using patient-specific guides, or mechanically aligned
TKR using conventional instruments. They were analysed on an intention-to-treat
basis. The patients and the clinical evaluator were blinded to the
method of alignment. At a minimum of two years, all outcomes were better for the kinematically
aligned group, as determined by the mean Oxford knee score (40 (15
to 48) In this study, the use of a kinematic alignment technique performed
with patient-specific guides provided better pain relief and restored
better function and range of movement than the mechanical alignment
technique performed with conventional instruments. Cite this article:
Corticosteroid use has been implicated in the
development of osteonecrosis of the femoral head (ONFH). The exact mechanism
and predisposing factors such as age, gender, dosage, type and combination
of steroid treatment remain controversial. Between March and July
2003, a total of 539 patients with severe acute respiratory syndrome (SARS)
were treated with five different types of steroid. There were 129
men (24%) and 410 women (76%) with a mean age of 33.7 years (21
to 59). Routine screening was undertaken with radiographs, MRI and/or
CT to determine the incidence of ONFH. Of the 129 male patients with SARS, 51 (39.5%) were diagnosed
as suffering from ONFH, compared with only 79 of 410 female patients
(19.3%). The incidence of ONFH in the patients aged between 20 and
49 years was much higher than that of the group aged between 50
and 59 years (25.9% (127 of 491) Cite this article: