We have reviewed the rate of revision of fully cemented, hybrid and uncemented primary total hip replacements (THRs) registered in the New Zealand Joint Registry between 1999 and December 2006 to determine whether there was any statistically significant difference in the early survival and reason for revision in these different types of fixation. The percentage rate of revision was calculated per 100 component years and compared with the reason for revision, the type of fixation and the age of the patients. Of the 42 665 primary THRs registered, 920 (2.16%) underwent revision requiring change of at least one component. Fully-cemented THRs had a lower rate of revision when considering all causes for failure (p <
0.001), but below the age of 65 years uncemented THRs had a lower rate (p <
0.01). The rate of revision of the acetabular component for aseptic loosening was less in the uncemented and hybrid groups compared with that in the fully cemented group (p <
0.001), and the rate of revision of cemented and uncemented femoral components was similar, except in patients over 75 years of age in whom revision of cemented femoral components was significantly less frequent (p <
0.02). Revision for infection was more common in patients aged below 65 years and in cemented and hybrid THRs compared with cementless THRs (p <
0.001). Dislocation was the most common cause of revision for all types of fixation and was more frequent in both uncemented acetabular groups (p <
0.001). The experience of the surgeon did not affect the findings. Although cemented THR had the lowest rate of revision for all causes in the short term (90 days), uncemented THR had the lowest rate of aseptic loosening in patients under 65 years of age and had rates comparable with international rates of aseptic loosening in those over 65 years.
The number of surgical procedures performed each year to treat
femoroacetabular impingement (FAI) continues to rise. Although there
is evidence that surgery can improve symptoms in the short-term,
there is no evidence that it slows the development of osteoarthritis
(OA). We performed a feasibility study to determine whether patient
and surgeon opinion was permissive for a Randomised Controlled Trial
(RCT) comparing operative with non-operative treatment for FAI. Surgeon opinion was obtained using validated questionnaires at
a Specialist Hip Meeting (n = 61, 30 of whom stated that they routinely
performed FAI surgery) and patient opinion was obtained from clinical
patients with a new diagnosis of FAI (n = 31).Objectives
Methods
We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist. We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable.
The revised Tokuhashi, Tomita and modified Bauer
scores are commonly used to make difficult decisions in the management
of patients presenting with spinal metastases. A prospective cohort
study of 199 consecutive patients presenting with spinal metastases,
treated with either surgery and/or radiotherapy, was used to compare
the three systems. Cox regression, Nagelkerke’s R2 and
Harrell’s concordance were used to compare the systems and find their
best predictive items. The three systems were equally good in terms
of overall prognostic performance. Their most predictive items were
used to develop the Oswestry Spinal Risk Index (OSRI), which has
a similar concordance, but a larger coefficient of determination
than any of these three scores. A bootstrap procedure was used to
internally validate this score and determine its prediction optimism. The OSRI is a simple summation of two elements: primary tumour
pathology (PTP) and general condition (GC): OSRI = PTP + (2 – GC). This simple score can predict life expectancy accurately in patients
presenting with spinal metastases. It will be helpful in making
difficult clinical decisions without the delay of extensive investigations. Cite this article:
Radiostereometric analysis (RSA) can detect early
micromovement in unstable implant designs which are likely subsequently
to have a high failure rate. In 2010, the Articular Surface Replacement
(ASR) was withdrawn because of a high failure rate. In 19 ASR femoral
components, the mean micromovement over the first two years after implantation
was 0.107 mm ( We conclude that the ASR femoral component achieves initial stability
and that early migration is not the mode of failure for this resurfacing
arthroplasty.
We undertook a retrospective analysis of 306
procedures on 233 patients, with a mean age of 12 years (1 to 21),
in order to evaluate the use of somatosensory evoked potential (SSEP)
monitoring for the early detection of nerve compromise during external
fixation procedures for limb lengthening and correction of deformity.
Significant SSEP changes were identified during 58 procedures (19%).
In 32 instances (10.5%) the changes were transient, and resolved
once the surgical cause had been removed. The remaining 26 (8.5%)
were analysed in two groups, depending on whether or not corrective
action had been performed in response to critical changes in the
SSEP recordings. In 16 cases in which no corrective action was taken,
13 (81.2%, 4.2% overall) developed a post-operative neurological
deficit, six of which were permanent and seven temporary, persisting
for five to 18 months. In the ten procedures in which corrective
action was taken, four patients (40%, 1.3% overall) had a temporary
(one to eight months) post-operative neuropathy and six had no deficit. After appropriate intervention in response to SSEP changes, the
incidence and severity of neurological deficits were significantly
reduced, with no cases of permanent neuropathy. SSEP monitoring
showed 100% sensitivity and 91% specificity for the detection of
nerve injury during external fixation. It is an excellent diagnostic
technique for identifying nerve lesions when they are still highly
reversible.
This study aimed to investigate time-dependent gene expression
of injured human anterior cruciate ligament (ACL), and to evaluate
the histological changes of the ACL remnant in terms of cellular
characterisation. Injured human ACL tissues were harvested from 105 patients undergoing
primary ACL reconstruction and divided into four phases based on
the period from injury to surgery. Phase I was <
three weeks,
phase II was three to eight weeks, phase III was eight to 20 weeks,
and phase IV was ≥ 21 weeks. Gene expressions of these tissues were
analysed in each phase by quantitative real-time polymerase chain
reaction using selected markers (collagen types 1 and 3, biglycan,
decorin, α-smooth muscle actin, IL-6, TGF-β1, MMP-1, MMP-2 and TIMP-1).
Immunohistochemical staining was also performed using primary antibodies
against CD68, CD55, Stat3 and phosphorylated-Stat3 (P-Stat3). Objectives
Methods
This article reviews the current knowledge of
the intervertebral disc (IVD) and its association with low back
pain (LBP). The normal IVD is a largely avascular and aneural structure
with a high water content, its nutrients mainly diffusing through
the end plates. IVD degeneration occurs when its cells die or become
dysfunctional, notably in an acidic environment. In the process
of degeneration, the IVD becomes dehydrated and vascularised, and
there is an ingrowth of nerves. Although not universally the case,
the altered physiology of the IVD is believed to precede or be associated
with many clinical symptoms or conditions including low back and/or
lower limb pain, paraesthesia, spinal stenosis and disc herniation. New treatment options have been developed in recent years. These
include biological therapies and novel surgical techniques (such
as total disc replacement), although many of these are still in
their experimental phase. Central to developing further methods
of treatment is the need for effective ways in which to assess patients
and measure their outcomes. However, significant difficulties remain
and it is therefore an appropriate time to be further investigating
the scientific basis of and treatment of LBP.
The August 2012 Trauma Roundup360 looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China.
Bone loss involving articular surface is a challenging
problem faced by the orthopaedic surgeon. In the hand and wrist,
there are articular defects that are amenable to autograft reconstruction
when primary fixation is not possible. In this article, the surgical
techniques and clinical outcomes of articular reconstructions in
the hand and wrist using non-vascularised osteochondral autografts
are reviewed.
The inherent challenges of total hip replacement
(THR) in children include the choice of implant for the often atypical
anatomical morphology, its fixation to an immature growing skeleton
and the bearing surface employed to achieve a successful long-term
result. We report the medium-term results of 52 consecutive uncemented
THRs undertaken in
35 paediatric patients with juvenile idiopathic arthritis. The mean
age at the time of surgery was 14.4 years (10 to 16). The median
follow-up was 10.5 years (6 to 15). During the study period 13 THRs
underwent revision surgery. With revision as an endpoint, subgroup
analysis revealed 100% survival of the 23 ceramic-on-ceramic THRs
and 55% (16 of 29) of the metal- or ceramic-on-polyethylene. This
resulted in 94% (95% CI 77.8 to 98.4) survivorship of the femoral
component and 62% (95% CI 41.0 to 78.0) of the acetabular component.
Revision of the acetabular component for wear and osteolysis were
the most common reasons for failure accounting for 11 of the 13
revisions. The success seen in patients with a ceramic-on-ceramic articulation
seems to indicate that this implant strategy has the potential to
make a major difference to the long-term outcome in this difficult
group of patients.
In order to elucidate the influence of sympathetic nerves on
lumbar radiculopathy, we investigated whether sympathectomy attenuated
pain behaviour and altered the electrical properties of the dorsal
root ganglion (DRG) neurons in a rat model of lumbar root constriction. Sprague-Dawley rats were divided into three experimental groups.
In the root constriction group, the left L5 spinal nerve root was
ligated proximal to the DRG as a lumbar radiculopathy model. In
the root constriction + sympathectomy group, sympathectomy was performed
after the root constriction procedure. In the control group, no
procedures were performed. In order to evaluate the pain relief
effect of sympathectomy, behavioural analysis using mechanical and
thermal stimulation was performed. In order to evaluate the excitability
of the DRG neurons, we recorded action potentials of the isolated
single DRG neuron by the whole-cell patch-clamp method.Objectives
Methods
This review briefly summarises some of the definitive
studies of articular cartilage by microscopic MRI (µMRI) that were
conducted with the highest spatial resolutions. The article has
four major sections. The first section introduces the cartilage
tissue, MRI and µMRI, and the concept of image contrast in MRI.
The second section describes the characteristic profiles of three
relaxation times (T1, T2 and T1ρ)
and self-diffusion in healthy articular cartilage. The third section
discusses several factors that can influence the visualisation of
articular cartilage and the detection of cartilage lesion by MRI
and µMRI. These factors include image resolution, image analysis
strategies, visualisation of the total tissue, topographical variations
of the tissue properties, surface fibril ambiguity, deformation
of the articular cartilage, and cartilage lesion. The final section
justifies the values of multidisciplinary imaging that correlates
MRI with other technical modalities, such as optical imaging. Rather
than an exhaustive review to capture all activities in the literature,
the studies cited in this review are merely illustrative.
Local corticosteroid infiltration is a common practice of treatment
for lateral epicondylitis. In recent studies no statistically significant
or clinically relevant results in favour of corticosteroid injections
were found. The injection of autologous blood has been reported
to be effective for both intermediate and long-term outcomes. It
is hypothesised that blood contains growth factors, which induce
the healing cascade. A total of 60 patients were included in this prospective randomised
study: 30 patients received 2 ml autologous blood drawn from contralateral
upper limb vein + 1 ml 0.5% bupivacaine, and 30 patients received
2 ml local corticosteroid + 1 ml 0.5% bupivacaine at the lateral
epicondyle. Outcome was measured using a pain score and Nirschl
staging of lateral epicondylitis. Follow-up was continued for total
of six months, with assessment at one week, four weeks, 12 weeks
and six months.Objectives
Methods
In distal fibular resection without reconstruction,
the stabilising effect of the lateral malleolus is lost. Thus, the ankle
may collapse into valgus and may be unstable in varus. Here, we
describe a child who underwent successful staged surgical correction
of a severe neglected valgus deformity after excision of the distal
fibula for a Ewing’s sarcoma.
The April 2012 Wrist &
Hand Roundup360 looks at releasing the trigger finger, function in the osteoarthritic hand, complex regional pain syndrome, arthroscopic ligamentoplasty for the injured scapholunate ligament, self-concept and upper limb deformities in children, wrist arthroscopy in children, internal or external fixation for the fractured distal radius, nerve grafting, splinting the PIPJ contracture, and finding the stalk of a dorsal wrist ganglion
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% ( 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 report a retrospective analysis of the results of combined arthroscopically-assisted posterior cruciate ligament reconstruction and open reconstruction of the posterolateral corner in 19 patients with chronic (three or more months) symptomatic instability and pain in the knee. All the operations were performed between 1996 and 2003 and all the patients were assessed pre- and post-operatively by physical examination and by applying three different ligament rating scores. All also had weight-bearing radiographs, MR scans and an examination under anaesthesia and arthroscopy pre-operatively. The posterior cruciate ligament reconstruction was performed using an arthroscopically-assisted single anterolateral bundle technique and the posterolateral corner structures were reconstructed using an open Larson type of tenodesis. The mean follow up was 66.8 months (24 to 110). Pre-operatively, all the patients had a grade III posterior sag according to Clancy and demonstrated more than 20° of external rotation compared with the opposite normal knee on the Dial test. Post-operatively, seven patients (37%) had no residual posterior sag, 11 (58%) had a grade I posterior sag and one (5%) had a grade II posterior sag. In five patients (26%) there was persistent minimal posterolateral laxity. The Lysholm score improved from a mean of 41.2 (28 to 53) to 76.5 (57 to 100) (p = 0.0001) and the Tegner score from a mean of 2.6 (1 to 4) to 6.4 (4 to 9) (p = 0.0001). We conclude that while a combined reconstruction of chronic posterior cruciate ligament and posterolateral corner instability improves the function of the knee, it does not restore complete stability.
We isolated multilineage mesenchymal progenitor cells from haematomas collected from fracture sites. After the haematoma was manually removed from the fracture site it was cut into strips and cultured. Homogenous fibroblastic adherent cells were obtained. Flow cytometry revealed that the adherent cells were consistently positive for mesenchymal stem-cell-related markers CD29, CD44, CD105 and CD166, and were negative for the haemopoietic markers CD14, CD34, CD45 and CD133 similar to bone-marrow-derived mesenchymal stem cells. In the presence of lineage-specific induction factors the adherent cells could differentiate Our results indicate that haematomas found at a fracture site contain multilineage mesenchymal progenitor cells and play an important role in bone healing. Our findings imply that to enhance healing the haematoma should not be removed from the fracture site during osteosynthesis.