We investigated the role of ion release in the assessment of fixation of the implant after total knee replacement and hypothesised that ion monitoring could be a useful parameter in the diagnosis of prosthetic loosening. We enrolled 59 patients with unilateral procedures and measured their serum aluminium, titanium, chromium and cobalt ion levels, blinded to the clinical and radiological outcome which was considered to be the reference standard. The cut-off levels for detection of the ions were obtained by measuring the levels in 41 healthy blood donors who had no implants. Based on the clinical and radiological evaluation the patients were divided into two groups with either stable (n = 24) or loosened (n = 35) implants. A significant increase in the mean level of Cr ions was seen in the group with failed implants (p = 0.001). The diagnostic accuracy was 71% providing strong evidence of failure when the level of Cr ions exceeded the cut-off value. The possibility of distinguishing loosening from other causes of failure was demonstrated by the higher diagnostic accuracy of 83%, when considering only patients with failure attributable to loosening. Measurement of the serum level of Cr ions may be of value for detecting failure due to loosening when the diagnosis is in doubt. The other metal ions studies did not have any diagnostic value.
The aim of this study was to analyse the functional outcome after a displaced intracapsular fracture of the femoral neck in active patients aged over 70 years without osteoarthritis or rheumatoid arthritis of the hip, randomised to receive either a hemiarthroplasty or a total hip replacement (THR). We studied 252 patients of whom 47 (19%) were men, with a mean age of 81.1 years (70.2 to 95.6). They were randomly allocated to be treated with either a cemented hemiarthroplasty (137 patients) or cemented THR (115 patients). At one- and five-year follow-up no differences were observed in the modified Harris hip score, revision rate of the prosthesis, local and general complications, or mortality. The intra-operative blood loss was lower in the hemiarthroplasty group (7% >
500 ml) than in the THR group (26% >
500 ml) and the duration of surgery was longer in the THR group (28% >
1.5 hours Because of a higher intra-operative blood loss (p <
0.001), an increased duration of the operation (p <
0.001) and a higher number of early and late dislocations (p = 0.002), we do not recommend THR as the treatment of choice in patients aged ≥ 70 years with a fracture of the femoral neck in the absence of advanced radiological osteoarthritis or rheumatoid arthritis of the hip.
The use of ilioischial cage reconstruction for
pelvic discontinuity has been replaced by the Trabecular Metal (Zimmer,
Warsaw, Indiana) cup-cage technique in our institution, due to the
unsatisfactory outcome of using a cage alone in this situation.
We report the outcome of 26 pelvic discontinuities in 24 patients
(20 women and four men, mean age 65 years (44 to 84)) treated by
the cup-cage technique at a mean follow-up of 82 months (12 to 113)
and compared them with a series of 19 pelvic discontinuities in
19 patients (18 women and one man, mean age 70 years (42 to 86))
treated with a cage at a mean follow-up of 69 months (1 to 170).
The clinical and radiological outcomes as well as the survivorship
of the groups were compared. In all, four of the cup-cage group
(15%) and 13 (68%) of the cage group failed due to septic or aseptic
loosening. The seven-year survivorship was 87.2% (95% confidence interval
(CI) 71 to 103) for the cup-cage group and 49.9% (95% CI 15 to 84)
for the cage-alone group (p = 0.009). There were four major complications
in the cup-cage group and nine in the cage group. Radiological union
of the discontinuity was found in all successful cases in the cup-cage
group and three of the successful cage cases. Three hips in the
cup-cage group developed early radiological migration of the components,
which stabilised with a successful outcome. Cup-cage reconstruction is a reliable technique for treating
pelvic discontinuity in mid-term follow-up and is preferred to ilioischial
cage reconstruction. If the continuity of the bone graft at the
discontinuity site is not disrupted, early migration of the components
does not necessarily result in failure. Cite this article:
We performed 96 Birmingham resurfacing arthroplasties of the hip in 71 consecutive patients with avascular necrosis of the femoral head. A modified neck-capsule-preserving approach was used which is described in detail. The University of California, Los Angeles outcome score, the radiological parameters and survival rates were assessed. The mean follow-up was for 5.4 years (4.0 to 8.1). All the patients remained active with a mean University of California, Los Angeles activity score of 6.86 (6 to 9). Three hips failed, giving a cumulative survival rate of 95.4%. With failure of the femoral component as the endpoint, the cumulative survival rate was 98.0%. We also describe the combined abduction-valgus angle of the bearing couple, which is the sum of the inclination angle of the acetabular component and the stem-shaft angle, as an index of the optimum positioning of the components in the coronal plane. Using a modified surgical technique, it is possible to preserve the femoral head in avascular necrosis by performing hip resurfacing in patients with good results.
The femoral head receives blood supply mainly
from the deep branch of the medial femoral circumflex artery (MFCA).
In previous studies we have performed anatomical dissections of
16 specimens and subsequently visualised the arteries supplying
the femoral head in
55 healthy individuals. In this further radiological study we compared
the arterial supply of the femoral head in 35 patients (34 men and
one woman, mean age 37.1 years (16 to 64)) with a fracture/dislocation
of the hip with a historical control group of 55 hips. Using CT
angiography, we identified the three main arteries supplying the femoral
head: the deep branch and the postero-inferior nutrient artery both
arising from the MFCA, and the piriformis branch of the inferior
gluteal artery. It was possible to visualise changes in blood flow
after fracture/dislocation. Our results suggest that blood flow is present after reduction
of the dislocated hip. The deep branch of the MFCA was patent and
contrast-enhanced in 32 patients, and the diameter of this branch
was significantly larger in the fracture/dislocation group than
in the control group (p = 0.022). In a subgroup of ten patients
with avascular necrosis (AVN) of the femoral head, we found a contrast-enhanced
deep branch of the MFCA in eight hips. Two patients with no blood
flow in any of the three main arteries supplying the femoral head
developed AVN. Cite this article:
In 2012 we reviewed a consecutive series of 92
uncemented THRs performed between 1986 and 1991 at our institution
using the CLS Spotorno stem, in order to assess clinical outcome
and radiographic data at a minimum of 21 years. The series comprised
92 patients with a mean age at surgery of 59.6 years (39 to 77)
(M:F 43;49). At the time of this review, seven (7.6%) patients had died and
two (2.2%) were lost to follow-up. The 23-year Kaplan–Meier survival
rates were 91.5% (95% confidence intervals (CI) 85.4% to 97.6%;
55 hips at risk) and 80.3% (95% CI, 71.8% to 88.7%; 48 hips at risk)
respectively, with revision of the femoral stem or of any component
as endpoints. At the time of this review, 76 patients without stem
revision were assessed clinically and radiologically (mean follow-up
24.0 years (21.5 to 26.5)). For the 76 unrevised hips the mean Harris
hip score was 87.1 (65 to 97). Femoral osteolysis was detected in
five hips (6.6%) only in Gruen zone 7. Undersized stems were at
higher risk of revision owing to aseptic loosening (p = 0.0003).
Patients implanted with the stem in a varus position were at higher risk
of femoral cortical hypertrophy and thigh pain (p = 0.0006 and p
= 0.0007, respectively). In our study, survival, clinical outcome and radiographic data
remained excellent in the third decade after implantation. Nonetheless,
undersized stems were at higher risk of revision owing to aseptic
loosening. Cite this article:
We report our experience using a biodegradable
calcium sulphate antibiotic carrier containing tobramycin in the surgical
management of patients with chronic osteomyelitis. The patients
were reviewed to determine the rate of recurrent infection, the
filling of bony defects, and any problems with wound healing. A
total of 193 patients (195 cases) with a mean age of 46.1 years
(16.1 to 82.0) underwent surgery. According to the Cierny–Mader
classification of osteomyelitis there were 12 type I, 1 type II,
144 type III and 38 type IV cases. The mean follow-up was 3.7 years (1.3
to 7.1) with recurrent infection occurring in 18 cases (9.2%) at
a mean of 10.3 months post-operatively (1 to 25.0). After further
treatment the infection resolved in 191 cases (97.9%). Prolonged
wound ooze (longer than two weeks post-operatively) occurred in
30 cases (15.4%) in which there were no recurrent infection. Radiographic
assessment at final follow-up showed no filling of the defect with
bone in 67 (36.6%), partial filling in 108 (59.0%) and complete filling
in eight (4.4%). A fracture occurred in nine (4.6%) of the treated
osteomyelitic segments at a mean of 1.9 years (0.4 to 4.9) after
operation. We conclude that Osteoset T is helpful in the management of patients
with chronic osteomyelitis, but the filling of the defect in bone
is variable. Prolonged wound ooze is usually self-limiting and not
associated with recurrent infection. Cite this article:
We used immediate post-operative The bending angles in the sagittal and axial planes were significantly
greater but the coronal-bending angle was significantly less in
the transtibial group than in the anteromedial portal and outside-in
groups (p <
0.001 each). The mean length of the femoral tunnel
in all three planes was significantly greater in the transtibial
group than the anteromedial portal and outside-in groups (p <
0.001 each), but all mean tunnel lengths in the three groups exceeded
30 mm. The only significant difference was the coronal graft- bending
angle in the anteromedial portal and outside-in groups (23.5° Compared with the transtibial technique, the anteromedial portal
and outside-in techniques may reduce the graft-bending stress at
the opening of the femoral tunnel. Despite the femoral tunnel length
being shorter in the anteromedial portal and outside-in techniques
than in the transtibial technique, a femoral tunnel length of more than
30 mm in the anteromedial portal and outside-in techniques may be
sufficient for the graft to heal. Cite this article:
We compared early post-operative rates of wound
infection in HIV-positive and -negative patients presenting with open
tibial fractures managed with surgical fixation. The wounds of 84 patients (85 fractures), 28 of whom were HIV
positive and 56 were HIV negative, were assessed for signs of infection
using the ASEPIS wound score. There were 19 women and 65 men with
a mean age of 34.8 years. A total of 57 fractures (17 HIV-positive The study does not support the hypothesis that HIV significantly
increases the rate of early wound or pin-site infection in open
tibial fractures. We would therefore suggest that a patient’s HIV
status should not alter the management of open tibial fractures
in patients who have a CD4 count >
350 cells/μl. Cite this article:
We assessed the clinical results, radiographic
outcomes and complications of patients undergoing total shoulder replacement
(TSR) for osteoarthritis with concurrent repair of a full-thickness
rotator cuff tear. Between 1996 and 2010, 45 of 932 patients (4.8%)
undergoing TSR for osteoarthritis underwent rotator cuff repair.
The final study group comprised 33 patients with a mean follow-up
of 4.7 years (3 months to 13 years). Tears were classified into small
(10), medium (14), large (9) or massive (0). On a scale of 1 to
5, pain decreased from a mean of 4.7 to 1.7 (p = <
0.0001), the
mean forward elevation improved from 99° to 139° (p = <
0.0001),
and the mean external rotation improved from 20° (0° to 75°) to
49° (20° to 80°) (p = <
0.0001). The improvement in elevation
was greater in those with a small tear (p = 0.03). Radiographic
evidence of instability developed in six patients with medium or
large tears, indicating lack of rotator cuff healing. In all, six
glenoid components, including one with instability, were radiologically
at risk of loosening. Complications were noted in five patients,
all with medium or large tears; four of these had symptomatic instability
and one sustained a late peri-prosthetic fracture. Four patients
(12%) required further surgery, three with instability and one with
a peri-prosthetic humeral fracture. Consideration should be given to performing rotator cuff repair
for stable shoulders during anatomical TSR, but reverse replacement
should be considered for older, less active patients with larger
tears. Cite this article:
We reviewed the outcome of 69 uncemented, custom-made,
distal femoral endoprosthetic replacements performed in 69 patients
between 1994 and 2006. There were 31 women and 38 men with a mean
age at implantation of 16.5 years (5 to 37). All procedures were
performed for primary malignant bone tumours of the distal femur.
At a mean follow-up of 124.2 months (4 to 212), 53 patients were
alive, with one patient lost to follow-up. All nine implants (13.0%)
were revised due to aseptic loosening at a mean of 52 months (8
to 91); three implants (4.3%) were revised due to fracture of the
shaft of the prosthesis and three patients (4.3%) had a peri-prosthetic
fracture. Bone remodelling associated with periosteal cortical thinning
adjacent to the uncemented intramedullary stem was seen in 24 patients
but this did not predispose to failure. All aseptically loose implants
in this series were diagnosed to be loose within the first five
years. The results from this study suggest that custom-made uncemented
distal femur replacements have a higher rate of aseptic loosening
compared to published results for this design when used with cemented
fixation. Loosening of uncemented replacements occurs early indicating
that initial fixation of the implant is crucial. Cite this article:
We prospectively randomised 78 patients into two groups, ‘drains’ or ‘no drains’ to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient. Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.
Fractures of the forearm (radius or ulna or both)
in children have traditionally been immobilised in plaster of Paris (POP)
but synthetic cast materials are becoming more popular. There have
been no randomised studies comparing the efficacy of these two materials.
The aim of this study was to investigate which cast material is
superior for the management of these fractures. We undertook a single-centre
prospective randomised trial involving 199 patients with acute fractures
of the forearm requiring general anaesthesia for reduction. Patients
were randomised by sealed envelope into either a POP or synthetic
group and then underwent routine closed reduction and immobilisation
in a cast. The patients were reviewed at one and six weeks. A satisfaction
questionnaire was completed following the removal of the cast. All
clinical complications were recorded and the cast indices were calculated.
There was an increase in complications in the POP group. These complications
included soft areas of POP requiring revision and loss of reduction
with some requiring re-manipulation. There was an increased mean
padding index in the fractures that lost reduction. Synthetic casts
were preferred by the patients. This study indicates that the clinical outcomes and patient satisfaction
are superior using synthetic casts with no reduction in safety. Cite this article:
This study prospectively compared the efficacy of kyphoplasty using a Jack vertebral dilator and balloon kyphoplasty to treat osteoporotic compression fractures between T10 and L5. Between 2004 and 2009, two groups of 55 patients each underwent vertebral dilator kyphoplasty and balloon kyphoplasty, respectively. Pain, function, the Cobb angle, and the anterior and middle height of the vertebral body were assessed before and after operation. Leakage of bone cement was recorded. The post-operative change in the Cobb angle was significantly greater in the dilator kyphoplasty group than in the balloon kyphoplasty group (−9.51° ( These findings suggest that vertebral dilator kyphoplasty can facilitate better correction of kyphotic deformity and may ultimately be a safer procedure in reducing leakage of bone cement.
There is a high risk of venous thromboembolism when patients are immobilised following trauma. The combination of low-molecular-weight heparin (LMWH) with graduated compression stockings is frequently used in orthopaedic surgery to try and prevent this, but a relatively high incidence of thromboembolic events remains. Mechanical devices which perform continuous passive motion imitate contractions and increase the volume and velocity of venous flow. In this study 227 trauma patients were randomised to receive either treatment with the Arthroflow device and LMWH or only with the latter. The Arthroflow device passively extends and plantarflexes the feet. Patients were assessed initially by venous-occlusion plethysmography, compression ultrasonography and continuous wave Doppler, which were repeated weekly without knowledge of the category of randomisation. Those who showed evidence of deep-vein thrombosis underwent venography for confirmation. The incidence of deep-vein thrombosis was 25% in the LMWH group compared with 3.6% in those who had additional treatment with the Arthroflow device (p <
0.001). There were no substantial complications or problems of non-compliance with the Arthroflow device. Logistic regression analysis of the risk factors of deep-vein thrombosis showed high odds ratios for operation (4.1), immobilisation (4.3), older than 40 years of age (2.8) and obesity (2.2).
There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher’s exact test, p = 0.018), have unique radiological features (p <
0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients.
Gender-specific total knee replacement has generated much interest recently. We reviewed 1970 Sigma knees implanted in 920 women and 592 men with a mean age of 69.7 years. At a mean follow-up of 7.3 years (minimum, five years), we found minimal differences in the outcome between genders. At the final follow-up, men had a higher overall Knee Society score and more osteolysis (3.8% vs 1.1%). However, there were no significant differences between men and women in terms of complications or improvements in knee function, pain score or range of movement. The estimated ten-year survivorship was 97% in women and 98% in men (p = 0.96). We concluded that there was little difference in outcome between the genders treated by a modern unisex design of total knee replacement in this large multicentre study.
We hypothesised that adjuvant intermittent pneumatic
compression (IPC) beneath a plaster cast would reduce the risk of
deep-vein thrombosis (DVT) during post-operative immobilisation
of the lower limb. Of 87 patients with acute tendo Achillis (TA)
rupture, 26 were prospectively randomised post-operatively after
open TA repair. The treatment group (n = 14) received two weeks of
IPC of the foot for at least six hours daily under a plaster cast.
The control group (n = 12) had no additional treatment. At two weeks
post-operatively all patients received an orthosis until follow-up
at six weeks. At two and six weeks the incidence of DVT was assessed
using colour duplex sonography by two ultrasonographers blinded
to the treatment. Two patients withdrew from the study due to inability
to tolerate IPC treatment. An interim analysis demonstrated a high incidence of DVT in both
the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p
= 0.18). No significant differences in incidence were detected at
two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction
of the IPC leading to a second plaster cast was found to correlate
with an increased DVT risk at two weeks (φ = 0.71; p = 0.019), leading
to a premature abandonment of the study. We cannot recommend adjuvant treatment with foot IPC under a
plaster cast for outpatient DVT prevention during post-operative
immobilisation, owing to a high incidence of DVT related to malfunctioning
of this type of IPC application. Cite this article:
The patellar clunk syndrome describes painful catching, grinding or jumping of the patella when the knee moves from a flexed to an extended position after total knee replacement (TKR). The posterior stabilised TKR had been noted to have a higher incidence of this problem. Mobile-bearing posteriorly stabilised TKRs have been introduced to improve patellar tracking and related problems by a mechanism of self-alignment. We evaluated the patellar clunk syndrome in 113 knees in 93 patients with such a TKR at a mean follow-up of 2.3 years (2.0 to 3.2). The syndrome was identified in 15 knees (13.3%). Logistic regression analysis showed that the absolute value of the post-operative angle of patellar tilt was significantly associated with the occurrence of patellar clunk (p = 0.025). Patellar tracking should be carefully checked during surgery.
We investigated differences in the location and
mode of labral tears between dysplastic hips and hips with femoroacetabular
impingement (FAI). We also investigated the relationship between
labral tear and adjacent cartilage damage. We retrospectively studied
72 symptomatic hips (in 68 patients: 19 men and 49 women) with radiological
evidence of dysplasia or FAI on high-resolution CT arthrography.
The incidence and location of labral tears and modes of tear associated
with the base of the labrum (Mode 1) or body of the labrum (Mode
2) were compared among FAI, mildly dysplastic and severely dysplastic
hips. The locations predominantly involved with labral tears were
different in FAI and mild dysplastic hips (anterior and anterosuperior
zones) and in severely dysplastic hips (anterosuperior and superior
zones) around the acetabulum. Significant differences were observed
in the prevalence of Mode 1 Hip pathology is significantly related to the locations and modes
of labral tears. Mode 1 tears may be a risk factor for the development
of adjacent acetabular cartilage damage. Cite this article: