There is a high risk of the development of avascular
necrosis of the femoral head and nonunion after the treatment of
displaced subcapital fractures of the femoral neck in patients aged
<
50 years. We retrospectively analysed the results following
fixation with two cannulated compression screws and a vascularised
iliac bone graft. We treated 18 women and 16 men with a mean age
of 38.5 years (20 to 50) whose treatment included the use of an
iliac bone graft based on the ascending branch of lateral femoral
circumflex artery. There were 20 Garden grade III and 14 grade IV
fractures. Clinical and radiological outcomes were evaluated. The
mean follow-up was 5.4 years (2 to 10). In 30 hips (88%) union was
achieved at a mean of 4.4 months (4 to 6). Nonunion occurred in
four hips (12%) and these patients had a mean age of 46.5 years
(42 to 50) and underwent revision to a hip replacement six months
after operation. The time to union was dependent on age with younger
patients achieving earlier union (p <
0.001). According to the
Harris hip score which was available for 27 of the 30 hips with
satisfactory union, excellent results were obtained in 15 (score ≥ 90
points), fair in ten (score 80 to 90 points), and poor in two hips
(≤ 80 points). One patient aged 48 years developed avascular necrosis
of femoral head six years after operation and underwent total hip
replacement. The management of displaced subcapital fractures of the femoral
neck, in patients aged <
50 years, with two cannulated compression
screws and an iliac bone graft based on the ascending branch of
lateral femoral circumflex artery, gives satisfactory results with
a low rate of complication including avascular necrosis and nonunion. Cite this article:
The aim of this prospective multicentre study
was to report the patient satisfaction after total knee replacement (TKR),
undertaken with the aid of intra-operative sensors, and to compare
these results with previous studies. A total of 135 patients undergoing
TKR were included in the study. The soft-tissue balance of each
TKR was quantified intra-operatively by the sensor, and 18 (13%)
were found to be unbalanced. A total of 113 patients (96.7%) in
the balanced group and 15 (82.1%) in the unbalanced group were satisfied
or very satisfied one year post-operatively (p = 0.043). A review of the literature identified no previous study with
a mean level of satisfaction that was greater than the reported
level of satisfaction of the balanced TKR group in this study. Ensuring
soft-tissue balance by using intra-operative sensors during TKR
may improve satisfaction. Cite this article:
We examined patient and surgical factors associated
with deep surgical site infection (SSI) following total hip replacement
(THR) in a large integrated healthcare system. A retrospective review
of a cohort of primary THRs performed between 2001 and 2009 was
conducted. Patient characteristics, surgical details, surgeon and
hospital volumes, and SSIs were identified using the Kaiser Permanente
Total Joint Replacement Registry (TJRR). Proportional-hazard regression
models were used to assess risk factors for SSI. The study cohort
consisted of 30 491 THRs, of which 17 474 (57%) were performed on
women. The mean age of the patients in the whole series was 65.5
years (13 to 97; A comprehensive infection surveillance system, combined with
a TJRR, identified patient and surgical factors associated with
SSI. Obesity and chronic medical conditions should be addressed
prior to THR. The finding of increased SSI risk with bilateral THR
requires further investigation.
The August 2014 Spine Roundup360 looks at: rhBMP complicates cervical spine surgery; posterior longitudinal ligament revisited; thoracolumbar posterior instrumentation without fusion in burst fractures; risk modelling for VTE events in spinal surgery; the consequences of dural tears in microdiscectomy; trends in revision spinal surgery; radiofrequency denervation likely effective in facet joint pain and hooks optimally biomechanically transition posterior instrumentation.
We carried out metal artefact-reduction MRI, three-dimensional CT measurement of the position of the component and inductively-coupled plasma mass spectrometry analysis of cobalt and chromium levels in whole blood on 26 patients with unexplained pain following metal-on-metal resurfacing arthroplasty. MRI showed periprosthetic lesions around 16 hips, with 14 collections of fluid and two soft-tissue masses. The lesions were seen in both men and women and in symptomatic and asymptomatic hips. Using three-dimensional CT, the median inclination of the acetabular component was found to be 55° and its positioning was outside the Lewinnek safe zone in 13 of 16 cases. Using inductively-coupled plasma mass spectrometry, the levels of blood metal ions tended to be higher in painful compared with well-functioning metal-on-metal hips. These three clinically useful investigations can help to determine the cause of failure of the implant, predict the need for future revision and aid the choice of revision prostheses.
Femoroacetabular impingement is a cause of hip pain in adults and is potentially a precursor of osteoarthritis. Our aim in this study was to determine the prevalence of bilateral deformity in patients with symptomatic cam-type femoroacetabular impingement as well as the presence of associated acetabular abnormalities and hip pain. We included all patients aged 55 years or less seen by the senior author for hip pain, with at least one anteroposterior and lateral pelvic radiograph available. All patients with dysplasia and/or arthritis were excluded. A total of 113 patients with a symptomatic cam-impingement deformity of at least one hip was evaluated. There were 82 men and 31 women with a mean age of 37.9 years (16 to 55). Bilateral cam-type deformity was present in 88 patients (77.8%) while only 23 of those (26.1%) had bilateral hip pain. Painful hips had a statistically significant higher mean alpha angle than asymptomatic hips (69.9° vs 63.1°, p <
0.001). Hips with an alpha angle of more than 60° had an odds ratio of being painful of 2.59 (95% confidence interval 1.32 to 5.08, p = 0.006) compared with those with an alpha angle of less than 60°. Of the 201 hips with a cam-impingement deformity 42% (84) also had a pincer deformity. Most patients with cam-type femoroacetabular impingement had bilateral deformities and there was an associated acetabular deformity in 84 of 201 patients (42%). This information is important in order to define the natural history of these deformities, and to determine treatment.
We identified a group of patients from the Swedish
Arthroplasty Register who reported no relief of pain or worse pain
one year after a total knee replacement (TKR). A total of two different
patient-reported pain scores were used during this process. We then
evaluated how the instruments used to measure pain affected the
number of patients who reported no relief of pain or worse pain,
and the relative effect of potential risk factors. Between 2008 and 2010, 2883 TKRs were performed for osteoarthritis
in two Swedish arthroplasty units. After applying exclusion criteria,
2123 primary TKRs (2123 patients) were included in the study. The
Knee injury and Osteoarthritis Outcome Score (KOOS) and a Visual
Analogue Scale (VAS) for knee pain were used to assess patients pre-operatively
and one year post-operatively. Only 50 of the 220 patients (23%) who reported no pain relief
on either the KOOS pain subscale or the VAS for knee pain did so
with both of these instruments. Patients who reported no pain relief
on either measure tended to have less pain pre-operatively but a
higher degree of anxiety. Charnley category C was a predictor for
not gaining pain relief as measured on a VAS for knee pain. The number of patients who are not relieved of pain after a TKR
differs considerably depending on the instrument used to measure
pain. Cite this article:
The June 2014 Spine Roundup360 looks at: spinal pedicle screws in paediatric patients; improving diagnosis in lumbar spine stenosis; back pain all in the head?; brace three patients, save one scoliosis operation; pedicle screws more often misplaced than one would think; and incidental dural tears usually no problem
The August 2014 Trauma Roundup360 looks at: On-table CT for calcaneal fractures; timing of femoral fracture surgery and outcomes; salvage arthroplasty for failed internal fixation of the femoral neck; screw insertion in osteoporotic bone; fibular intramedullary nailing on the ascendant; posterior wall acetabular fractures not all that innocent; bugs, plating and resistance and improving outcomes in olecranon tension band wiring.
The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.
Previous studies have identified clinical and
demographic risk factors for recurrence in the treatment of idiopathic clubfoot
(congenital talipes equinovarus). Evertor muscle activity is not
usually considered amongst them. This study aimed to evaluate whether
recurrence could be predicted by demographic, clinical and gait
parameters. From a series of 103 children with clubfeet, 67 had
completed a follow-up of two years: 41 male and 26 female, 38 with idiopathic
and 29 with non-idiopathic deformities. The mean age was 3.2 years
(2.1 to 6.3). Primary correction was obtained in all 38 children
(100%) with an idiopathic deformity, and in 26 of 29 patients (90%)
with a non-idiopathic deformity. Overall, 60 children (90%) complied
with the abduction brace regime. At a mean follow-up of 31.4 months (24
to 62), recurrence was noted in six children (15.8%) in the idiopathic
and 14 children (48.3%) in the non-idiopathic group. Significant
correlation was found between poor evertor activity and recurrence
in both groups. No statistically significant relationship was found
between the rate of recurrence and the severity of the initial deformity,
the age at the time of treatment, the number of casts required or
the compliance with the brace. After correction of idiopathic and non-idiopathic clubfoot using
the Ponseti method, only poor evertor muscle activity was statistically
associated with recurrence. The identification of risk factors for
recurrent deformity allows clinicians to anticipate problems and
advocate early additional treatment to improve muscle balance around
the ankle. Cite this article:
Medium-term results of the Discovery elbow replacement
are presented. We reviewed 51 consecutive primary Discovery total
elbow replacements (TERs) implanted in 48 patients. The mean age
of the patients was 69.2 years (49 to 92), there were 19 males and
32 females (37%:63%) The mean follow-up was 40.6 months (24 to 69).
A total of six patients were lost to follow-up. Statistically significant
improvements in range movement and Oxford Elbow Score were found
(p <
0.001). Radiolucent lines were much more common in, and
aseptic loosening was exclusive to, the humeral component. Kaplan–Meier
survivorship at five years was 92.2% (95% CI 74.5% to 96.4%) for
aseptic loosening. In four TERs, periprosthetic infection occurred
resulting in failure. A statistically significant association between
infection and increased BMI was found (p = 0.0268). Triceps failure
was more frequent after the Mayo surgical approach and TER performed
after previous trauma surgery. No failures of the implant were noted. Our comparison shows that the Discovery has early clinical results
that are similar to other semi-constrained TERs. We found continued
radiological surveillance with particular focus on humeral lucency
is warranted and has not previously been reported. Despite advances
in the design of total elbow replacement prostheses, rates of complication
remain high. Cite this article:
The relationship between post-operative bone
density and subsequent failure of total knee replacement (TKR) is
not known. This retrospective study aimed to determine the relationship
between bone density and failure, both overall and according to
failure mechanism. All 54 aseptic failures occurring in 50 patients
from 7760 consecutive primary cemented TKRs between 1983 and 2004
were matched with non-failing TKRs, and 47 failures in 44 patients
involved tibial failures with the matching characteristics of age
(65.1 for failed and 69.8 for non-failed), gender (70.2% female), diagnosis
(93.6% OA), date of operation, bilaterality, pre-operative alignment
(0.4 and 0.3 respectively), and body mass index (30.2 and 30.0 respectively).
In each case, the density of bone beneath the tibial component was assessed
at each follow-up interval using standardised, calibrated radiographs.
Failing knees were compared with controls both overall and, as a
subgroup analysis, by failure mechanism. Knees were compared with
controls using univariable linear regression. Significant and continuous elevation in tibial density was found
in knees that eventually failed by medial collapse (p <
0.001)
and progressive radiolucency (p <
0.001) compared with controls,
particularly in the medial region of the tibia. Knees failing due
to ligamentous instability demonstrated an initial decline in density
(p = 0.0152) followed by a non-decreasing density over time (p =
0.034 for equivalence). Non-failing knees reported a decline in
density similar to that reported previously using dual-energy x-ray
absorptiometry (DEXA). Differences between failing and non-failing
knees were observable as early as two months following surgery.
This tool may be used to identify patients at risk of failure following
TKR, but more validation work is needed. Cite this article:
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
The April 2014 Wrist &
Hand Roundup360 looks at: diagnosis of compressive neuropathy; relevant reviews; the biomechanics of dorsal PIP fracture dislocation; the more strands the better; and state of mind the best predictor of outcome.
We hypothesised that the use of pulsed electromagnetic
field (PEMF) bone growth stimulation in acute scaphoid fractures
would significantly shorten the time to union and reduce the number
of nonunions in a randomised, double-blind, placebo-controlled multicentre
trial. A total of 102 patients (78 male, 24 female; mean age 35
years (18 to 77)) from five different medical centres with a unilateral
undisplaced acute scaphoid fracture were randomly allocated to PEMF
(n = 51) or placebo (n = 51) and assessed with regard to functional
and radiological outcomes (multiplanar reconstructed CT scans) at
6, 9, 12, 24 and 52 weeks. The overall time to clinical and radiological healing
did not differ significantly between the active PEMF group and the
placebo group. We concluded that the addition of PEMF bone growth
stimulation to the conservative treatment of acute scaphoid fractures
does not accelerate bone healing. Cite this article:
We report a 12- to 15-year implant survival assessment
of a prospective single-surgeon series of Birmingham Hip Resurfacings
(BHRs). The earliest 1000 consecutive BHRs including 288 women (335
hips) and 598 men (665 hips) of all ages and diagnoses with no exclusions
were prospectively followed-up with postal questionnaires, of whom
the first 402 BHRs (350 patients) also had clinical and radiological
review. Mean follow-up was 13.7 years (12.3 to 15.3). In total, 59 patients
(68 hips) died 0.7 to 12.6 years following surgery from unrelated
causes. There were 38 revisions, 0.1 to 13.9 years (median 8.7)
following operation, including 17 femoral failures (1.7%) and seven
each of infections, soft-tissue reactions and other causes. With
revision for any reason as the end-point Kaplan–Meier survival analysis
showed 97.4% (95% confidence interval (CI) 96.9 to 97.9) and 95.8%
(95% CI 95.1 to 96.5) survival at ten and 15 years, respectively.
Radiological assessment showed 11 (3.5%) femoral and 13 (4.1%) acetabular
radiolucencies which were not deemed failures and one radiological
femoral failure (0.3%). Our study shows that the performance of the BHR continues to
be good at 12- to 15-year follow-up. Men have better implant survival
(98.0%; 95% CI 97.4 to 98.6) at 15 years than women (91.5%; 95%
CI 89.8 to 93.2), and women <
60 years (90.5%; 95% CI 88.3 to
92.7) fare worse than others. Hip dysplasia and osteonecrosis are
risk factors for failure. Patients under 50 years with osteoarthritis
fare best (99.4%; 95% CI 98.8 to 100 survival at 15 years), with
no failures in men in this group. Cite this article:
We undertook a retrospective cohort study to
determine clinical outcomes following the revision of metal-on-metal (MoM)
hip replacements for adverse reaction to metal debris (ARMD), and
to identify predictors of time to revision and outcomes following
revision. Between 1998 and 2012 a total of 64 MoM hips (mean age
at revision of 57.8 years; 46 (72%) female; 46 (72%) hip resurfacings
and 18 (28%) total hip replacements) were revised for ARMD at one specialist
centre. At a mean follow-up of 4.5 years (1.0 to 14.6) from revision
for ARMD there were 13 hips (20.3%) with post-operative complications
and eight (12.5%) requiring re-revision. The Kaplan–Meier five-year survival rate for ARMD revision was
87.9% (95% confidence interval 78.9 to 98.0; 19 hips at risk). Excluding
re-revisions, the median absolute Oxford hip score (OHS) following
ARMD revision using the percentage method (0% best outcome and 100%
worst outcome) was 18.8% (interquartile range (IQR) 7.8% to 48.3%),
which is equivalent to 39/48 (IQR 24.8/48 to 44.3/48) when using
the modified OHS. Histopathological response did not affect time
to revision for ARMD (p = 0.334) or the subsequent risk of re-revision
(p = 0.879). Similarly, the presence or absence of a contralateral
MoM hip bearing did not affect time to revision for ARMD (p = 0.066)
or the subsequent risk of re-revision (p = 0.178). Patients revised to MoM bearings had higher rates of re-revision
(five of 16 MoM hips re-revised; p = 0.046), but those not requiring
re-revision had good functional results (median absolute OHS 14.6%
or 41.0/48). Short-term morbidity following revision for ARMD was
comparable with previous reports. Caution should be exercised when choosing
bearing surfaces for ARMD revisions. Cite this article:
Wrong-level surgery is a unique pitfall in spinal
surgery and is part of the wider field of wrong-site surgery. Wrong-site
surgery affects both patients and surgeons and has received much
media attention. We performed this systematic review to determine
the incidence and prevalence of wrong-level procedures in spinal
surgery and to identify effective prevention strategies. We retrieved
12 studies reporting the incidence or prevalence of wrong-site surgery
and that provided information about prevention strategies. Of these,
ten studies were performed on patients undergoing lumbar spine surgery
and two on patients undergoing lumbar, thoracic or cervical spine procedures.
A higher frequency of wrong-level surgery in lumbar procedures than
in cervical procedures was found. Only one study assessed preventative
strategies for wrong-site surgery, demonstrating that current site-verification protocols
did not prevent about one-third of the cases. The current literature
does not provide a definitive estimate of the occurrence of wrong-site
spinal surgery, and there is no published evidence to support the
effectiveness of site-verification protocols. Further prevention
strategies need to be developed to reduce the risk of wrong-site surgery.
We present the long-term results of open surgery
for internal shoulder rotational deformity in brachial plexus birth palsy
(BPBP). From 1997 to 2005, 207 patients (107 females, 100 males, mean
age 6.2 (0.6 to 34)) were operated on with subscapularis elongation
and/or latissimus dorsi to infraspinatus transfer. Incongruent shoulder
joints were relocated. The early results of these patients has been
reported previously. We analysed 118 (64 females, 54 males, mean
age 15.1 (7.6 to 34)) of the original patient cohort at a mean of
10.4 years (7.0 to 15.1) post-operatively. A third of patients with
relocated joints had undergone secondary internal rotational osteotomy
of the humerus. A mixed effects models approach was used to evaluate the effects
of surgery on shoulder rotation, abduction, and the Mallet score.
Independent factors were time (pre-and post-surgery), gender, age,
joint category (congruent, relocated, relocated plus osteotomy)
and whether or not a transfer had been performed. Data from a previously published
short-term evaluation were reworked in order to obtain pre-operative
values. The mean improvement in external rotation from pre-surgery to
the long-term follow-up was 66.5° (95% confidence interval (CI)
61.5 to 71.6). The internal rotation had decreased by a mean of
22.6° (95% CI -18.7 to -26.5). The mean improvement in the three-grade
aggregate Mallet score was 3.1 (95% CI 2.7 to 3.4), from 8.7 (95%
CI 8.4 to 9.0) to 11.8 (11.5 to 12.1). Our results show that open subscapularis elongation achieves
good long-term results for patients with BPBP and an internal rotation
contracture, providing lasting joint congruency and resolution of
the trumpet sign, but with a moderate mean loss of internal rotation. Cite this article: