The medial approach for the treatment of children
with developmental dysplasia of the hip (DDH) in whom closed reduction
has failed requires minimal access with negligible blood loss. In
the United Kingdom, there is a preference for these children to
be treated using an anterolateral approach after the appearance
of the ossific nucleus. In this study we compared these two protocols,
primarily for the risk of osteonecrosis. Data were gathered prospectively for protocols involving the
medial approach (26 hips in 22 children) and the anterolateral approach
(22 hips in 21 children) in children aged <
24 months at the
time of surgery. Osteonecrosis of the femoral head was assessed
with validated scores. The acetabular index (AI) and centre–edge
angle (CEA) were also measured. The mean age of the children at the time of surgery was 11 months
(3 to 24) for the medial approach group and 18 months (12 to 24)
for the anterolateral group, and the combined mean follow-up was
70 months (26 to 228). Osteonecrosis of the femoral head was evident
or asphericity predicted in three of 26 hips (12%) in the medial approach
group and four of 22 (18%) in the anterolateral group (p = 0.52).
The mean improvement in AI was 8.8° (4° to 12°) and 7.9° (6° to
10°), respectively, at two years post-operatively (p = 0.18). There
was no significant difference in CEA values of affected hips between
the two groups. Children treated using an early medial approach did not have
a higher risk of developing osteonecrosis at early to mid-term follow-up
than those treated using a delayed anterolateral approach. The rates
of acetabular remodelling were similar for both protocols. Cite this article:
Bicondylar tibial plateau fractures result from
high-energy injuries. Fractures of the tibial plateau can involve
the tibial tubercle, which represents a disruption to the extensor
mechanism and logically must be stabilised. The purpose of this
study was to identify the incidence of an independent tibial tubercle
fracture in bicondylar tibial plateau fractures, and to report management
strategies and potential complications. We retrospectively reviewed
a prospectively collected orthopaedic trauma database for the period
January 2003 to December 2008, and identified 392 bicondylar fractures
of the tibial plateau, in which 85 tibial tubercle fractures (21.6%)
were identified in 84 patients. There were 60 men and 24 women in
our study group, with a mean age of 45.4 years (18 to 71). In 84 fractures
open reduction and internal fixation was undertaken, either with
screws alone (23 patients) or with a plate and screws (61 patients).
The remaining patient was treated non-operatively. In all, 52 fractures
were available for clinical and radiological assessment at a mean
follow-up of 58.5 weeks (24 to 94). All fractures of the tibial
tubercle united, but 24 of 54 fractures (46%) required a secondary
procedure for their tibial plateau fracture. Four patients reported
pain arising from prominent tubercle plates and screws, which in
one patient required removal. Tibial tubercle fractures occurred
in over one-fifth of the bicondylar tibial plateau fractures in
our series. Fixation is necessary and can be reliably performed
with screws alone or with a screw and plate, which restores the
extensor mechanism and facilitates early knee flexion. Cite this article:
We determined the short-term clinical outcome
and migration within the bone of the humeral cementless component
of the Instrumented Bone Preserving (IBP) total elbow replacement
in a series of 16 patients. There were four men and 12 women with
a mean age at operation of 63 years (40 to 81). Migration was calculated
using radiostereometric analysis. There were no intra-operative
complications and no revisions. At two-year follow-up, all patients
showed a significant reduction in pain and functional improvement
of the elbow (both p <
0.001). Although ten components (63%)
showed movement or micromovement during the first six weeks, 14
(88%) were stable at one year post-operatively. Translation was
primarily found in the proximal direction (median 0.3 mm (interquartile range
(IQR) -0.09 to 0.8); the major rotational movement was an anterior
tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component
continued to migrate during the second year, and one component could
not be followed beyond three months because migration had caused
the markers to break off the prosthesis. This study shows promising early results for the cementless humeral
component of the IBP total elbow replacement. All patients had a
good clinical outcome, and most components stabilised within six
months of the operation. Cite this article:
We retrospectively studied the major complications occurring after one- and two-stage bilateral unicompartmental knee replacements (UKR). Between 1999 and 2008, 911 patients underwent 1150 UKRs through a minimally invasive approach in our unit. Of these, 159 patients (318 UKRs) had one-stage and 80 patients (160 UKRs) had two-stage bilateral UKRs. The bilateral UKR groups were comparable in age and American Society of Anaesthesiology grade, but more women were in the two-stage group (p = 0.019). Mechanical thromboprophylaxis was used in all cases. Major complications were recorded as death, pulmonary embolus, proximal deep-vein thrombosis and adverse cardiac events within 30 days of surgery. No statistical differences between the groups were found regarding the operating surgeon, the tourniquet time or minor complications except for distal deep-vein thrombosis. The anaesthetic times were longer for the two-stage group (p = 0.0001). Major complications were seen in 13 patients (8.2%) with one-stage operations but none were encountered in the two-stage group (p = 0.005). Distal deep-vein thrombosis was more frequent in the two-stage group (p = 0.036). Because of the significantly higher risk of major complications associated with one-stage bilateral UKR we advocate caution before undertaking such a procedure.
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:
The purpose of this study was to assess N-acetyl aspartate changes
in the thalamus in patients with osteoarthritis of the hip using
proton magnetic resonance spectroscopy. Nine patients with osteoarthritis of the hip (symptomatic group,
nine women; mean age 61.4 years (48 to 78)) and nine healthy volunteers
(control group, six men, three women; mean age 30.0 years (26 to
38)) underwent proton magnetic resonance spectroscopy to assess
the changes of N-acetyl aspartate in the thalamus. Objectives
Methods
There are three basic concepts that are important to the biomechanics of pedicle screw-based instrumentation. First, the outer diameter of the screw determines pullout strength, while the inner diameter determines fatigue strength. Secondly, when inserting a pedicle screw, the dorsal cortex of the spine should not be violated and the screws on each side should converge and be of good length. Thirdly, fixation can be augmented in cases of severe osteoporosis or revision. A trajectory parallel or caudal to the superior endplate can minimise breakage of the screw from repeated axial loading. Straight insertion of the pedicle screw in the mid-sagittal plane provides the strongest stability. Rotational stability can be improved by adding transverse connectors. The indications for their use include anterior column instability, and the correction of rotational deformity.
Blood loss during total knee replacement (TKR)
remains a significant concern. In this study, 114 patients underwent TKR,
and were divided into two groups based on whether they received
a new generation fibrin sealant intra-operatively, or a local infiltration
containing adrenaline. Groups were then compared for mean calculated
total blood volume (TBV) loss, transfusion rates, and knee range
of movement. Mean TBV loss was similar between groups: fibrin sealant
mean was 705 ml (281 to 1744), local adrenaline mean was 712 ml
(261 to 2308) (p = 0.929). Overall, significantly fewer units of
blood were transfused in the fibrin sealant group (seven units)
compared with the local adrenaline group (15 units) (p = 0.0479).
Per patient transfused, significantly fewer units of blood were transfused
in the fibrin sealant group (1.0 units) compared with the local
adrenaline group (1.67 units) (p = 0.027), suggesting that the fibrin
sealant may reduce the need for multiple unit transfusions. Knee
range of movement was similar between groups. From our results,
it appears that application of this newer fibrin sealant results
in blood loss and transfusion rates that are low and similar to
previously applied fibrin sealants. Cite this article:
Patients with transfemoral amputation (TFA) often
experience problems related to the use of socket-suspended prostheses.
The clinical development of osseointegrated percutaneous prostheses
for patients with a TFA started in 1990, based on the long-term
successful results of osseointegrated dental implants. Between1999 and 2007, 51 patients with 55 TFAs were consecutively
enrolled in a prospective, single-centre non-randomised study and
followed for two years. The indication for amputation was trauma
in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical
procedure was used to introduce a percutaneous implant to which
an external amputation prosthesis was attached. The assessment of
outcome included the use of two self-report questionnaires, the
Questionnaire for Persons with a Transfemoral Amputation (Q-TFA)
and the Short-Form (SF)-36. The cumulative survival at two years’ follow-up was 92%. The
Q-TFA showed improved prosthetic use, mobility, global situation
and fewer problems (all p <
0.001). The physical function SF-36
scores were also improved (p <
0.001). Superficial infection
was the most frequent complication, occurring 41 times in 28 patients
(rate of infection 54.9%). Most were treated effectively with oral
antibiotics. The implant was removed in four patients because of loosening
(three aseptic, one infection). Osseointegrated percutaneous implants constitute a novel form
of treatment for patients with TFA. The high cumulative survival
rate at two years (92%) combined with enhanced prosthetic use and
mobility, fewer problems and improved quality of life, supports
the ‘revolutionary change’ that patients with TFA have reported
following treatment with osseointegrated percutaneous prostheses. Cite this article:
The aims of this study were to assess the efficacy
of a newly designed radiological technique (the radial groove view)
for the detection of protrusion of screws in the groove for the
extensor pollicis longus tendon (EPL) during plating of distal radial
fractures. We also aimed to determine the optimum position of the
forearm to obtain this view. We initially analysed the anatomy of
the EPL groove by performing three-dimensional CT on 51 normal forearms.
The mean horizontal angle of the groove was 17.8° (14° to 23°).
We found that the ideal position of the fluoroscopic beam to obtain
this view was 20° in the horizontal plane and 5° in the sagittal
plane. We then intra-operatively assessed the use of the radial groove
view for detecting protrusion of screws in the EPL groove in 93
fractures that were treated by volar plating. A total of 13 protruding
screws were detected. They were changed to shorter screws and these
patients underwent CT scans of the wrist immediately post-operatively.
There remained one screw that was protruding. These findings suggest
that the use of the radial groove view intra-operatively is a good
method of assessing the possible protrusion of screws into the groove
of EPL when plating a fracture of the distal radius. Cite this article:
The October 2013 Shoulder &
Elbow Roundup360 looks at: Deltoid impairment not necessarily a contra-indication for shoulder arthroplasty; The tricky radiograph; Not so asymptomatic cuff tears; Total shoulder arthroplasty: kinder on the glenoid; Barbotage for calcific tendonitis; What happens to the arthritic glenoid?; Two screws a screw too few?; Sloppy hinge best for elbow arthroplasty.
A total of 187 patients with primary osteoarthritis
(OA) of the knee undergoing total knee replacement (TKR) were randomly
divided into two groups, one of which underwent synovectomy. The
patients and assessors were blinded to the randomisation both before
and after surgery. The duration of surgery, hospitalisation period,
concealed bleeding, drainage volume, blood transfusion rate and
range of movement of the knee at three days after the operation
were analysed. Patients were followed up at four weeks and 12 months
after their operation, and a visual analogue score (VAS) for pain,
Knee Society score (KSS) and a patellar ballottement test were compared
between the groups. The mean amount of concealed bleeding was higher in the synovectomy
group compared with the control group (1.24 l (0.08 to 3.28) Cite this article:
The primary aim of this study was to develop
a patient-reported Activity &
Participation Questionnaire (the
OKS-APQ) to supplement the Oxford knee score, in order to assess
higher levels of activity and participation. The generation of items
for the questionnaire involved interviews with 26 patients. Psychometric
analysis (exploratory and confirmatory factor analysis and Rasch
analysis) guided the reduction of items and the generation of a
scale within a prospective study of 122 relatively young patients
(mean age 61.5 years (42 to 71)) prior to knee replacement. A total
of 99, completed pre-operative and six month post-operative assessments
(new items, OKS, Short-Form 36 and American Knee Society Score). The eight-item OKS-APQ scale is unidimensional, reliable (Cronbach’s
alpha 0.85; intraclass correlation coefficient (ICC) 0.79; or 0.92
when one outlier was excluded), valid (r >
0.5 with related scales)
and responsive (effect size 4.16). We recommend that it is used with the OKS with adults of all
ages when further detail regarding the levels of activity and participation
of a patient is required. Cite this article:
We report the findings of an independent review
of 230 consecutive Birmingham hip resurfacings (BHRs) in 213 patients
(230 hips) at a mean follow-up of 10.4 years (9.6 to 11.7). A total
of 11 hips underwent revision; six patients (six hips) died from
unrelated causes; and 13 patients (16 hips) were lost to follow-up.
The survival rate for the whole cohort was 94.5% (95% confidence
interval (CI) 90.1 to 96.9). The survival rate in women was 89.1%
(95% CI 79.2 to 94.4) and in men was 97.5% (95% CI 92.4 to 99.2).
Women were 1.4 times more likely to suffer failure than men. For
each millimetre increase in component size there was a 19% lower
chance of a failure. The mean Oxford hip score was 45.0 (median
47.0, 28 to 48); mean University of California, Los Angeles activity
score was 7.4 (median 8.0, 3 to 9); mean patient satisfaction score
was 1.4 (median 1.0, 0 to 9). A total of eight hips had lysis in
the femoral neck and two hips had acetabular lysis. One hip had
progressive radiological changes around the peg of the femoral component.
There was no evidence of progressive neck narrowing between five
and ten years. Our results confirm that BHR provides good functional outcome
and durability for men, at a mean follow-up of ten years. We are
now reluctant to undertake hip resurfacing in women with this implant.
The strain on clinic and surgeon resources resulting
from a rise in demand for total knee replacement (TKR) requires reconsideration
of when and how often patients need to be seen for follow-up. Surgeons
will otherwise require increased paramedical staff or need to limit
the number of TKRs they undertake. We reviewed the outcome data
of 16 414 primary TKRs undertaken at our centre to determine the
time to re-operation for any reason and for specific failure mechanisms.
Peak risk years for failure were determined by comparing the conditional
probability of failure, the number of failures divided by the total
number of TKRs cases, for each year. The median times to failure
for the most common failure mechanisms were 4.9 years (interquartile
range (IQR) 1.7 to 10.7) for femoral and tibial loosening, 1.9 years
(IQR 0.8 to 3.9) for infection, 3.1 years (IQR 1.6 to 5.5) for tibial
collapse and 5.6 years (IQR 3.4 to 9.3) for instability. The median
time to failure for all revisions was 3.3 years (IQR 1.2 to 8.5),
with an overall revision rate of 1.7% (n = 282). Results from our
patient population suggest that patients be seen for follow-up at
six months, one year, three years, eight years, 12 years, and every
five years thereafter. Patients with higher pain in the early post-operative
period or high body mass index (≥ 41 kg/m2) should be
monitored more closely. Cite this article:
We have investigated the benefits of patient
specific instrument guides, applied to osteotomies around the knee. Single,
dual and triple planar osteotomies were performed on tibias or femurs
in 14 subjects. In all patients, a detailed pre-operative plan was
prepared based upon full leg standing radiographic and CT scan information.
The planned level of the osteotomy and open wedge resection was
relayed to the surgery by virtue of a patient specific guide developed
from the images. The mean deviation between the planned wedge angle
and the executed wedge angle was 0° (-1 to 1, Cite this article:
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:
We carried out a prospective study of 118 hydroxyapatite-coated, cementless total knee replacements in patients who were ≤ 55 years of age and who had primary (92; 78%) or post-traumatic (26; 22%) osteoarthritis. The mean period of follow-up was 7.9 years (5 to 12.5). The Knee Society clinical scores improved from a pre-operative mean of 98 (0 to 137) to a mean of 185 (135 to 200) at five years, and 173 (137 to 200) at ten years. There were two revisions of the tibial component because of aseptic loosening, and one case of polyethylene wear requiring further surgery. There was no osteolysis or progressive radiological loosening of any other component. At 12 years, the overall rate of implant survival was 97.5% (excluding exchange of spacer) and 92.1% (including exchange of spacer). Cementless total knee replacement can achieve excellent long-term results in young, active patients with osteoarthritis. In contrast to total hip replacement, polyethylene wear, osteolysis and loosening of the prosthesis were not major problems for these patients, although it is possible that this observation could change with longer periods of follow-up.
Fracture of a pedicle is a rare complication of spinal instrumentation using pedicular screws, but it can lead to instability and pain and may necessitate extension of the fusion. Osteosynthesis of the fractured pedicle by cerclage-wire fixation and augmentation of the screw fixation by vertebroplasty or temporary elongation of the fixation, allows stabilisation without sacrifice of the adjacent healthy segment. We describe three patients who developed a fracture of the pedicle in the most caudal instrumented vertebra early after lumbar spinal fusion. During revision surgery the pedicles were reduced and secured by a soft cerclage wire bilaterally. Fusion was obtained at the site of the primary instrumentation and healing of the pedicles was achieved. Cerclage wiring of the fractured pedicle seems to be safe and avoids permanent extension of the fusion without the sacrifice of an otherwise healthy segment.
Orientation of the acetabular component influences
wear, range of movement and the incidence of dislocation after total
hip replacement (THR). During surgery, such orientation is often
referenced to the anterior pelvic plane (APP), but APP inclination
relative to the coronal plane (pelvic tilt) varies substantially
between individuals. In contrast, the change in pelvic tilt from
supine to standing (dPT) is small for nearly all individuals. Therefore,
in THR performed with the patient supine and the patient’s coronal
plane parallel to the operating table, we propose that freehand placement
of the acetabular component placement is reliable and reflects standing
(functional) cup position. We examined this hypothesis in 56 hips
in 56 patients (19 men) with a mean age of 61 years (29 to 80) using
three-dimensional CT pelvic reconstructions and standing lateral
pelvic radiographs. We found a low variability of acetabular component
placement, with 46 implants (82%) placed within a combined range
of 30° to 50° inclination and 5° to 25° anteversion. Changing from
the supine to the standing position (analysed in 47 patients) was associated
with an anteversion change <
10° in 45 patients (96%). dPT was
<
10° in 41 patients (87%). In conclusion, supine THR appears
to provide reliable freehand acetabular component placement. In
most patients a small reclination of the pelvis going from supine
to standing causes a small increase in anteversion of the acetabular component Cite this article: