We retrospectively reviewed the outcomes of 33
consecutive patients who had undergone an extra-articular, total or
partial scapulectomy for a malignant tumour of the shoulder girdle
between 1 July 2001 and 30 September 2013. Of these, 26 had tumours
which originated in the scapula or the adjacent soft tissue and
underwent a classic Tikhoff–Linberg procedure, while seven with
tumours arising from the proximal humerus were treated with a modified
Tikhoff-Linberg operation. We used a Ligament Advanced Reinforcement
System for soft-tissue reconstruction in nine patients, but not
in the other 24. The mean Musculoskeletal Tumor Society score (MSTS) was 17.6
(95% confidence interval (CI) 15.9 to 19.4); 17.6 (95% CI 15.5 to
19.6) after the classic Tikhoff–Linberg procedure and 18.1 (95%
CI 13.8 to 22.3) after the modified Tikhoff–Linberg procedure. Patients
who had undergone a LARS soft-tissue reconstruction had a mean score
of 18.6 (95% (CI) 13.9 to 22.4) compared with 17.2 (95% CI 15.5
to 19.0) for those who did not. The Tikhoff–Linberg procedure is a useful method for wide resection
of a malignant tumour of the shoulder girdle which helps to preserve
hand and elbow function. The method of soft-tissue reconstruction
has no effect on functional outcome. Cite this article:
The purpose of this study was to investigate
the development of the osseous acetabular index (OAI) and cartilaginous
acetabular index (CAI) using MRI. The OAI and CAI were measured
on the coronal MR images of the hip in 81 children with developmental
dysplasia of the hip (DDH), with a mean age of 19.6 months (3 to
70), and 241 normal control children with a mean age of 5.1 years
(1 month to 12.5 years). Additionally the developmental patterns
of the OAI and CAI in normal children were determined by age-based
cross-sectional analysis. Unlike the OAI, the normal CAI decreased rapidly from a mean
of 10.17° (
Restoration of leg length and offset is an important
goal in total hip replacement. This paper reports a calliper-based technique
to help achieve these goals by restoring the location of the centre
of the femoral head. This was validated first by using a co-ordinate
measuring machine to see how closely the calliper technique could
record and restore the centre of the femoral head when simulating
hip replacement on Sawbone femur, and secondly by using CT in patients
undergoing hip replacement. Results from the co-ordinate measuring machine showed that the
centre of the femoral head was predicted by the calliper to within
4.3 mm for offset (mean 1.6 (95% confidence interval (CI) 0.4 to
2.8)) and 2.4 mm for vertical height (mean -0.6 (95% CI -1.4 to
0.2)).
The CT scans showed that offset and vertical height were restored
to within 8 mm
(mean -1 (95% CI -2.1 to 0.6)) and -14 mm (mean 4 (95% CI 1.8 to
4.3)), respectively. Accurate assessment and restoration of the centre of the femoral
head is feasible with a calliper. It is quick, inexpensive, simple
to use and can be applied to any design of femoral component.
The aim of this study was to determine whether the foundation programme for junior doctors, implemented across the United Kingdom in 2005, provides adequate training in musculoskeletal medicine. We recruited 112 doctors on completion of their foundation programme and assessed them using the Freedman and Bernstein musculoskeletal examination tool. Only 8.9% passed the assessment. Those with exposure to orthopaedics, with a career interest in orthopaedics, and who felt that they had gained adequate exposure to musculoskeletal medicine obtained significantly higher scores. Those interested in general practice as a career obtained significantly lower scores. Only 15% had any exposure to orthopaedics during the foundation programme and only 13% felt they had adequate exposure to musculoskeletal medicine. The foundation programme currently provides inadequate training in musculoskeletal medicine. The quality and quantity of exposure to musculoskeletal medicine during the foundation programme must be improved.
Neurological conditions affecting the hip pose a considerable challenge in replacement surgery since poor and imbalanced muscle tone predisposes to dislocation and loosening. Consequently, total hip replacement (THR) is rarely performed in such patients. In a systematic review of the literature concerning THR in neurological conditions, we found only 13 studies which described the outcome. We have reviewed the evidence and discussed the technical challenges of this procedure in patients with cerebral palsy, Parkinson’s disease, poliomyelitis and following a cerebrovascular accident, spinal injury or development of a Charcot joint. Contrary to traditional perceptions, THR can give a good outcome in these often severly disabled patients.
Obtaining a balanced flexion gap with correct
femoral component rotation is one of the prerequisites for a successful
outcome after total knee replacement (TKR). Different techniques
for achieving this have been described. In this study we prospectively
compared gap-balancing Both groups systematically reproduced a similar external rotation
of the femoral component relative to the surgical transepicondylar
axis: 2.4°
The orientation of the acetabular component can
influence both the short- and long-term outcomes of total hip replacement
(THR). We performed a prospective, randomised, controlled trial
of two groups, comprising of 40 patients each, in order to compare
freehand introduction of the component with introduction using the transverse
acetabular ligament (TAL) as a reference for anteversion. Anteversion
and inclination were measured on pelvic radiographs. With respect to anteversion, in the freehand group 22.5% of the
components were outside the safe zone With respect to inclination, in the freehand group 37.5% of the
components were outside the safe zone The transverse acetabular ligament may be used to obtain the
appropriate anteversion when introducing the acetabular component
during THR, but not acetabular component inclination. Cite this article:
In a global environment of rising costs and limited funds, robotic and computer-assisted orthopaedic technologies could provide the means to drive a necessary revolution in arthroplasty productivity. Robots have been used to operate on humans for 20 years, but the adoption of the technology has lagged behind that of the manufacturing industry. The use of robots in surgery should enable cost savings by reducing instrumentation and inventories, and improving accuracy. Despite these benefits, the orthopaedic community has been resistant to change. If the ergonomics and economics are right, robotic technology just might transform the provision of joint replacement.
This study assessed whether undergraduate performance improved following the introduction in 2006 of a musculoskeletal teaching programme lasting for seven weeks. Different methods were used to deliver knowledge and skills in trauma and orthopaedic surgery, rheumatology and allied specialties. The programme combined four main elements: traditional firm-based teaching, weekly plenary sessions, a task-based workbook and additional specialist clinics. The block of 139 students who attended in its first year were assessed using a multiple choice question examination just before their final examinations in 2008. They showed a 6% improvement in performance over a control group of 130 students assessed in 2005 before the programme had commenced. There was no difference in performance between the students assessed in 2005 and a second group of 46 students from 2008 who did not attend the new teaching programme. Performance was improved by providing more focused musculoskeletal training using available resources, as well as increasing the length of the programme.
The “Universal Protocol” (UP) was launched as a regulatory compliance standard by the Joint Commission on 1st July 1 2004, with the primary intent of reducing the occurrence of wrong-site and wrong-patient surgery. As we’re heading into the tenth year of the UP implementation in the United States, it is time for critical assessment of the protocol’s impact on patient safety related to the incidence of preventable never-events. This article opens the debate on the potential shortcomings and pitfalls of the UP, and provides recommendations on how to circumvent specific inherent vulnerabilities of this widely established patient safety protocol.
The December 2013 Spine Roundup360 looks at: Just how common is lumbar spinal stenosis?; How much will they bleed?; C5 palsy associated with stenosis; Atlanto-axial dislocations revisited; 3D predictors of progression in scoliosis; No difference in outcomes by surgical approach for fusion; Cervical balance changes after thoracolumbar surgery; and spinal surgeons first in space.
The identification of the extent of neural damage
in patients with acute or chronic spinal cord injury is imperative for
the accurate prediction of neurological recovery. The changes in
signal intensity shown on routine MRI sequences are of limited value
for predicting functional outcome. Diffusion tensor imaging (DTI)
is a novel radiological imaging technique which has the potential
to identify intact nerve fibre tracts, and has been used to image
the brain for a variety of conditions. DTI imaging of the spinal
cord is currently only a research tool, but preliminary studies
have shown that it holds considerable promise in predicting the
severity of spinal cord injury. This paper briefly reviews our current knowledge of this technique.
The management of spinal deformity in children
with univentricular cardiac pathology poses significant challenges to
the surgical and anaesthetic teams. To date, only posterior instrumented
fusion techniques have been used in these children and these are
associated with a high rate of complications. We reviewed our experience
of both growing rod instrumentation and posterior instrumented fusion
in children with a univentricular circulation. Six children underwent spinal corrective surgery, two with cavopulmonary
shunts and four following completion of a Fontan procedure. Three
underwent growing rod instrumentation, two had a posterior fusion
and one had spinal growth arrest. There were no complications following
surgery, and the children undergoing growing rod instrumentation
were successfully lengthened. We noted a trend for greater blood
loss and haemodynamic instability in those whose surgery was undertaken
following completion of a Fontan procedure. At a median follow-up
of 87.6 months (interquartile range (IQR) 62.9 to 96.5) the median
correction of deformity was 24.2% (64.5° (IQR 46° to 80°) We believe that early surgical intervention with growing rod
instrumentation systems allows staged correction of the spinal deformity
and reduces the haemodynamic insult to these physiologically compromised
children. Due to the haemodynamic changes that occur with the completed
Fontan circulation, the initial scoliosis surgery should ideally
be undertaken when in the cavopulmonary shunt stage. Cite this article:
The use of a navigation system in musculoskeletal tumour surgery enables the integration of pre-operative CT and MRI images to generate a precise three-dimensional anatomical model of the site and the extent of the tumour. We carried out six consecutive resections of musculoskeletal tumour in five patients using an existing commercial computer navigation system. There were three women and two men with a mean age of 41 years (24 to 47). Reconstruction was performed using a tumour prosthesis in three lesions and a vascularised fibular graft in one. No reconstruction was needed in two cases. The mean follow-up was 6.9 months (3.5 to 10). The mean duration of surgery was 28 minutes (13 to 50). Examination of the resected specimens showed clear margins in all the tumour lesions and a resection that was exactly as planned.
Pelvic discontinuity represents a rare but challenging
problem for orthopaedic surgeons. It is most commonly encountered
during revision total hip replacement, but can also result from
an iatrogentic acetabular fracture during hip replacement. The general
principles in management of pelvic discontinuity include restoration
of the continuity between the ilium and the ischium, typically with
some form of plating. Bone grafting is frequently required to restore
pelvic bone stock. The acetabular component is then impacted, typically
using an uncemented, trabecular metal component. Fixation with multiple
supplemental screws is performed. For larger defects, a so-called
‘cup–cage’ reconstruction, or a custom triflange implant may be
required. Pre-operative CT scanning can greatly assist in planning
and evaluating the remaining bone stock available for bony ingrowth.
Generally, good results have been reported for constructs that restore
stability to the pelvis and allow some form of biologic ingrowth. Cite this article:
We describe the technique and results of medial
submuscular plating of the femur in paediatric patients and discuss its
indications and limitations. Specifically, the technique is used
as part of a plate-after-lengthening strategy, where the period
of external fixation is reduced and the plate introduced by avoiding
direct contact with the lateral entry wounds of the external fixator
pins. The technique emphasises that vastus medialis is interposed
between the plate and the vascular structures. A total of 16 patients (11 male and five female, mean age 9.6
years (5 to 17)), had medial submuscular plating of the femur. All
underwent distraction osteogenesis of the femur with a mean lengthening
of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation
of the regenerate without deformity. The mean follow-up was 10.5 months
(7 to 15) after plating for those with plates still Placing the plate on the medial side is advantageous when the
external fixator is present on the lateral side, and is biomechanically
optimal in the presence of a femoral defect. We conclude that medial
femoral submuscular plating is a useful technique for specific indications
and can be performed safely with a prior understanding of the regional
anatomy. Cite this article:
Osteochondral lesions (OCLs) occur in up to 70%
of sprains and fractures involving the ankle. Atraumatic aetiologies have
also been described. Techniques such as microfracture, and replacement
strategies such as autologous osteochondral transplantation, or
autologous chondrocyte implantation are the major forms of surgical
treatment. Current literature suggests that microfracture is indicated
for lesions up to 15 mm in diameter, with replacement strategies
indicated for larger or cystic lesions. Short- and medium-term results
have been reported, where concerns over potential deterioration
of fibrocartilage leads to a need for long-term evaluation. Biological augmentation may also be used in the treatment of
OCLs, as they potentially enhance the biological environment for
a natural healing response. Further research is required to establish
the critical size of defect, beyond which replacement strategies
should be used, as well as the most appropriate use of biological augmentation.
This paper reviews the current evidence for surgical management
and use of biological adjuncts for treatment of osteochondral lesions
of the talus. Cite this article: