The June 2015 Hip &
Pelvis Roundup360 looks at: neuraxial anaesthesia and large joint arthroplasty; revision total hip arthoplasty: factors associated with re-revision surgery; acetabular version and clinical outcomes in impingement surgery; hip precautions may be ineffective; implant selection and cost effectiveness; femoroacetabular impingement in the older age group; multiple revision in hip arthroplasty
The objective of this double-blind randomised controlled trial
was to assess whether ultrasound guidance improved the efficacy
of corticosteroid injections for Morton’s neuroma (MN). In all, 50 feet (40 patients) were recruited for this study but
five feet were excluded due to the patients declining further participation.
The mean age of the remaining 36 patients (45 feet) was 57.8 years
(standard deviation (Aims
Patients and Methods
The anatomy and microstructure of the menisci
allow the effective distribution of load across the knee. Meniscectomy
alters the biomechanical environment and is a potent risk factor
for osteoarthritis. Despite a trend towards meniscus-preserving
surgery, many tears are irreparable, and many repairs fail. Meniscal allograft transplantation has principally been carried
out for pain in patients who have had a meniscectomy. Numerous case
series have reported a significant improvement in patient-reported
outcomes after surgery, but randomised controlled trials have not
been undertaken. It is scientifically plausible that meniscal allograft transplantation
is protective of cartilage, but this has not been established clinically
to date. Cite this article:
The aims of this study were to describe the course of non-operatively
managed, bilateral Perthes’ disease, and to determine specific prognostic
factors for the radiographic and clinical outcome. We identified 40 children with a mean age of 5.9 years (1.8 to
13.5), who were managed non-operatively for bilateral Perthes’ disease
from our prospective, multicentre study of this condition, which
included all children in Norway who were diagnosed with Perthes’
disease in the five-year period between 1996 and 2000. All children
were followed up for five years. The hips were classified according to the Catterall classification.
A modified three-group Stulberg classification was used as an outcome
measure, with a spherical femoral head being defined as a good outcome,
an oval head as fair, and a flat femoral head as a poor outcome. Aims
Patients and Methods
This review summarises the evidence for the treatment
of displaced fractures of the femoral neck in elderly patients.
Results from randomised clinical trials and national register studies are
presented when available. The advantages of arthroplasty compared with internal fixation
are supported by several studies. A number of studies contribute
to the discussions of total hip arthroplasty (THA) The direct lateral approach reduces the risk of dislocation compared
with the posterior approach. Cemented implants lower the risk of
periprosthetic fracture and its subsequent morbidity and mortality.
As the risk of peri-operative death related to bone cement can be reduced
by adequate measures, cemented implants are recommended in fracture
cases. Take home message: There remains a great variation in the surgical
management of patients with a hip fracture, and an evidence-based
approach should improve the outcomes for this vulnerable patient
group. Cite this article:
Obesity is a worldwide epidemic that has both
economic and health implications of enormous consequence. The obese
patients tend to have earlier symptoms related to osteoarthritis,
more peri-operative medical problems, higher rates of infection
and more technical difficulties intra-operatively following hip
and knee arthroplasty. Nevertheless, these patients have good long-term
clinical outcomes and implant survival rates and are often some of
the most satisfied patients after joint arthroplasty. Therefore,
obese patients should not be denied surgery based on their weight
alone. Cite this article:
Surgical intervention in patients with bone metastases from breast
cancer is dependent on the estimated survival of the patient. The
purpose of this paper was to identify factors that would predict
survival so that specific decisions could be made in terms of surgical
(or non-surgical) management. The records of 113 consecutive patients (112 women) with metastatic
breast cancer were analysed for clinical, radiological, serological
and surgical outcomes. Their median age was 61 years (interquartile
range 29 to 90) and the median duration of follow-up was 1.6 years
(standard deviation (Aims
Methods
The pre-operative level of haemoglobin is the strongest predictor
of the peri-operative requirement for blood transfusion after total
knee arthroplasty (TKA). There are, however, no studies reporting
a value that could be considered to be appropriate pre-operatively. This study aimed to identify threshold pre-operative levels of
haemoglobin that would predict the requirement for blood transfusion
in patients who undergo TKA. Analysis of receiver operator characteristic (ROC) curves of
2284 consecutive patients undergoing unilateral TKA was used to
determine gender specific thresholds predicting peri-operative transfusion
with the highest combined sensitivity and specificity (area under
ROC curve 0.79 for males; 0.78 for females).Aims
Patients and Methods
This study assessed the effect of concomitant
back pain on the Oxford knee score (OKS), Short-Form (SF)-12 and patient
satisfaction after total knee replacement (TKR). It involved a prospectively
compiled database of demographics and outcome scores for 2392 patients
undergoing primary TKR, of whom 829 patients (35%) reported back
pain. Compared with those patients without back pain, those with
back pain were more likely to be female (odds ratio (OR) 1.5 (95%
confidence interval (CI) 1.3 to 1.8)), have a greater level of comorbidity,
a worse pre-operative OKS (2.3 points (95% CI 1.7 to 3.0)) and worse
SF-12 physical (2.0 points (95% CI 1.4 to 2.6)) and mental (3.3
points (95% CI 2.3 to 4.3)) components. One year post-operatively, those with back pain had significantly
worse outcome scores than those without with a mean difference in
the OKS of 5 points (95% CI 3.8 to 5.4), in the SF-12 physical component
of 6 points (95% CI 5.4 to 7.1) and in the mental component of
4 points (95% CI 3.1 to 4.9). Patients with back pain were less
likely to be satisfied (OR 0.62, 95% CI 0.5 to 0.78). After adjusting for confounding variables, concomitant back pain
was an independent predictor of a worse post-operative OKS, and
of dissatisfaction. Clinicians should be aware that patients suffering
concomitant back pain pre-operatively are at an increased risk of
being dissatisfied post-operatively. Cite this article:
We aimed to determine quality of life and burnout
among Dutch orthopaedic trainees following a modern orthopaedic
curriculum, with strict compliance to a 48-hour working week. We
also evaluated the effect of the clinical climate of learning on
their emotional well-being. We assessed burnout, quality of life and the clinical climate
of learning in 105 orthopaedic trainees using the Maslach Burnout
Inventory, linear analogue scale self-assessments, and Dutch Residency
Educational Climate Test (D-RECT), respectively. A total of 19 trainees (18%) had poor quality of life and 49
(47%) were dissatisfied with the balance between their personal
and professional life. Some symptoms of burnout were found in 29
trainees (28%). Higher D-RECT scores (indicating a better climate
of learning) were associated with a better quality of life (r =
0.31, p = 0.001), more work-life balance satisfaction (r = 0.31,
p = 0.002), fewer symptoms of emotional exhaustion (r = -0.21, p = 0.028)
and depersonalisation (r = -0,28, p = 0.04). A reduced quality of life with evidence of burnout were still
seen in a significant proportion of orthopaedic trainees despite
following a modern curriculum with strict compliance to a 48-hour
working week. It is vital that further work is undertaken to improve
the quality of life and reduce burnout in this cohort. Cite this article:
The goals of this study were to define the risk factors, nature,
chronology, and treatment strategies adopted for periprosthetic
femoral fractures in 32 644 primary total hip arthroplasties (THAs). There were 564 intra-operative fractures (1.7%); 529 during uncemented
stem placement (3.0%) and 35 during cemented stem placement (0.23%).
Intra-operative fractures were more common in females and patients
over 65 years (p <
0.001). The majority occurred during placement
of the femoral component (60%), and involved the calcar (69%). There
were 557 post-operative fractures (20-year probability: 3.5%; 95%
confidence interval (CI) 3.2 to 3.9); 335 fractures after placement
of an uncemented stem (20-year probability: 7.7%; 95% CI 6.2 to
9.1) and 222 after placement of a cemented stem (20-year probability:
2.1%; 95% CI 1.8 to 2.5). The probability of a post-operative fracture
within 30 days after an uncemented stem was ten times higher than
a cemented stem. The most common post-operative fracture type was
a Vancouver AG (32%; n = 135), with 67% occurring after
a fall. In all, 36% (n = 152) were treated with revision arthroplasty. Aim and Methods
Results
To confirm whether developmental dysplasia of
the hip has a risk of hip impingement, we analysed maximum ranges
of movement to the point of bony impingement, and impingement location
using three-dimensional (3D) surface models of the pelvis and femur
in combination with 3D morphology of the hip joint using computer-assisted methods.
Results of computed tomography were examined for 52 hip joints with
DDH and 73 normal healthy hip joints. DDH shows larger maximum extension
(p = 0.001) and internal rotation at 90° flexion (p <
0.001).
Similar maximum flexion (p = 0.835) and external rotation (p = 0.713)
were observed between groups, while high rates of extra-articular
impingement were noticed in these directions in DDH (p <
0.001).
Smaller cranial acetabular anteversion (p = 0.048), centre-edge
angles (p <
0.001), a circumferentially shallower acetabulum,
larger femoral neck anteversion (p <
0.001), and larger alpha
angle were identified in DDH. Risk of anterior impingement in retroverted
DDH hips is similar to that in retroverted normal hips in excessive
adduction but minimal in less adduction. These findings might be
borne in mind when considering the possibility of extra-articular
posterior impingement in DDH being a source of pain, particularly
for patients with a highly anteverted femoral neck. Cite this article:
The February 2015 Children’s orthopaedics Roundup360 looks at: Hip dislocation in children with CTEV: two decades of experience; Population-based prevention of DDH in cerebral palsy: 20 years’ experience; Shoulder derotation in congenital plexus palsy; Back pain in the paediatric population: could MRI be the answer?; Intercondylar fracture of the humerus in children; The Dunn osteotomy in SUFE; Radiocapitellar line a myth!; Do ‘flatfooted’ children suffer?
The April 2014 Spine Roundup360 looks at: medical treatment for ankylosing spondylitis; unilateral TLIF effective; peg fractures akin to neck of femur fractures; sleep apnoea and spinal surgery; scoliosis in osteogenesis imperfect; paediatric atlanto-occipital dislocation; back pain and obesity: chicken or egg?; BMP associated with lumbar plexus deficit; and just how common is back pain?
Increasing demand for total hip and knee arthroplasty (THA/TKA)
and associated follow-up has placed huge demands on orthopaedic
services. Feasible follow-up mechanisms are therefore essential. We conducted an audit of clinical follow-up decision-making for
THA/TKA based on questionnaire/radiograph review compared with local
practice of Arthroplasty Care Practitioner (ACP)-led outpatient
follow-up. In all 599 patients attending an ACP-led THA/TKA follow-up
clinic had a pelvic/knee radiograph, completed a pain/function questionnaire
and were reviewed by an ACP. An experienced orthopaedic surgeon
reviewed the same radiographs and questionnaires, without patient
contact or knowledge of the ACP’s decision. Each pathway classified
patients into: urgent review, annual monitoring, routine follow-up
or discharge. Aims
Methods
The December 2015 Knee Roundup360 looks at: Albumin and complications in knee arthroplasty; Tantalum: a knee fixation for all seasons?; Dynamic knee alignment; Tibial component design in UKA; Managing the tidal wave of revision knee arthroplasty; Scoring pain in TKR; Does anyone have a ‘normal’ tibial slope?; XLPE in TKR? A five-year clinical study; Spacers and infected revision arthroplasties; Dialysis and arthroplasty
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.
Moderate to severe hallux valgus is conventionally
treated by proximal metatarsal osteotomy. Several recent studies
have shown that the indications for distal metatarsal osteotomy
with a distal soft-tissue procedure could be extended to include
moderate to severe hallux valgus. The purpose of this prospective randomised controlled trial was
to compare the outcome of proximal and distal Chevron osteotomy
in patients undergoing simultaneous bilateral correction of moderate
to severe hallux valgus. The original study cohort consisted of 50 female patients (100
feet). Of these, four (8 feet) were excluded for lack of adequate
follow-up, leaving 46 female patients (92 feet) in the study. The
mean age of the patients was 53.8 years (30.1 to 62.1) and the mean
duration of follow-up 40.2 months (24.1 to 80.5). After randomisation,
patients underwent a proximal Chevron osteotomy on one foot and
a distal Chevron osteotomy on the other. At follow-up, the American Orthopedic Foot and Ankle Society
(AOFAS) hallux metatarsophalangeal interphalangeal (MTP-IP) score,
patient satisfaction, post-operative complications, hallux valgus
angle, first-second intermetatarsal angle, and tibial sesamoid position
were similar in each group. Both procedures gave similar good clinical
and radiological outcomes. This study suggests that distal Chevron osteotomy with a distal
soft-tissue procedure is as effective and reliable a means of correcting
moderate to severe hallux valgus as proximal Chevron osteotomy with
a distal soft-tissue procedure. Cite this article:
