We determined the frequency, rate and extent
of development of scoliosis (coronal plane deformity) in wheelchair-dependent
patients with Duchenne muscular dystrophy (DMD) who were not receiving
steroid treatment. We also assessed kyphosis and lordosis (sagittal
plane deformity). The extent of scoliosis was assessed on sitting anteroposterior
(AP) spinal radiographs in 88 consecutive non-ambulatory patients
with DMD. Radiographs were studied from the time the patients became
wheelchair-dependent until the time of spinal fusion, or the latest assessment
if surgery was not undertaken. Progression was estimated using a
longitudinal mixed-model regression analysis to handle repeated
measurements. Scoliosis ≥ 10° occurred in 85 of 88 patients (97%), ≥ 20° in
78 of 88 (89%) and ≥ 30° in 66 of 88 patients (75%). The fitted
longitudinal model revealed that time in a wheelchair was a highly
significant predictor of the magnitude of the curve, independent
of the age of the patient (p <
0.001). Scoliosis developed in
virtually all DMD patients not receiving steroids once they became
wheelchair-dependent, and the degree of deformity deteriorated over
time. In general, scoliosis increased at a constant rate, beginning
at the time of wheelchair-dependency (p <
0.001). In some there
was no scoliosis for as long as three years after dependency, but
scoliosis then developed and increased at a constant rate. Some
patients showed a rapid increase in the rate of progression of the
curve after a few years – the clinical phenomenon of a rapidly collapsing
curve over a few months. A sagittal plane kyphotic deformity was seen in 37 of 60 patients
(62%) with appropriate radiographs, with 23 (38%) showing lumbar
lordosis (16 (27%) abnormal and seven (11%) normal). This study provides a baseline to assess the effects of steroids
and other forms of treatment on the natural history of scoliosis
in patients with DMD, and an approach to assessing spinal deformity
in the coronal and sagittal planes in wheelchair-dependent patients
with other neuromuscular disorders. Cite this article:
There are few reports describing the technique
of managing acetabular protrusio in primary total hip replacement. Most
are small series with different methods of addressing the challenges
of significant medial and proximal migration of the joint centre,
deficient medial bone and reduced peripheral bony support to the
acetabular component. We describe our technique and the clinical
and radiological outcome of using impacted morsellised autograft
with a porous-coated cementless cup in 30 primary THRs with mild
(n = 8), moderate (n = 10) and severe (n = 12) grades of acetabular
protrusio. The mean Harris hip score had improved from 52 pre-operatively
to 85 at a mean follow-up of 4.2 years (2 to 10). At final follow-up,
27 hips (90%) had a good or excellent result, two (7%) had a fair
result and one (3%) had a poor result. All bone grafts had united
by the sixth post-operative month and none of the hips showed any
radiological evidence of recurrence of protrusio, osteolysis or
loosening. By using impacted morsellised autograft and cementless
acetabular components it was possible to achieve restoration of
hip mechanics, provide a biological solution to bone deficiency
and ensure long-term fixation without recurrence in arthritic hips
with protrusio undergoing THR. Cite this article:
We present a new CT-based method which measures cover of the femoral head in both normal and dysplastic hips and allows assessment of acetabular inclination and anteversion. A clear topographical image of the head with its covered area is generated. We studied 36 normal and 39 dysplastic hips. In the normal hips the mean cover was 73% (66% to 81%), whereas in the dysplastic group it was 51% (38% to 64%). The significant advantage of this technique is that it allows the measurements to be standardised with reference to a specific anatomical plane. When this is applied to assessing cover in surgery for dysplasia of the hip it gives a clearer understanding of where the corrected hip stands in relation to normal and allows accurate assessment of inclination and anteversion.
The December 2013 Oncology Roundup360 looks at: Peri-articular resection fraught with complications; Navigated margins; Skeletal tumours and thromboembolism; Conditional survival in Ewing’s sarcoma; Reverse shoulders and tumour; For how long should we follow up sarcoma patients?; and already metastasised?
Total hip replacement (THR) after acetabular
fracture presents unique challenges to the orthopaedic surgeon.
The majority of patients can be treated with a standard THR, resulting
in a very reasonable outcome. Technical challenges however include
infection, residual pelvic deformity, acetabular bone loss with
ununited fractures, osteonecrosis of bone fragments, retained metalwork,
heterotopic ossification, dealing with the sciatic nerve, and the
difficulties of obtaining long-term acetabular component fixation.
Indications for an acute THR include young patients with both femoral
head and acetabular involvement with severe comminution that cannot
be reconstructed, and the elderly, with severe bony comminution.
The outcomes of THR for established post-traumatic arthritis include
excellent pain relief and functional improvements. The use of modern
implants and alternative bearing surfaces should improve outcomes
further. Cite this article:
The conventional method for reconstructing acetabular
bone loss at revision surgery includes using structural bone allograft.
The disadvantages of this technique promoted the advent of metallic
but biocompatible porous implants to fill bone defects enhancing
initial and long-term stability of the acetabular component. This
paper presents the indications, surgical technique and the outcome
of using porous metal acetabular augments for reconstructing acetabular
defects. Cite this article:
Reconstructive acetabular osteotomy is a well established and effective procedure in the treatment of acetabular dysplasia. However, the dysplasia is frequently accompanied by intra-articular pathology such as labral tears. We intended to determine whether a concomitant hip arthroscopy with peri-acetabular rotational osteotomy could identify and treat intra-articular pathology associated with dysplasia and thereby produce a favourable outcome. We prospectively evaluated 43 consecutive hips treated by combined arthroscopy and acetabular osteotomy. Intra-operative arthroscopic examination revealed labral lesions in 38 hips. At a mean follow-up of 74 months (60 to 97) the mean Harris hip score improved from 72.4 to 94.0 (p < 0.001), as did all the radiological parameters (p < 0.001). Complications included penetration of the joint by the osteotome in one patient, a fracture of the posterior column in another and deep-vein thrombosis in one further patient. This combined surgical treatment gave good results in the medium term. We suggest that arthroscopy of the hip can be performed in conjunction with peri-acetabular osteotomy to provide good results in patients with symptomatic dysplasia of the hip, and the arthroscopic treatment of intra-articular pathology may alter the progression of osteoarthritis.
We evaluated 31 patients who were treated with a non-vascularised fibular graft after resection of primary musculoskeletal tumours, with a median follow-up of 5.6 years (3 to 26.7 years). Primary union was achieved in 89% (41 of 46) of the grafts in a median period of 24 weeks. All 25 grafts in 18 patients without additional chemotheraphy and/or radiotherapy achieved primary union, compared with 16 of the 21 grafts (76%; 13 patients) with additional therapy (p = 0.017). Radiographs showed an increase in diameter in 70% (59) of the grafts. There were seven fatigue fractures in six patients, but only two needed treatment. Non-vascularised fibular transfer is a simpler, less expensive and a shorter procedure than the use of vascularised grafts and allows remodelling of the fibula at the donor site. It is a biological reconstruction with good long-term results, and a relatively low donor site complication rate of 16%.
The October 2013 Research Roundup360 looks at: Orthopaedics: a dangerous profession?; Freezing and biomarkers for bone turnover; Herniation or degeneration first?; MARS MRI and metallosis; Programmed cell death in partial thickness cuff tears; Lead glasses for trauma surgery?; Smoking inhibits bone healing; Optimising polyethylene microstructure.
Our aim was to review the efficacy of the wound vacuum-assisted closure (VAC) system in the treatment of deep infection after extensive instrumentation and fusion for spinal deformity in children and adolescents. A total of 14 patients with early deep spinal infection were treated using this technique. Of these, 12 had neuromuscular or syndromic problems. Clinical and laboratory data were reviewed. The mean follow-up was 44 months (24 to 72). All wounds healed. Two patients required plastic surgery to speed up the process. In no patient was the hardware removed and there was no loss of correction or recurrent infection. We believe that the wound VAC system is a useful tool in the armamentarium of the spinal surgeon dealing with patients susceptible to wound infections, especially those with neuromuscular diseases. It allows for the retention of the instrumentation and the maintenance of spinal correction. It is reliable and easy to use.
Sacral insufficiency fractures are traditionally treated with bed rest and analgesia. The importance of early rehabilitation is generally appreciated; but pain frequently delays this, resulting in prolonged hospital stay and the risk of complications related to immobility. We describe three women with sacral insufficiency fractures who were treated with percutaneous sacroiliac screws and followed up for a mean of 18 months (12 to 24). They had immediate pain relief, uncomplicated rehabilitation and uneventful healing.
The aim of this study was to identify whether there was any difference in patient, tumour, treatment or outcome characteristics between patients with skeletal or extra-skeletal Ewing’s sarcoma. We identified 300 patients with new primary Ewing’s sarcoma diagnosed between 1980 and 2005 from the centres’ local database. There were 253 (84%) with skeletal and 47 (16%) with extra-skeletal Ewing’s sarcomas. Although patients with skeletal Ewing’s were younger (mean age 16.8 years) than those with extra-skeletal Ewing’s sarcoma (mean age 27.5 years), there was little difference between the groups in terms of tumour stage or treatment. Nearly all the patients were treated with chemotherapy and most had surgery. There was no difference in the overall survival of patients with skeletal (64%) and extra-skeletal Ewing’s sarcoma (61%) (p = 0.85), and this was also the case when both groups were split by whether they had metastases or not. This large series has shown that the oncological outcomes of Ewing’s sarcoma are related to tumour characteristics and patient age, and not determined by whether they arise in bone or soft tissue.
It is accepted that resurfacing hip replacement
preserves the bone mineral density (BMD) of the femur better than total
hip replacement (THR). However, no studies have investigated any
possible difference on the acetabular side. Between April 2007 and March 2009, 39 patients were randomised
into two groups to receive either a resurfacing or a THR and were
followed for two years. One patient’s resurfacing subsequently failed,
leaving 19 patients in each group. Resurfaced replacements maintained proximal femoral BMD and,
compared with THR, had an increased bone mineral density in Gruen
zones 2, 3, 6, and particularly zone 7, with a gain of 7.5% (95%
confidence interval (CI) 2.6 to 12.5) compared with a loss of 14.6%
(95% CI 7.6 to 21.6). Resurfacing replacements maintained the BMD
of the medial femoral neck and increased that in the lateral zones
between 12.8% (95% CI 4.3 to 21.4) and 25.9% (95% CI 7.1 to 44.6). On the acetabular side, BMD was similar in every zone at each
point in time. The mean BMD of all acetabular regions in the resurfaced
group was reduced to 96.2% (95% CI 93.7 to 98.6) and for the total
hip replacement group to 97.6% (95% CI 93.7 to 101.5) (p = 0.4863).
A mean total loss of 3.7% (95% CI 1.0 to 6.5) and 4.9% (95% CI 0.8
to 9.0) of BMD was found above the acetabular component in W1 and
10.2% (95% CI 0.9 to 19.4) and 9.1% (95% CI 3.8 to 14.4) medial
to the implant in W2 for resurfaced replacements and THRs respectively.
Resurfacing resulted in a mean loss of BMD of 6.7% (95% CI 0.7 to
12.7) in W3 but the BMD inferior to the acetabular component was
maintained in both groups. These results suggest that the ability of a resurfacing hip replacement
to preserve BMD only applies to the femoral side.
We report the clinical and radiological outcomes
of a series of contemporary cementless ceramic-on-ceramic total hip
replacements (THRs) at ten years in patients aged ≤ 55 years of
age. Pre- and post-operative activity levels are described. A total
of 120 consecutive ceramic cementless THRs were performed at a single
centre in 110 patients from 1997 to 1999. The mean age of the patients
at operation was 45 years (20 to 55). At ten years, four patients
had died and six were lost to follow-up, comprising ten hips. The
mean post-operative Harris hip score was 94.7 (55 to 100). Radiological
analysis was undertaken in 90 available THRs of the surviving 106
hips at final review: all had evidence of stable bony ingrowth,
with no cases of osteolysis. Wear was undetectable. There were four
revisions. The survival for both components with revision for any
cause as an endpoint was 96.5% (95% confidence interval 94.5 to
98.7). The mean modified University of California, Los Angeles activity
level rose from a mean of 6.4 (4 to 10) pre-operatively to 9.0 (6
to 10) at the ten-year post-operative period. Alumina ceramic-on-ceramic bearings in cementless primary THR
in this series have resulted in good clinical and radiological outcomes
with undetectable rates of wear and excellent function in the demanding
younger patient group at ten years. Cite this article:
The June 2013 Knee Roundup360 looks at: iodine washout: chondrotoxic or antiseptic?; stem tip pain following revision knee replacements; metalwork removal prior to TKR; astroturf and ACL rupture; Robert Jones dressings; if thicker gloves safer; and the long leg radiograph: is it still the gold standard?
Femoroacetabular impingement causes pain in the hip in young adults and may predispose to the development of osteoarthritis. Genetic factors are important in the aetiology of osteoarthritis of the hip and may have a role in that of femoroacetabular impingement. We compared 96 siblings of 64 patients treated for primary impingement with a spouse control group of 77 individuals. All the subjects were screened clinically and radiologically using a standardised protocol for the presence of cam and pincer deformities and osteoarthritis. The siblings of those patients with a cam deformity had a relative risk of 2.8 of having the same deformity (66 of 160 siblings hips versus 23 of 154 control hips, p <
0.00001). The siblings of those patients with a pincer deformity had a relative risk of 2.0 of having the same deformity (43 of 116 sibling hips versus 29 of 154 control hips, p = 0.001). Bilateral deformity occurred more often in the siblings (42 of 96 siblings versus 13 of 77 control subjects, relative risk 2.6, p = 0.0002). The prevalence of clinical features in those hips with abnormal morphology was also greater in the sibling group compared with the control group (41 of 109 sibling hips versus 7 of 46 control hips, relative risk 2.5, p = 0.007). In 11 sibling hips there was grade-2 osteoarthritis according to Kellgren and Lawrence versus none in the control group (p = 0.002). Genetic influences are important in the aetiology of primary femoroacetabular impingement. This risk appears to be manifested through not only abnormal joint morphology, but also through other factors which may modulate progression of the disease.
We treated 50 patients with bony malignancy by The mean survivor follow-up was 38 months (12 to 92) when 42 patients were alive and without disease. There were four recurrences. The functional results were good according to the Mankin score (17 excellent, 13 good, nine fair, three failures), the Musculoskeletal Tumour Society score (mean 77) and the Toronto Extremity Salvage score (mean 81). There was solid union, but bone resorption was seen in some cases. The dose of radiation was lethal to all cells and produced a dead autograft of perfect fit. Extracorporeal irradiation is a useful technique for limb salvage when there is reasonable residual bone stock. It allows effective re-attachment of tendons and produces a lasting biological reconstruction. There should be no risk of local recurrence or of radiotherapy-induced malignancy in the replanted bone.