The purpose of this study was to evaluate the natural history of rheumatoid disease of the shoulder over an eight-year period. Our hypothesis was that progression of the disease is associated with a decrease in function with time.

A total of 22 patients (44 shoulders; 17 women, 5 men, (mean age 63)) with rheumatoid arthritis were followed for eight years. All shoulders were assessed using the Constant score, anteroposterior radiographs (Larsen score, Upward-Migration-Index (UMI)) and ultrasound (US). At final follow-up, the Short Form-36, disabilities of the arm, shoulder and hand (DASH) Score, erythrocyte sedimentation rate and use of anti-rheumatic medication were determined.

The mean Constant score was 72 points (50 to 88) at baseline and 69 points (25 to 100) at final follow-up. Radiological evaluation showed progressive destruction of the peri-articular structures with time. This progression of joint and rotator cuff destruction was significantly associated with the Constant score. However, at baseline only the extent of rotator cuff disease and the UMI could predict the Constant score at final follow-up.

A plain anteroposterior radiograph of the shoulder is sufficient to assess any progression of rheumatoid disease and to predict functional outcome in the long term by using the UMI as an indicator of rotator cuff degeneration.

Cite this article: Bone Joint J 2014;96-B:1520–4.

The October 2014 Knee Roundup³⁶⁰ looks at: microfracture equivalent to OATS; examination better than MRI in predicting hamstrings re-injury; a second view on return to play with hamstrings injuries; dislocation risks in the Oxford Unicompartmental Knee; what about the tibia?; getting on top of lateral facet pain post TKR; readmission in TKR; patient-specific instrumentation; treating infrapatellar saphenous neuralgia; and arthroscopy in the middle-aged.

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: Bone Joint J 2014;96-B:1222–6.

Ketamine has been used in combination with a variety of other agents for intra-articular analgesia, with promising results. However, although it has been shown to be toxic to various types of cell, there is no available information on the effects of ketamine on chondrocytes.

We conducted a prospective randomised controlled study to evaluate the effects of ketamine on cultured chondrocytes isolated from rat articular cartilage. The cultured cells were treated with 0.125 mM, 0.250 mM, 0.5 mM, 1 mM and 2 mM of ketamine respectively for 6 h, 24 hours and 48 hours, and compared with controls. Changes of apoptosis were evaluated using fluorescence microscopy with a 490 nm excitation wavelength. Apoptosis and eventual necrosis were seen at each concentration. The percentage viability of the cells was inversely proportional to both the duration and dose of treatment (p = 0.002 and p = 0.009). Doses of 0.5 mM, 1 mM and 2mM were absolutely toxic.

We concluded that in the absence of solid data to support the efficacy of intra-articular ketamine for the control of pain, and the toxic effects of ketamine on cultured chondrocytes shown by this study, intra-articular ketamine, either alone or in combination with other agents, should not be used to control pain.

Cite this article: Bone Joint J 2014; 96-B:989–94.

Objectives

The aim of this study was to determine whether there is any significant difference in temporal measurements of pain, function and rates of re-tear for arthroscopic rotator cuff repair (RCR) patients compared with those patients undergoing open RCR.

The April 2013 Knee Roundup³⁶⁰ looks at: graft tension and outcome; chondrocytes at the midterm; pre-operative deformity and failure; the designer effect; whether chondroitin sulphate really does work; whether ACL reconstruction is really required; analgesia after TKR; and degenerative meniscus.

We performed a retrospective review of a consecutive series of 178 Mobility total ankle replacements (TARs) performed by three surgeons between January 2004 and June 2009, and analysed radiological parameters and clinical outcomes in a subgroup of 129 patients. The mean follow-up was 4 years (2 to 6.3). A total of ten revision procedures (5.6%) were undertaken. The mean Ankle Osteoarthritis Scale (AOS) pain score was 17 (0 to 88) and 86% of patients were clinically improved at follow-up. However, 18 patients (18 TARs, 14%) had a poor outcome with an AOS pain score of > 30. A worse outcome was associated with a pre-operative diagnosis of post-traumatic degenerative arthritis. However, no pre- or post-operative radiological parameters were significantly associated with a poor outcome. Of the patients with persistent pain, eight had predominantly medial-sided pain. Thirty TARs (29%) had a radiolucency in at least one zone.

The outcome of the Mobility TAR at a mean of four years is satisfactory in > 85% of patients. However, there is a significant incidence of persistent pain, particularly on the medial side, for which we were unable to establish a cause.

Cite this article: Bone Joint J 2013;95-B:1366–71.

Unstable bicondylar tibial plateau fractures are rare and there is little guidance in the literature as to the best form of treatment. We examined the short- to medium-term outcome of this injury in a consecutive series of patients presenting to two trauma centres. Between December 2005 and May 2010, a total of 55 fractures in 54 patients were treated by fixation, 34 with peri-articular locking plates and 21 with limited access direct internal fixation in combination with circular external fixation using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively, patient-reported outcome measures including the WOMAC index and SF-36 scores showed functional deficits, although there was no significant difference between the two forms of treatment. Despite low outcome scores, patients were generally satisfied with the outcome. We achieved good clinical and radiological outcomes, with low rates of complication. In total, only three patients (5%) had collapse of the joint of > 4 mm, and metaphysis to diaphysis angulation of greater than 5º, and five patients (9%) with displacement of > 4 mm. All patients in our study went on to achieve full union.

This study highlights the serious nature of this injury and generally poor patient-reported outcome measures following surgery, despite treatment by experienced surgeons using modern surgical techniques. Our findings suggest that treatment of complex bicondylar tibial plateau fractures with either a locking plate or a TSF gives similar clinical and radiological outcomes.

Cite this article: Bone Joint J 2014;96-B:956–62.

The first Cochrane Corner of 2014 reports on a bumper number of new and updated reviews from the Cochrane Collaboration. Since November the Cochrane collaboration have turned their beady eye to scrutinise several topical (and sometimes controversial) orthopaedic issues such as pin site care, the use of Continuous Passive Motion (CPM) in the rehabilitation of total knee replacement (TKR) and the efficacy of nerve blocks.

The April 2014 Hip & Pelvis Roundup³⁶⁰ looks at: Recent arthroplasty and flight; whether that squeak could be a fracture; diagnosing early infected hip replacement; impaction grafting at a decade; whether squeaking is more common than previously thought; femoral offset associated with post THR outcomes; and periprosthetic fracture stabilisation.

We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.

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?

The effects of surgical approach in total hip replacement on health-related quality of life and long-term pain and satisfaction are unknown. From the Swedish Hip Arthroplasty Register, we extracted data on all patients that had received a total hip replacement for osteoarthritis through either the posterior or the direct lateral approach, with complete pre- and one-year post-operative Patient Reported Outcome Measures (PROMs). A total of 42 233 patients met the inclusion criteria and of these 4962 also had complete six-year PROM data. The posterior approach resulted in an increased mean satisfaction score of 15 (sd 19) vs 18 (sd 22) (p <  0.001) compared with the direct lateral approach. The mean pain score was 13 (sd 17) vs 15 (sd 19) (p < 0.001) and the proportion of patients with no or minimal pain was 78% vs 74% (p < 0.001) favouring the posterior approach. The patients in the posterior approach group reported a superior mean EQ-5D index of 0.79 (sd 0.23) vs 0.77 (sd 0.24) (p < 0.001) and mean EQ score of 76 (sd 20) vs 75 (sd 20) (p < 0.001). All observed differences between the groups persisted after six years follow-up. Although PROMs after THR in general are very good regardless of surgical approach, the results indicate that some patients operated by the direct lateral approach report an inferior outcome compared with the posterior approach. The large number of procedures and the seemingly sustained differences make it likely these findings are clinically relevant.

Cite this article: Bone Joint J 2014;96-B:590–6.

Component malalignment can be associated with pain following total knee replacement (TKR). Using MRI, we reviewed 50 patients with painful TKRs and compared them with a group of 16 asymptomatic controls to determine the feasibility of using MRI in evaluating the rotational alignment of the components. Using the additional soft-tissue detail provided by this modality, we also evaluated the extent of synovitis within these two groups. Angular measurements were based on the femoral transepicondylar axis and tibial tubercle. Between two observers, there was very high interobserver agreement in the measurements of all values. Patients with painful TKRs demonstrated statistically significant relative internal rotation of the femoral component (p = 0.030). There was relative internal rotation of the tibial to femoral component and combined excessive internal rotation of the components in symptomatic knees, although these results were significant only with one of the observers (p = 0.031). There was a statistically significant association between the presence and severity of synovitis and painful TKR (p < 0.001).

MRI is an effective modality in evaluating component rotational alignment.

In a prospective multicentre study we investigated variations in pain management used by knee arthroplasty surgeons in order to compare the differences in pain levels among patients undergoing total knee replacements (TKR), and to compare the effectiveness of pain management protocols. The protocols, peri-operative levels of pain and patient satisfaction were investigated in 424 patients who underwent TKR in 14 hospitals. The protocols were highly variable and peri-operative pain levels varied substantially, particularly during the first two post-operative days. Differences in levels of pain were greatest during the night after TKR, when visual analogue scores ranged from 16.9 to 94.3 points.

Of the methods of managing pain, the combined use of peri-articular infiltration and nerve blocks provided better pain relief than other methods during the first two post-operative days. Patients managed with peri-articular injection plus nerve block, and epidural analgesia were more likely to have higher satisfaction at two weeks after TKR. This study highlights the need to establish a consistent pain management strategy after TKR.

The December 2013 Knee Roundup³⁶⁰ looks at: Conflict of interest and hyaluronic acid; Will time indeed tell in microfracture?; Contralateral knee pain and joint replacement outcomes; Patient satisfaction and knee replacement?; Hope in the cytokines for painful TKRs?; Pain severity, cytokines and osteoarthritis?; Quadriceps weakness and pain; and spontaneous osteonecrosis of the knee

We performed a randomised controlled trial comparing computer-assisted surgery (CAS) with conventional surgery (CONV) in total knee replacement (TKR). Between 2009 and 2011 a total of 192 patients with a mean age of 68 years (55 to 85) with osteoarthritis or arthritic disease of the knee were recruited from four Norwegian hospitals. At three months follow-up, functional results were marginally better for the CAS group. Mean differences (MD) in favour of CAS were found for the Knee Society function score (MD: 5.9, 95% confidence interval (CI) 0.3 to 11.4, p = 0.039), the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales for ‘pain’ (MD: 7.7, 95% CI 1.7 to 13.6, p = 0.012), ‘sports’ (MD: 13.5, 95% CI 5.6 to 21.4, p = 0.001) and ‘quality of life’ (MD: 7.2, 95% CI 0.1 to 14.3, p = 0.046). At one-year follow-up, differences favouring CAS were found for KOOS ‘sports’ (MD: 11.0, 95% CI 3.0 to 19.0, p = 0.007) and KOOS ‘symptoms’ (MD: 6.7, 95% CI 0.5 to 13.0, p = 0.035). The use of CAS resulted in fewer outliers in frontal alignment (> 3° malalignment), both for the entire TKR (37.9% vs 17.9%, p = 0.042) and for the tibial component separately (28.4% vs 6.3%, p = 0.002). Tibial slope was better achieved with CAS (58.9% vs 26.3%, p < 0.001). Operation time was 20 minutes longer with CAS. In conclusion, functional results were, statistically, marginally in favour of CAS. Also, CAS was more predictable than CONV for mechanical alignment and positioning of the prosthesis. However, the long-term outcomes must be further investigated.

Cite this article: Bone Joint J 2014; 96-B:609–18.

Satisfaction is increasingly employed as an outcome measure for a successful total knee replacement (TKR). Satisfaction as an outcome measure encompasses many different intrinsic and extrinsic factors related to a person’s experience before and after TKR. The Swedish Knee Arthroplasty Registry has previously demonstrated on a large population study that 17% of TKR recipients are not satisfied with their TKR outcome. This finding has been replicated in other countries. Similar significant factors emerged from these registry studies that are related to satisfaction. It would appear that satisfaction is better after more chronic diseases and whether the TKR results in pain relief or improved function. Importantly, unmet pre-operative expectations are a significant predictor for dissatisfaction following a TKR. It may be possible to improve rates by addressing the issues surrounding pain, function and expectation before embarking on surgery.

Cite this article: Bone Joint J 2013;95-B, Supple A:148–52.

The April 2012 Shoulder & Elbow Roundup³⁶⁰ looks at katakori in Japan, frozen shoulder, if shoulder impingement actually exists, shoulder arthroscopy and suprascapular nerve blocks, why shoulder replacements fail, the infected elbow replacement, the four-part fracture, the acromion index, and arm transplantation

In an initial randomised controlled trial (RCT) we segregated 180 patients to one of two knee positions following total knee replacement (TKR): six hours of knee flexion using either a jig or knee extension. Outcome measures included post-operative blood loss, fall in haemoglobin, blood transfusion requirements, knee range of movement, limb swelling and functional scores. A second RCT consisted of 420 TKR patients randomised to one of three post-operative knee positions: flexion for three or six hours post-operatively, or knee extension.

Positioning of the knee in flexion for six hours immediately after surgery significantly reduced blood loss (p = 0.002). There were no significant differences in post-operative range of movement, swelling, pain or outcome scores between the various knee positions in either study. Post-operative knee flexion may offer a simple and cost-effective way to reduce blood loss and transfusion requirements following TKR.

We also report a cautionary note regarding the potential risks of prolonged knee flexion for more than six hours observed during clinical practice in the intervening period between the two trials, with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy at their three-month review.

Cite this article: Bone Joint J 2014;96-B:201–9.