We investigated the incidence of anomalies in
the vertebral arteries and Circle of Willis with three-dimensional
CT angiography in 55 consecutive patients who had undergone an instrumented
posterior fusion of the cervical spine. We recorded any peri-operative and post-operative complications.
The frequency of congenital anomalies was 30.9%, abnormal vertebral
artery blood flow was 58.2% and vertebral artery dominance 40%. The posterior communicating artery was occluded on one side in
41.8% of patients and bilaterally in 38.2%. Variations in the vertebral
arteries and Circle of Willis were not significantly related to
the presence or absence of posterior communicating arteries. Importantly,
18.2% of patients showed characteristic variations in the Circle
of Willis with unilateral vertebral artery stenosis or a dominant
vertebral artery, indicating that injury may cause lethal complications.
One patient had post-operative cerebellar symptoms due to intra-operative
injury of the vertebral artery, and one underwent a different surgical
procedure because of insufficient collateral circulation. Pre-operative assessment of the vertebral arteries and Circle
of Willis is essential if a posterior spinal fusion with instrumentation
is to be carried out safely. Cite this article:
The aim of this review is to address controversies
in the management of dislocations of the acromioclavicular joint. Current
evidence suggests that operative rather than non-operative treatment
of Rockwood grade III dislocations results in better cosmetic and
radiological results, similar functional outcomes and longer time
off work. Early surgery results in better functional and radiological
outcomes with a reduced risk of infection and loss of reduction compared
with delayed surgery. Surgical options include acromioclavicular fixation, coracoclavicular
fixation and coracoclavicular ligament reconstruction. Although
non-controlled studies report promising results for arthroscopic
coracoclavicular fixation, there are no comparative studies with
open techniques to draw conclusions about the best surgical approach.
Non-rigid coracoclavicular fixation with tendon graft or synthetic
materials, or rigid acromioclavicular fixation with a hook plate,
is preferable to fixation with coracoclavicular screws owing to
significant risks of loosening and breakage. The evidence, although limited, also suggests that anatomical
ligament reconstruction with autograft or certain synthetic grafts
may have better outcomes than non-anatomical transfer of the coracoacromial
ligament. It has been suggested that this is due to better restoration
horizontal and vertical stability of the joint. Despite the large number of recently published studies, there
remains a lack of high-quality evidence, making it difficult to
draw firm conclusions regarding these controversial issues. Cite this article:
Although the vast majority of patients that undergo
total knee replacement have satisfactory outcomes with a generally
low complication rate, occasionally a patient will be encountered
that has had multiple failed surgeries, and now reaches a crossroad
as to whether limb salvage will be acceptable or not. Cite this article:
The December 2014 Oncology Roundup360 looks at: metaphyseal and diaphyseal osteosarcoma subtly different beasts; sports and endoprosthetic reconstruction of the knee; is curettage without tissue diagnosis sensible in cartilaginous tumours?; autoclaved autograft in bone tumour reconstruction; vascularised graft a step too far in bone defects?; interdigitated neoadjuvant chemoradiotherapy in high-grade sarcoma; predicting life expectancy in patients with painful metastasis; and osteolytic lesions of the hands and feet.
The role of arthroscopy in the treatment of soft-tissue
injuries associated with proximal tibial fractures remains debatable.
Our hypothesis was that MRI over-diagnoses clinically relevant associated
soft-tissue injuries. This prospective study involved 50 consecutive
patients who underwent surgical treatment for a split-depression fracture
of the lateral tibial condyle (AO/OTA type B3.1). The mean age of
patients was 50 years (23 to 86) and 27 (54%) were female. All patients
had MRI and arthroscopy. Arthroscopy identified 12 tears of the
lateral meniscus, including eight bucket-handle tears that were
sutured and four that were resected, as well as six tears of the
medial meniscus, of which five were resected. Lateral meniscal injuries
were diagnosed on MRI in four of 12 patients, yielding an overall
sensitivity of 33% (95% confidence interval (CI) 11 to 65). Specificity
was 76% (95% CI 59 to 88), with nine tears diagnosed among 38 menisci
that did not contain a tear. MRI identified medial meniscal injuries
in four of six patients, yielding an overall sensitivity of 67%
(95% CI 24 to 94). Specificity was 66% (95% CI 50 to 79), with 15
tears diagnosed in 44 menisci that did not contain tears. MRI appears to offer only a marginal benefit as the specificity
and sensitivity for diagnosing meniscal injuries are poor in patients
with a fracture. There were fewer arthroscopically-confirmed associated
lesions than reported previously in MRI studies. Cite this article:
Over the past 30 years there have been many improvements
in implant fixation, correction of deformity, improved polyethylene
wear, and survival after knee replacement. The work over the last
decade has focused on less invasive surgical techniques, multimodal
pain management protocols, more rapid functional recovery and reduced
length of stay, aiming to minimise the side effects of treatment
while maintaining function and implant durability. When combined
and standardised these pre-, intra- and post-operative factors have
now facilitated outpatient knee replacement procedures for unicompartmental
replacement, patella femoral arthroplasty and total knee replacement
(TKR). We have found liposomal bupivacaine, with potential for longer
therapeutic action, to be a helpful adjunct and describe our current
pain management program. The next step in our multimodal program
is to improve the duration of patient satisfaction and reduce cost
and length of stay after TKR. Cite this article:
The aim of this study was to investigate the
epidemiology of fractures of the distal radius in the Swedish population and
to review the methods used to treat them between 2005 and 2010. The study population consisted of every patient in Sweden who
was diagnosed with a fracture of the wrist between 1 January 2005
and 31 December 2010. There were 177 893 fractures of the distal
radius. The incidence rate in the total population was 32 per 10
000 person-years. The mean age of the patients was 44 years (0 to
104). The proportion of fractures treated operatively increased
from 16% in 2005 to 20% in 2010. The incidence rate for plate fixation
in the adult population increased 3.61 fold. The incidence rate
for external fixation decreased by 67%. The change was greatest
in the 50 years to 74 years age group. In Sweden, there is an increasing tendency to operate on fractures
of the distal radius. The previously reported increase in the use
of plating is confirmed: it has increased more than threefold over
a five-year period. Cite this article:
We compared the use of broth culture medium for
samples taken in theatre with the standard practice of placing tissue
samples in universal containers. A total of 67 consecutive patients
had standard multiple samples of deep tissue harvested at surgery
and distributed equally in theatre either to standard universal
containers or to broth culture medium. These samples were cultured
by direct and enrichment methods. The addition of broth in theatre to
standard practice led to an increase in sensitivity from 83% to
95% and an increase in negative predictive value from 77% to 91%.
Placing tissue samples directly into broth in the operating theatre
is a simple, inexpensive way to increase the sensitivity of cultures
from infected patients, and does not appear to compromise the specificity
of these cultures. Cite this article:
There are significant differences in the methods and styles of orthopaedic surgical training between continents, all with the aim to produce competent consultant surgeons, but the differences in training content and pathway are vast. We review and contrast the key differences between three continents.
The common recommended treatment for infected
total hip replacement is two-staged exchange including removal of
all components. However, removal of well-fixed femoral stems can
result in structural bone damage. We recently reported on an alternative
treatment of partial two-stage exchange used in selected cases,
in which a well-fixed femoral stem was left and only the acetabular
component removed, the joint space was debrided thoroughly, an antibiotic-laden
polymethylmethacrylate spacer was moulded using a bulb-type syringe
and placed in the acetabulum, intravenous antibiotics were administered
during the interval, and delayed re-implantation was performed.
In 19 patients treated with this technique from January 2000 to
January 2011, 89% were free of infection at a mean follow-up of
four years (2 to 11). Since then, disposable silicone moulds have
become available to fabricate spacers in separate femoral and head
units. The head spacer mould, which incorporates various neck taper adapter
options, greatly facilitates the technique of partial two-stage
exchange. We report our early experience using disposable silicone
head spacer moulds for partial two-stage exchange in seven patients
with infected primary hip replacements. Cite this article:
Large femoral heads have become popular in total
hip replacement (THR) as a method of reducing the risk of dislocation.
However, if large heads are used in ceramic-on-ceramic THR, the
liner must be thinner, which may increase the risk of fracture.
To compare the rates of ceramic fracture and dislocation between
28 mm and 32 mm ceramic heads, 120 hips in 109 patients (51 men
and 58 women, mean age 49.2 years) were randomised to THR with either
a 28 mm or a 32 mm ceramic articulation. A total of 57/60 hips assigned
to the 28 mm group and 55/60 hips assigned to the 32 mm group were
followed for at least five years. No ceramic component fractures
occured in any patient in either group. There was one dislocation
in the 32 mm group and none in the 28 mm group (p = 0.464). No hip
had detectable wear, focal osteolysis or prosthetic loosening. In
our small study the 32 mm ceramic articulation appeared to be safe
in terms of ceramic liner fracture. Cite this article:
The objective of this study was to explore dimensionality of
the Oxford Hip Score (OHS) and examine whether self-reported pain
and functioning can be distinguished in the form of subscales. This was a secondary data analysis of the UK NHS hospital episode
statistics/patient-reported outcome measures dataset containing
pre-operative OHS scores on 97 487 patients who were undergoing
hip replacement surgery. Objective
Methods
Necrotising soft-tissue infections (NSTIs) of
the upper limb are uncommon, but potentially life-threatening. We
used a national database to investigate the risk factors for amputation
of the limb and death. We extracted data from the Japanese Diagnosis Procedure Combination
database on 116 patients (79 men and 37 women) who had a NSTI of
the upper extremity between 2007 and 2010. The overall in-hospital mortality was 15.5%. Univariate analysis
of in-hospital mortality showed that the significant variables were
age (p = 0.015), liver dysfunction (p = 0.005), renal dysfunction
(P <
0.001), altered consciousness (p = 0.049), and sepsis (p
= 0.021). Logistic regression analysis showed that the factors associated with
death in hospital were age over 70 years (Odds Ratio (OR) 6.6; 95%
confidence interval (CI) 1.5 to 28.2; p = 0.011) and renal dysfunction
(OR 15.4; 95% CI 3.8 to 62.8; p <
0.001). Univariate analysis of limb amputation showed that the significant
variables were diabetes (p = 0.017) mellitus and sepsis (p = 0.001).
Multivariable logistic regression analysis showed that the factors
related to limb amputation were sepsis (OR 1.8; 95% CI 1.5 to 24.0;
p = 0.013) and diabetes mellitus (OR 1.6; 95% CI 1.1 to 21.1; p
= 0.038). For NSTIs of the upper extremity, advanced age and renal dysfunction
are both associated with a higher rate of in-hospital mortality.
Sepsis and diabetes mellitus are both associated with a higher rate
of amputation. Cite this article:
Intramedullary infection in long bones represents
a complex clinical challenge, with an increasing incidence due to the
increasing use of intramedullary fixation. We report a prospective
case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator
(RIA) system, in association with antibiotic cement rods for the
treatment of lower limb long bone infections. A total of 24 such
patients, 16 men and eight women, with a mean age of 44.5 years
(17 to 75), 14 with femoral and 10 with tibial infection, were treated
in a staged manner over a period of 2.5 years in a single referral
centre. Of these, 21 patients had had previous surgery, usually
for fixation of a fracture (seven had sustained an open fracture
originally and one had undergone fasciotomies). According to the
Cierny–Mader classification system, 18 patients were classified
as type 1A, four as 3A (discharging sinus tract), one as type 4A
and one as type 1B. Cite this article:
Previous classification systems of failure of
limb salvage focused primarily on endoprosthetic failures and lacked sufficient
depth for the effective study of the causes of failure. In order
to address these inadequacies, the International Society of Limb
Salvage (ISOLS) formed a committee to recommend revisions of the
previous systems. The purpose of this study was to report on their
recommendations. The modifications were prepared using an earlier,
evidence-based model with subclassification based on the existing
medical literature. Subclassification for all five primary types
of failure of limb salvage following endoprosthetic reconstruction
were formulated and a complementary system was derived for the failure
of biological reconstruction. An additional classification of failure
in paediatric patients was also described. Limb salvage surgery presents a complex array of potential mechanisms
of failure, and a complete and precise classification of types of
failure is required. Earlier classification systems lacked specificity,
and the evidence-based system outlined here is designed to correct
these weaknesses and to provide a means of reporting failures of
limb salvage in order to allow the interpretation of outcome following
reconstructive surgery. Cite this article:
There has been an in increase in the availability
of effective biological agents for the treatment of rheumatoid arthritis
as well as a shift towards early diagnosis and management of the
inflammatory process. This article explores the impact this may
have on the place of orthopaedic surgery in the management of patients
with rheumatoid arthritis. Cite this article:
Femoroacetabular Junction Impingement (FAI) describes abnormalities
in the shape of the femoral head–neck junction, or abnormalities
in the orientation of the acetabulum. In the short term, FAI can
give rise to pain and disability, and in the long-term it significantly increases
the risk of developing osteoarthritis. The Femoroacetabular Impingement
Trial (FAIT) aims to determine whether operative or non-operative
intervention is more effective at improving symptoms and preventing
the development and progression of osteoarthritis. FAIT is a multicentre superiority parallel two-arm randomised
controlled trial comparing physiotherapy and activity modification
with arthroscopic surgery for the treatment of symptomatic FAI.
Patients aged 18 to 60 with clinical and radiological evidence of
FAI are eligible. Principal exclusion criteria include previous
surgery to the index hip, established osteoarthritis (Kellgren–Lawrence
≥ 2), hip dysplasia (centre-edge angle <
20°), and completion
of a physiotherapy programme targeting FAI within the previous 12
months. Recruitment will take place over 24 months and 120 patients
will be randomised in a 1:1 ratio and followed up for three years.
The two primary outcome measures are change in hip outcome score
eight months post-randomisation (approximately six-months post-intervention
initiation) and change in radiographic minimum joint space width
38 months post-randomisation. ClinicalTrials.gov: NCT01893034. Cite this article: Aims
Methods
Little information is available about the incidence
and outcome of incidental dural tears associated with microendoscopic
lumbar decompressive surgery. We prospectively examined the incidence
of dural tears and their influence on the outcome six months post-operatively
in 555 consecutive patients (mean age 47.4 years (13 to 89)) who
underwent this form of surgery. The incidence of dural tears was
5.05% (28/555). The risk factors were the age of the patient and
the procedure of bilateral decompression via a unilateral approach.
The rate of recovery of the Japanese Orthopaedic Association score
in patients with dural tears was significantly lower than that in
those without a tear (77.7% Cite this article:
