Aims

The aim of this study was to report a single surgeon series of consecutive patients with moderate hallux valgus managed with a percutaneous extra-articular reverse-L chevron (PERC) osteotomy.

Objectives

The biomembrane (induced membrane) formed around polymethylmethacrylate (PMMA) spacers has value in clinical applications for bone defect reconstruction. Few studies have evaluated its cellular, molecular or stem cell features. Our objective was to characterise induced membrane morphology, molecular features and osteogenic stem cell characteristics.

Objectives

To employ a simple and fast method to evaluate those patients with neurological deficits and misplaced screws in relatively safe lumbosacral spine, and to determine if it is necessary to undertake revision surgery.

There is no consensus on the benefit of arthroscopically assisted reduction of the articular surface combined with fixation using a volar locking plate for the treatment of intra-articular distal radial fractures. In this study we compared the functional and radiographic outcomes of fluoroscopically and arthroscopically guided reduction of these fractures.

Between February 2009 and May 2013, 74 patients with unilateral unstable intra-articular distal radial fractures were randomised equally into the two groups for treatment. The mean age of these 74 patients was 64 years (24 to 92). We compared functional outcomes including active range of movement of the wrist, grip strength and Disabilities of the Arm, Shoulder, and Hand scores at six and 48 weeks; and radiographic outcomes that included gap, step, radial inclination, volar angulation and ulnar variance.

There were no significant differences between the techniques with regard to functional outcomes or radiographic parameters. The mean gap and step in the fluoroscopic and arthroscopic groups were comparable at 0.9 mm (standard deviation (sd) 0.7) and 0.7 mm (sd 0.7) and 0.6 mm (sd 0.6) and 0.4 mm (sd 0.5), respectively; p = 0.18 and p = 0.35).

Arthroscopic reduction conferred no advantage over conventional fluoroscopic guidance in achieving anatomical reduction of intra-articular distal radial fractures when using a volar locking plate.

Cite this article: Bone Joint J 2015; 97-B:957–62.

We present detailed information about early morbidity after aseptic revision knee replacement from a nationwide study. All aseptic revision knee replacements undertaken between 1st October 2009 and 30th September 2011 were analysed using the Danish National Patient Registry with additional information from the Danish Knee Arthroplasty Registry. The 1218 revisions involving 1165 patients were subdivided into total revisions, large partial revisions, partial revisions and revisions of unicondylar replacements (UKR revisions). The mean age was 65.0 years (27 to 94) and the median length of hospital stay was four days (interquartile range: 3 to 5), with a 90 days re-admission rate of 9.9%, re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges of 51 to 55 years (p = 0.018), 76 to 80 years (p < 0.001) and ≥ 81 years (p < 0.001) were related to an increased risk of re-admission. The age ranges of 76 to 80 years (p = 0.018) and the large partial revision subgroup (p = 0.073) were related to an increased risk of re-operation. The ages from 76 to 80 years (p < 0.001), age ≥ 81 years (p < 0.001) and surgical time > 120 min (p <  0.001) were related to increased length of hospital stay, whereas the use of a tourniquet (p = 0.008) and surgery in a low volume centre (p = 0.013) were related to shorter length of stay.

In conclusion, we found a similar incidence of early post-operative morbidity after aseptic knee revisions as has been reported after primary procedures. This suggests that a length of hospital stay ≤ four days and discharge home at that time is safe following aseptic knee revision surgery in Denmark.

Cite this article: Bone Joint J 2014;96-B:1649–56.

Tranexamic acid (TXA), an inhibitor of fibrinolysis, reduces blood loss after total knee arthroplasty. However, its effect on minimally invasive total hip arthroplasty (THA) is not clear. We performed a prospective, randomised double-blind study to evaluate the effect of two intravenous injections of TXA on blood loss in patients undergoing minimally invasive THA.

In total, 60 patients (35 women and 25 men with a mean age of 58.1 years; 17 to 84) who underwent unilateral minimally invasive uncemented THA were randomly divided into the study group (30 patients, 20 women and ten men with a mean age of 56.5 years; 17 to 79) that received two intravenous injections 1 g of TXA pre- and post-operatively (TXA group), and a placebo group (30 patients, 15 women and 15 men with a mean age of 59.5 years; 23 to 84). We compared the peri-operative blood loss of the two groups. Actual blood loss was calculated from the maximum reduction in the level of haemoglobin. All patients were followed clinically for the presence of venous thromboembolism.

The TXA group had a lower mean intra-operative blood loss of 441 ml (150 to 800) versus 615 ml (50 to 1580) in the placebo (p = 0.044), lower mean post-operative blood loss (285 ml (120 to 570) versus 392 ml (126 to 660) (p = 0.002), lower mean total blood loss (1070 ml (688 to 1478) versus 1337 ml (495 to 2238) (p = 0.004) and lower requirement for transfusion (p = 0.021). No patients in either group had symptoms of venous thromboembolism or wound complications.

This prospective, randomised controlled study showed that a regimen of two intravenous injections of 1 g TXA is effective for blood conservation after minimally invasive THA.

Cite this article: Bone Joint J 2015;97-B:905–10.

We present an economic evaluation using data from the Distal Radius Acute Fracture Fixation Trial (DRAFFT) to compare the relative cost effectiveness of percutaneous Kirschner wire (K-wire) fixation and volar locking-plate fixation for patients with dorsally-displaced fractures of the distal radius.

The cost effectiveness analysis (cost per quality-adjusted life year; QALY) was derived from a multi-centre, two-arm, parallel group, assessor-blind, randomised controlled trial which took place in 18 trauma centres in the United Kingdom. Data from 460 patients were available for analysis, which includes both a National Health Service cost perspective including costs of surgery, implants and healthcare resource use over a 12-month period after surgery, and a societal perspective, which includes the cost of time off work and the need for additional private care.

There was only a small difference in QALYs gained for patients treated with locking-plate fixation over those treated with K-wires. At a mean additional cost of £714 (95% confidence interval 588 to 865) per patient, locking-plate fixation presented an incremental cost effectiveness ratio (ICER) of £89 322 per QALY within the first 12 months of treatment. Sensitivity analyses were undertaken to assess the ICER of locking-plate fixation compared with K-wires. These were greater than £30 000.

Compared with locking-plate fixation, K-wire fixation is a ‘cost saving’ intervention, with similar health benefits.

Cite this article: Bone Joint J 2015;97-B:1082–9.

Assessment of skeletal age is important in children’s orthopaedics. We compared two simplified methods used in the assessment of skeletal age. Both methods have been described previously with one based on the appearance of the epiphysis at the olecranon and the other on the digital epiphyses. We also investigated the influence of assessor experience on applying these two methods.

Our investigation was based on the anteroposterior left hand and lateral elbow radiographs of 44 boys (mean: 14.4; 12.4 to 16.1 ) and 78 girls (mean: 13.0; 11.1 to14.9) obtained during the pubertal growth spurt. A total of nine observers examined the radiographs with the observers assigned to three groups based on their experience (experienced, intermediate and novice). These raters were required to determined skeletal ages twice at six-week intervals. The correlation between the two methods was determined per assessment and per observer groups. Interclass correlation coefficients (ICC) evaluated the reproducibility of the two methods.

The overall correlation between the two methods was r = 0.83 for boys and r = 0.84 for girls. The correlation was equal between first and second assessment, and between the observer groups (r ≥ 0.82). There was an equally strong ICC for the assessment effect (ICC ≤ 0.4%) and observer effect (ICC ≤ 3%) for each method. There was no significant (p < 0.05) difference between the levels of experience.

The two methods are equally reliable in assessing skeletal maturity. The olecranon method offers detailed information during the pubertal growth spurt, while the digital method is as accurate but less detailed, making it more useful after the pubertal growth spurt once the olecranon has ossified.

Cite this article: Bone Joint J 2014;3:1556–60

The June 2015 Knee Roundup360 looks at: Cruciate substituting versus retaining knee replacement; What’s behind the psychology of anterior cruciate ligament (ACL) reconstruction?; Is there a difference in total knee arthroplasty risk of revision in highly crosslinked versus conventional polyethylene?; Unicompartmental knee arthroplasty: is age the missing variable?; Satisfaction rates following total knee arthroplasty; Is knee alignment dynamic?; Unicompartmental knee arthroplasty: cemented or cementless?; Can revision knee services pay?

Aims

There are many guidelines that help direct the management of patients with metal-on-metal (MOM) hip arthroplasties. We have undertaken a study to compare the management of patients with MOM hip arthroplasties in different countries.

Aims

We present a case series of ten metal-on-polyethylene total hip arthroplasties (MoP THAs) with delayed dislocation associated with unrecognised adverse local tissue reaction due to corrosion at the trunnion and pseudotumour formation.

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.

A total of 20 patients with a depressed fracture of the lateral tibial plateau (Schatzker II or III) who would undergo open reduction and internal fixation were randomised to have the metaphyseal void in the bone filled with either porous titanium granules or autograft bone. Radiographs were undertaken within one week, after six weeks, three months, six months, and after 12 months.

The primary outcome measure was recurrent depression of the joint surface: a secondary outcome was the duration of surgery.

The risk of recurrent depression of the joint surface was lower (p < 0.001) and the operating time less (p < 0.002) when titanium granules were used.

The indication is that it is therefore beneficial to use porous titanium granules than autograft bone to fill the void created by reducing a depressed fracture of the lateral tibial plateau. There is no donor site morbidity, the operating time is shorter and the risk of recurrent depression of the articular surface is less.

Cite this article: Bone Joint J 2015; 97-B:836–41

Cemented femoral stems with force closed fixation designs have shown good clinical results despite high early subsidence. A new triple-tapered stem in this category (C-stem AMT) was introduced in 2005. This study compares this new stem with an established stem of similar design (Exeter) in terms of migration (as measured using radiostereometric analysis), peri-prosthetic bone remodelling (measured using dual energy x-ray densitometry, DXA), Oxford Hip Score, and plain radiographs.

A total of 70 patients (70 hips) with a mean age of 66 years (53 to 78) were followed for two years. Owing to missing data of miscellaneous reasons, the final analysis represents data from 51 (RSA) and 65 (DXA) patients. Both stems showed a typical pattern of migration: Subsidence and retroversion that primarily occurred during the first three months. C-stem AMT subsided less during the first three months (p = 0.01), before stabilising at a subsidence rate similar to the Exeter stem from years one to two. The rate of migration into retroversion was slightly higher for C-stem AMT during the second year (p = 0.03). Whilst there were slight differences in movement patterns between the stems, the C-stem AMT exhibits good early clinical outcomes and displays a pattern of migration and bone remodelling that predicts good clinical performance.

Cite this article: Bone Joint J 2015;97-B:755–61.

We scanned 25 left knees in healthy human subjects using MRI. Multiplanar reconstruction software was used to take measurements of the inferior and posterior facets of the femoral condyles and the trochlea.

A ‘basic circle’ can be defined which, in the sagittal plane, fits the posterior and inferior facets of the lateral condyle, the posterior facet of the medial condyle and the floor of the groove of the trochlea. It also approximately fits both condyles in the coronal plane (inferior facets) and the axial plane (posterior facets). The circle fitting the inferior facet of the medial condyle in the sagittal plane was consistently 35% larger than the other circles and was termed the ‘medial inferior circle’. There were strong correlations between the radii of the circles, the relative positions of the centres of the condyles, the width of the condyles, the total knee width and skeletal measurements including height. There was poor correlation between the radii of the circles and the position of the trochlea relative to the condyles.

In summary, the condyles are approximately spherical except for the inferior facet medially, which has a larger radius in the sagittal plane. The size and position of the condyles are consistent and change with the size of the person. However, the position of the trochlea is variable even though its radius is similar to that of the condyles. This information has implications for understanding anterior knee pain and for the design of knee replacements.

Cite this article: Bone Joint J 2014;96-B:1623–30.

Objectives

Acetabular component orientation in total hip arthroplasty (THA) influences results. Intra-operatively, the natural arthritic acetabulum is often used as a reference to position the acetabular component. Detailed information regarding its orientation is therefore essential. The aim of this study was to identify the acetabular inclination and anteversion in arthritic hips.

We report a 12- to 15-year implant survival assessment of a prospective single-surgeon series of Birmingham Hip Resurfacings (BHRs). The earliest 1000 consecutive BHRs including 288 women (335 hips) and 598 men (665 hips) of all ages and diagnoses with no exclusions were prospectively followed-up with postal questionnaires, of whom the first 402 BHRs (350 patients) also had clinical and radiological review.

Mean follow-up was 13.7 years (12.3 to 15.3). In total, 59 patients (68 hips) died 0.7 to 12.6 years following surgery from unrelated causes. There were 38 revisions, 0.1 to 13.9 years (median 8.7) following operation, including 17 femoral failures (1.7%) and seven each of infections, soft-tissue reactions and other causes. With revision for any reason as the end-point Kaplan–Meier survival analysis showed 97.4% (95% confidence interval (CI) 96.9 to 97.9) and 95.8% (95% CI 95.1 to 96.5) survival at ten and 15 years, respectively. Radiological assessment showed 11 (3.5%) femoral and 13 (4.1%) acetabular radiolucencies which were not deemed failures and one radiological femoral failure (0.3%).

Our study shows that the performance of the BHR continues to be good at 12- to 15-year follow-up. Men have better implant survival (98.0%; 95% CI 97.4 to 98.6) at 15 years than women (91.5%; 95% CI 89.8 to 93.2), and women < 60 years (90.5%; 95% CI 88.3 to 92.7) fare worse than others. Hip dysplasia and osteonecrosis are risk factors for failure. Patients under 50 years with osteoarthritis fare best (99.4%; 95% CI 98.8 to 100 survival at 15 years), with no failures in men in this group.

Cite this article: Bone Joint J 2014;96-B:1298–1306.

Objectives

T-cells are considered to play an important role in the inflammatory response causing arthroplasty failure. The study objectives were to investigate the composition and distribution of CD4+ T-cell phenotypes in the peripheral blood (PB) and synovial fluid (SF) of patients undergoing revision surgery for failed metal-on-metal (MoM) and metal-on-polyethylene (MoP) hip arthroplasties, and in patients awaiting total hip arthroplasty.

Randomised controlled trials (RCTs) that assessed the efficacy of bracing for adolescent idiopathic scoliosis have suffered from small sample sizes, low compliance and lack of willingness to participate. The aim of this study was to assess the feasibility of a comprehensive cohort study for evaluating both the efficacy and the effectiveness of bracing in patients with adolescent idiopathic scoliosis. Patients with curves at greater risk of progression were invited to join a randomised controlled trial. Those who declined were given the option to remain in the study and to choose whether they wished to be braced or observed. Of 87 eligible patients (5 boys and 63 girls) identified over one year, 68 (78%) with mean age of 12.5 years (10 to 15) consented to participate, with a mean follow-up of 168 weeks (0 to 290). Of these, 19 (28%) accepted randomisation. Of those who declined randomisation, 18 (37%) chose a brace. Patients who were more satisfied with their image were more likely to choose bracing (Odds Ratio 4.1; 95% confidence interval 1.1 to 15.0; p = 0.035). This comprehensive cohort study design facilitates the assessment of both efficacy and effectiveness of bracing in patients with adolescent idiopathic scoliosis, which is not feasible in a conventional randomised controlled trial.

Cite this article: Bone Joint J 2015; 97-B:973–81

The aim of this study was to assess the effect of injecting genetically engineered chondrocytes expressing transforming growth factor beta 1 (TGF-β1) into the knees of patients with osteoarthritis. We assessed the resultant function, pain and quality of life.

A total of 54 patients (20 men, 34 women) who had a mean age of 58 years (50 to 66) were blinded and randomised (1:1) to receive a single injection of the active treatment or a placebo. We assessed post-treatment function, pain severity, physical function, quality of life and the incidence of treatment-associated adverse events. Patients were followed at four, 12 and 24 weeks after injection.

At final follow-up the treatment group had a significantly greater improvement in the mean International Knee Documentation Committee score than the placebo group (16 points; -18 to 49, vs 8 points; -4 to 37, respectively; p = 0.03). The treatment group also had a significantly improved mean visual analogue score at final follow-up (-25; -85 to 34, vs -11 points; -51 to 25, respectively; p = 0.032). Both cohorts showed an improvement in Western Ontario and McMaster Osteoarthritis Index and Knee Injury and Osteoarthritis Outcome Scores, but these differences were not statistically significant. One patient had an anaphylactic reaction to the preservation medium, but recovered within 24 hours. All other adverse events were localised and resolved without further action.

This technique may result in improved clinical outcomes, with the aim of slowing the degenerative process, leading to improvements in pain and function. However, imaging and direct observational studies are needed to verify cartilage regeneration. Nevertheless, this study provided a sufficient basis to proceed to further clinical testing.

Cite this article: Bone Joint J 2015;97-B:924–32.