We reviewed 27 diabetic patients who sustained a tibial fracture treated with a reamed intramedullary nail and compared them with a control group who did not have diabetes. There were 23 closed fractures and four were open. Union was delayed until after six months in 12 of the 23 (52%) diabetic patients with closed fractures and ten of the 23 (43%) control patients (p = 0.768). In two patients with diabetes (9%), closed tibial fractures failed to unite and required exchange nailing, whereas all closed fractures in the control group healed without further surgery (p = 0.489). In both the diabetic and control groups with closed fractures two patients (9%) developed superficial infections. There were two (9%) deep infections in diabetic patients with closed fractures, but none in the control group (p = 0.489).

Overall, there was no significant difference in the rate of complications between the diabetic patients and the control group, but there was a tendency for more severe infections in patients with diabetes.

A total of 14 women and seven men with a mean age of 43 years (18 to 68) who sustained a Mason type IV fracture of the elbow, without an additional type II or III coronoid fracture, were evaluated after a mean of 21 years (14 to 46). Primary treatment included closed elbow reduction followed by immobilisation in a plaster in all cases, with an additional excision of the radial head in 11, partial resection in two and suturing of the annular ligament in two. Delayed radial head excision was performed in two patients and an ulnar nerve transposition in one. The uninjured elbows served as controls. Nine patients had no symptoms, 11 reported slight impairment, and one severe impairment of the elbow. Elbow flexion was impaired by a mean of 3° (sd 4) and extension by a mean of 9° (sd 4) (p < 0.01). None experienced chronic elbow instability or recurrent dislocation. There were more degenerative changes in the formerly injured elbows, but none had developed a reduction in joint space.

We conclude that most patients with a Mason type IV fracture of the elbow report a good long-term outcome.

We assessed the effect of mental disability on the outcome of total knee replacement (TKR) and investigated whether mental health improves post-operatively. Outcome data were prospectively recorded over a three-year period for 962 patients undergoing primary TKR for osteoarthritis. Pre-operative and one year Short-Form (SF)-12 scores and Oxford knee scores (OKS) were obtained. The mental component of the SF-12 was stratified into four groups according to level of mental disability (none ≥ 50, mild 40 to 49, moderate 30 to 39, severe < 30). Patients with any degree of mental disability had a significantly greater subjective physical disability according to the SF-12 (p = 0.06) and OKS (p < 0.001). The improvement in the disease-specific score (OKS) was not affected by a patient’s mental health (p = 0.33). In contrast, patients with mental disability had less of an improvement in their global physical health (SF-12) (p < 0.001). However, patients with any degree of mental disability had a significant improvement in their mental health post-operatively (p < 0.001).

Despite a similar improvement in their disease-specific scores and improvement in their mental health, patients with mental disability were significantly more likely to be dissatisfied with their TKR at one year (p = 0.001). Patients with poor mental health do benefit from improvements in their mental health and knee function after TKR, but also have a higher rate of dissatisfaction.

Cite this article: Bone Joint J 2013;95-B:360–6.

The October 2012 Research Roundup³⁶⁰ looks at: whether you can escape your genes; oral prophylaxis for DVT; non-responders and the internet; metal-on-metal, mice and damaged livers; sleeping on the job; cartilage contact stress in the normal human hip; and a perfect reason to subscribe to 360.

Hyaline articular cartilage has been known to be a troublesome tissue to repair once damaged. Since the introduction of autologous chondrocyte implantation (ACI) in 1994, a renewed interest in the field of cartilage repair with new repair techniques and the hope for products that are regenerative have blossomed. This article reviews the basic science structure and function of articular cartilage, and techniques that are presently available to effect repair and their expected outcomes.

The aim of this study was to perform a cost–utility analysis of total hip (THR) and knee replacement (TKR). Arthritis is a disabling condition that leads to long-term deterioration in quality of life. Total joint replacement, despite being one of the greatest advances in medicine of the modern era, has recently come under scrutiny. The National Health Service (NHS) has competing demands, and resource allocation is challenging in times of economic restraint. Patients who underwent THR (n = 348) or TKR (n = 323) between January and July 2010 in one Scottish region were entered into a prospective arthroplasty database. A health–utility score was derived from the EuroQol (EQ-5D) score pre-operatively and at one year, and was combined with individual life expectancy to derive the quality-adjusted life years (QALYs) gained. Two-way analysis of variance was used to compare QALYs gained between procedures, while controlling for baseline differences. The number of QALYs gained was higher after THR than after TKR (6.5 vs 4.0 years, p < 0.001). The cost per QALY for THR was £1372 compared with £2101 for TKR. The predictors of an increase in QALYs gained were poorer health before surgery (p < 0.001) and younger age (p < 0.001). General health (EQ-5D VAS) showed greater improvement after THR than after TKR (p < 0.001). This study provides up-to-date cost-effectiveness data for total joint replacement. THR and TKR are extremely effective both clinically and in terms of cost effectiveness, with costs that compare favourably to those of other medical interventions.

Cite this article: Bone Joint J 2013;95-B:115–21.

Isolated patellofemoral osteoarthritis can be a disabling disease. When conservative treatment fails, surgical options can be unpredictable and may be considered too aggressive for middle-aged and active people. We analysed the clinical and radiological results of a new coronal osteotomy involving thinning of the patella in a selected group of patients with isolated patellofemoral osteoarthritis. Since 1991, 31 patients (35 knees) have been treated, of whom 34 were available for follow-up at a mean of 9.1 years. The Knee Society Score, the Patellar score and the Short-form-36 questionnaire were used for clinical evaluation. We also examined the radiological features to confirm bone consolidation and assess the progression of osteoarthritis. A significant improvement in the functional scores and radiological parameters was noted. All patients except one were satisfied with the operation. Radiological progression of the patellofemoral osteoarthritis was slowed but radiological femorotibial osteoarthritis progressed in 23 (65%) cases, with a total knee replacement becoming necessary in four cases without technical problems in resurfacing the patella. We compared the results with other forms of surgical treatment reported in the literature.

This treatment offers good clinical and radiological results, presenting an alternative method of managing patellofemoral osteoarthritis.

Total shoulder replacement is a successful procedure for degenerative or some inflammatory diseases of the shoulder. However, fixation of the glenoid seems to be the main weakness with a high rate of loosening. The results using all-polyethylene components have been better than those using metal-backed components. We describe our experience with 35 consecutive total shoulder replacements using a new metal-backed glenoid component with a mean follow-up of 75.4 months (48 to 154).

Our implant differs from others because of its mechanism of fixation. It has a convex metal-backed bone interface and the main stabilising factor is a large hollow central peg. The patients were evaulated with standard radiographs and with the Constant Score, the Simple Shoulder Test and a visual analogue scale. All the scores improved and there was no loosening, no polyethylene-glenoid disassembly and no other implant-related complications.

We conclude that a metal-backed glenoid component is a good option in total shoulder replacement with no worse results than of those using a cemented all-polyethylene prosthesis.

Haemophilia is an x-linked inherited bleeding disorder which can cause severe arthropathy. We have reviewed the results of 70 primary total knee replacements (TKR) performed in 57 haemophilic patients between 1983 and 2007. The functional results were assessed using the Hospital for Special Surgery (HSS) knee scoring system and Kaplan-Meier survivorship analysis. Six patients died. HSS scores were available for 60 TKRs at a mean follow-up of 9.2 years (2 to 23); 57 (95%) had good or excellent results. Deep infection was recorded in one patient. Kaplan-Meier analysis using infection and aseptic loosening as endpoints showed the survival rate at 20 years to be 94.0%.

A reduction in infection, spontaneous haemarthrosis and improvement in the quality of life were noted to justify surgery in our series of patients with a mean age of 43 (25 to 70). We have found that using the latest techniques of continuous infusion of clotting Factor have significantly helped to reduce the complication rates and have achieved results which match those of the non-haemophilic population undergoing TKR.

We examined the one-year risk of symptomatic venous thromboembolism (VTE) following primary total hip replacement (THR) among Danish patients and a comparison cohort from the general population. From the Danish Hip Arthroplasty Registry we identified all primary THRs performed in Denmark between 1995 and 2010 (n = 85 965). In all, 97% of patients undergoing THR received low-molecular-weight heparin products during hospitalisation. Through the Danish Civil Registration System we sampled a comparison cohort who had not undergone THR from the general population (n = 257 895). Among the patients undergoing THR, the risk of symptomatic VTE was 0.79% between 0 and 90 days after surgery and 0.29% between 91 and 365 days after surgery. In the comparison cohort the corresponding risks were 0.05% and 0.12%, respectively. The adjusted relative risks of symptomatic VTE among patients undergoing THR were 15.84 (95% confidence interval (CI) 13.12 to 19.12) during the first 90 days after surgery and 2.41 (95% CI 2.04 to 2.85) during 91 to 365 days after surgery, compared with the comparison cohort. The relative risk of VTE was elevated irrespective of the gender, age and level of comorbidity at the time of THR.

We concluded that THR was associated with an increased risk of symptomatic VTE up to one year after surgery compared with the general population, although the absolute risk is small.

Spinal stenosis and disc herniation are the two most frequent causes of lumbosacral nerve root compression. This can result in muscle weakness and present with or without pain. The difficulty when managing patients with these conditions is knowing when surgery is better than non-operative treatment: the evidence is controversial. Younger patients with a lesser degree of weakness for a shorter period of time have been shown to respond better to surgical treatment than older patients with greater weakness for longer. However, they also constitute a group that fares better without surgery. The main indication for surgical treatment in the management of patients with lumbosacral nerve root compression should be pain rather than weakness.

No previous studies have examined the physical characteristics of patients with cauda equina syndrome (CES). We compared the anthropometric features of patients who developed CES after a disc prolapse with those who did not but who had symptoms that required elective surgery. We recorded the age, gender, height, weight and body mass index (BMI) of 92 consecutive patients who underwent elective lumbar discectomy and 40 consecutive patients who underwent discectomy for CES. On univariate analysis, the mean BMI of the elective discectomy cohort (26.5 kg/m² (16.6 to 41.7) was very similar to that of the age-matched national mean (27.6 kg/m², p = 1.0). However, the mean BMI of the CES cohort (31.1 kg/m² (21.0 to 54.9)) was significantly higher than both that of the elective group (p < 0.001) and the age-matched national mean (p < 0.001). A similar pattern was seen with the weight of the groups. Multivariate logistic regression analysis was performed, adjusted for age, gender, height, weight and BMI. Increasing BMI and weight were strongly associated with an increased risk of CES (odds ratio (OR) 1.17, p < 0.001; and OR 1.06, p <  0.001, respectively). However, increasing height was linked with a reduced risk of CES (OR 0.9, p < 0.01). The odds of developing CES were 3.7 times higher (95% confidence interval (CI) 1.2 to 7.8, p = 0.016) in the overweight and obese (as defined by the World Health Organization: BMI ≥ 25 kg/m²) than in those of ideal weight. Those with very large discs (obstructing > 75% of the spinal canal) had a larger BMI than those with small discs (obstructing < 25% of the canal; p < 0.01). We therefore conclude that increasing BMI is associated with CES.

The August 2012 Children’s orthopaedics Roundup³⁶⁰ looks at: whether 3D-CT gives a better idea of coverage than plain radiographs; forearm fractures after trampolining accidents; forearm fractures and the Rush pin; the fractured distal radius; elastic stable intramedullary nailing for long-bone fractures; aponeurotic recession for the equinus foot; the torn medial patellofemoral ligament and the adductor tubercle; slipped capital femoral epiphysis; paediatric wrist arthroscopy; and Pirani scores and clubfoot.

A total of 445 consecutive primary total knee replacements (TKRs) were followed up prospectively at six and 18 months and three, six and nine years. Patients were divided into two groups: non-obese (body mass index (BMI) < 30 kg/m²) and obese (BMI ≥ 30 kg/m²). The obese group was subdivided into mildly obese (BMI 30 to 35 kg/m²) and highly obese (BMI ≥ 35 kg/m²) in order to determine the effects of increasing obesity on outcome. The clinical data analysed included the Knee Society score, peri-operative complications and implant survival. There was no difference in the overall complication rates or implant survival between the two groups.

Obesity appears to have a small but significant adverse effect on clinical outcome, with highly obese patients showing lower function scores than non-obese patients. However, significant improvements in outcome are sustained in all groups nine years after TKR. Given the substantial, sustainable relief of symptoms after TKR and the low peri-operative complication and revision rates in these two groups, we have found no reason to limit access to TKR in obese patients.

We evaluated the short-term of 0 to 90 days and the longer term, up to 12.7 years, mortality for patients undergoing primary total hip replacement (THR) in Denmark in comparison to the general population. Through the Danish Hip Arthroplasty Registry we identified all primary THRs undertaken for osteoarthritis between 1 January 1995 and 31 December 2006. Each patient (n = 44 558) was matched at the time of surgery with three people from the general population (n = 133 674). We estimated mortality rates and mortality rate ratios with 95% confidence intervals for THR patients compared with the general population. There was a one-month period of increased mortality immediately after surgery among THR patients, but overall short-term mortality (0 to 90 days) was significantly lower (mortality rate ratio 0.8; 95% confidence interval 0.7 to 0.9). However, THR surgery was associated with increased short-term mortality in subjects under 60 years old, and among THR patients without comorbidity. Long-term mortality was lower among THR patients than in controls (mortality rate ratio 0.7; 95% confidence interval 0.7 to 0.7).

Overall, THR was associated with lower short- and long-term mortality among patients with osteoarthritis. Younger patients and patients without comorbidity before surgery may also experience increased mortality after THR surgery, although the absolute risk of death is small.

The incidence of anterior knee pain following total knee replacement (TKR) is reported to be as high as 49%. The source of the pain is poorly understood but the soft tissues around the patella have been implicated.

In theory circumferential electrocautery denervates the patella thereby reducing efferent pain signals. However, there is mixed evidence that this practice translates into improved outcomes.

We aimed to investigate the clinical effect of intra-operative circumpatellar electrocautery in patients undergoing TKR using the LCS mobile bearing or Kinemax fixed bearing TKR. A total of 200 patients were randomised to receive either circumpatellar electrocautery (diathermy) or not (control). Patients were assessed by visual analogue scale (VAS) for anterior knee pain and Oxford knee score (OKS) pre-operatively and three months, six months and one year post-operatively. Patients and assessors were blinded.

There were 91 patients in the diathermy group and 94 in the control. The mean VAS improvement at one year was 3.9 in both groups (control; -10 to 6, diathermy; -9 to 8, p < 0.001 in both cases, paired, two-tailed t-test). There was no significant difference in VAS between the groups at any other time. The mean OKS improvement was 17.7 points (0 to 34) in the intervention group and 16.6 (0 to 42) points in the control (p = 0.36). There was no significant difference between the two groups in OKS at any other time.

We found no relevant effect of patellar electrocautery on either VAS anterior knee pain or OKS for patients undergoing LCS and Kinemax TKR.

Antibiotic prophylaxis is routinely administered during joint replacement surgery and may predispose patients to Clostridium difficile-associated disease (CDAD). The primary aim of this study was to determine the incidence of this following joint replacement, using a cefuroxime-based regimen. Patients developing CDAD were compared with a control group of patients without CDAD. The incidence of the former was 1.7 per 1000 primary joint replacements. Those patients prescribed additional antibiotics had a higher incidence of CDAD (p = 0.047), but there was no difference between the two groups in relation to the use of gastroprotective agents (p = 0.703). A trial of a new prophylaxis regimen would require 43 198 patients in each arm to show a reduction of one case per 1000 procedures. Cefuroxime-based antibiotic prophylaxis is safe in patients undergoing primary elective joint replacement.

The June 2012 Foot & Ankle Roundup³⁶⁰ looks at: the Achilles tendon Total Rupture Score (ATRS); endoscopic treatment of Haglund’s syndrome; whether it is worth removing metalwork; hyaluronic acid injection; thromboembolic events after fracture fixation in the ankle; whether surgeons are as good as CT scans for OCD of the talus; proximal fractures of the fifth metatarsal; nerve blocks for hallux valgus surgery; chronic osteomyelitis in the non-diabetic patient; Charcot arthropathy.

We compared the results of 146 patients who received an anatomic modular knee fixed-bearing total knee replacement (TKR) in one knee and a low contact stress rotating platform mobile-bearing TKR in the other. There were 138 women and eight men with a mean age of 69.8 years (42 to 80). The mean follow-up was 13.2 years (11.0 to 14.5). The patients were assessed clinically and radiologically using the rating systems of the Hospital for Special Surgery and the Knee Society at three months, six months, one year, and annually thereafter.

The assessment scores of both rating systems pre-operatively and at the final review did not show any statistically significant differences between the two designs of implant. In the anatomic modular knee group, one knee was revised because of aseptic loosening of the tibial component and one because of infection. In addition, three knees were revised because of wear of the polyethylene tibial bearing. In the low contact stress group, two knees were revised because of instability requiring exchange of the polyethylene insert and one because of infection.

The radiological analysis found no statistical difference in the incidence of radiolucent lines at the final review (Student’s t-test, p = 0.08), most of which occurred at tibial zone 1. The Kaplan-Meier survivorship for aseptic loosening of the anatomic modular knee and the low contact stress implants at 14.5 years was 99% and 100%, respectively, with a 95% confidence interval of 94% to 100% for both designs.

We found no evidence of the superiority of one design over the other at long-term follow-up.