It has been suggested that extracorporeal shockwave
therapy is a safe and effective treatment for pain relief from recalcitrant
plantar fasciopathy (PF). However, the changes in gait and associated
biomechanical parameters have not been well characterised. We recruited
12 female patients with recalcitrant PF who had a mean age of 59
years (50 to 70) and mean body mass index of 25 kg/m2 (22
to 30). The patients reported a mean duration of symptoms of 9.3
months (6 to 15). Shockwave therapy consisting of 1500 impulses
(energy flux density 0.26 mJ/mm2) was applied for three
sessions, each three weeks apart. A pain visual analogue scale (VAS)
rating, plantar pressure assessment and motion analysis were carried
out before and nine weeks after first shock wave therapy. It was demonstrated
that patients increased their walking velocity and cadence as well
indicating a decrease in pain after shockwave therapy. In the symptomatic
foot, the peak contact pressure over the forefoot increased and
the contact area over the digits decreased. The total foot impulse
also decreased as did stance duration. The duration the centre of
pressure remained in the hindfoot increased in the symptomatic foot
after shockwave therapy. The differences in centre of pressure trajectory
at baseline decreased at final follow-up. In conclusion, shockwave
therapy not only decreased the pain VAS rating but also improved
the gait parameters of the symptomatic foot in PF patients. Cite this article:
Filling the empty holes in peri-articular locking
plates may improve the fatigue strength of the fixation. The purpose of
this A locking/compression plate was applied to 33 synthetic femurs
and then a 6 cm metaphyseal defect was created (AO Type 33-A3).
The specimens were then divided into three groups: unplugged, plugged
with locking screw only and fully plugged holes. They were then
tested using a stepwise or run-out fatigue protocol, each applying
cyclic physiological multiaxial loads. All specimens in the stepwise group failed at the 770 N load
level. The mean number of cycles to failure for the stepwise specimen
was 25 500 cycles ( In conclusion, filling the empty combination locking/compression
holes in peri-articular distal femur locking plates at the level
of supracondylar comminution does not increase the fatigue life
of the fixation in a comminuted supracondylar femoral fracture model
(AO 33-A3) with a 6 cm gap.
Electromagnetic fields (EMF) are widely used in musculoskeletal
disorders. There are indications that EMF might also be effective
in the treatment of osteoporosis. To justify clinical follow-up
experiments, we examined the effects of EMF on bone micro-architectural
changes in osteoporotic and healthy rats. Moreover, we tested the
effects of EMF on fracture healing. EMF (20 Gauss) was examined in rats (aged 20 weeks), which underwent
an ovariectomy (OVX; n = 8) or sham-ovariectomy (sham-OVX; n = 8).
As a putative positive control, all rats received bilateral fibular
osteotomies to examine the effects on fracture healing. Treatment
was applied to one proximal lower leg (three hours a day, five days
a week); the lower leg was not treated and served as a control.
Bone architectural changes of the proximal tibia and bone formation
around the osteotomy were evaluated using Objectives
Methods
Because of the contradictory body of evidence related to the
potential benefits of helical blades in trochanteric fracture fixation,
we studied the effect of bone compaction resulting from the insertion
of a proximal femoral nail anti-rotation (PFNA). We developed a subject-specific computational model of a trochanteric
fracture (31-A2 in the AO classification) with lack of medial support
and varied the bone density to account for variability in bone properties
among hip fracture patients.Objectives
Methods
Although it is clear that opening-wedge high
tibial osteotomy (HTO) changes alignment in the coronal plane, which is
its objective, it is not clear how this procedure affects knee kinematics
throughout the range of joint movement and in other planes. Our research question was: how does opening-wedge HTO change
three-dimensional tibiofemoral and patellofemoral kinematics in
loaded flexion in patients with varus deformity?Three-dimensional
kinematics were assessed over 0° to 60° of loaded flexion using
an MRI method before and after opening-wedge HTO in a cohort of
13 men (14 knees). Results obtained from an iterative statistical
model found that at six and 12 months after operation, opening-wedge
HTO caused increased anterior translation of the tibia (mean 2.6
mm, p <
0.001), decreased proximal translation of the patella
(mean –2.2 mm, p <
0.001), decreased patellar spin (mean –1.4°,
p <
0.05), increased patellar tilt (mean 2.2°, p <
0.05) and
changed three other parameters. The mean Western Ontario and McMaster
Universities Arthritis Index improved significantly (p <
0.001)
from 49.6 (standard deviation ( The three-dimensional kinematic changes found may be important
in explaining inconsistency in clinical outcomes, and suggest that
measures in addition to coronal plane alignment should be considered. Cite this article:
We have previously reported the short-term radiological
results of a randomised controlled trial comparing kinematically
aligned total knee replacement (TKR) and mechanically aligned TKR,
along with early pain and function scores. In this study we report
the two-year clinical results from this trial. A total of 88 patients
(88 knees) were randomly allocated to undergo either kinematically
aligned TKR using patient-specific guides, or mechanically aligned
TKR using conventional instruments. They were analysed on an intention-to-treat
basis. The patients and the clinical evaluator were blinded to the
method of alignment. At a minimum of two years, all outcomes were better for the kinematically
aligned group, as determined by the mean Oxford knee score (40 (15
to 48) In this study, the use of a kinematic alignment technique performed
with patient-specific guides provided better pain relief and restored
better function and range of movement than the mechanical alignment
technique performed with conventional instruments. Cite this article:
This short contribution aims to explain how intervertebral disc ‘degeneration’ differs from normal ageing, and to suggest how mechanical loading and constitutional factors interact to cause disc degeneration and prolapse. We suggest that disagreement on these matters in medico-legal practice often arises from a misunderstanding of the nature of ‘soft-tissue injuries’.
Following the recall of modular neck hip stems
in July 2012, research into femoral modularity will intensify over
the next few years. This review aims to provide surgeons with an
up-to-date summary of the clinically relevant evidence. The development
of femoral modularity, and a classification system, is described.
The theoretical rationale for modularity is summarised and the clinical
outcomes are explored. The review also examines the clinically relevant problems
reported following the use of femoral stems with a modular neck. Joint replacement registries in the United Kingdom and Australia
have provided data on the failure rates of modular devices but cannot
identify the mechanism of failure. This information is needed to
determine whether modular neck femoral stems will be used in the
future, and how we should monitor patients who already have them implanted. Cite this article:
Metatarsus primus varus deformity correction
is one of the main objectives in hallux valgus surgery. A ‘syndesmosis’
procedure may be used to correct hallux valgus. An osteotomy is
not involved. The aim is to realign the first metatarsal using soft
tissues and a cerclage wire around the necks of the first and second
metatarsals. We have retrospectively assessed 27 patients (54 feet) using
the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs
and measurements of the plantar pressures after bilateral syndesmosis
procedures. There were 26 women. The mean age of the patients was
46 years (18 to 70) and the mean follow-up was 26.4 months (24 to
33.4). Matched-pair comparisons of the AOFAS scores, the radiological
parameters and the plantar pressure measurements were conducted
pre- and post-operatively, with the mean of the left and right feet.
The mean AOFAS score improved from 62.8 to 94.4 points (p <
0.001).
Significant differences were found on all radiological parameters
(p <
0.001). The mean hallux valgus and first intermetatarsal
angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1°
to 45.3°) (p <
0.001) and from 15.0° (10.2° to 18.6°) to 7.2°
(4.2° to 11.4°) (p <
0.001) respectively. The mean medial sesamoid
position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p <
0.001)
according to the Hardy’s scale (0 to 7). The mean maximum force
and the force–time integral under the hallux region were significantly
increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63
to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70
(1.28 to 19.23)) respectively. The occurrence of the maximum force
under the hallux region was delayed by 11% (p = 0.02), (87.3% stance
(36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data
reflected the restoration of the function of the hallux. Three patients
suffered a stress fracture of the neck of the second metatarsal.
The short-term results of this surgical procedure for the treatment
of hallux valgus are satisfactory. Cite this article:
The February 2013 Spine Roundup360 looks at: complications with anterior decompression and fusion; lumbar claudication and peripheral vascular disease; increasing cervical instability in rheumatoids; kyphoplasty; cervical stenosis; exercise or fusion for chronic lower back pain; lumbar disc arthroplasty and adjacent level changes; and obese disc prolapses.
We present the ten- to 15-year follow-up of 31
patients (34 knees), who underwent an Elmslie-Trillat tibial tubercle osteotomy
for chronic, severe patellar instability, unresponsive to non-operative
treatment. The mean age of the patients at the time of surgery was
31 years (18 to 46) and they were reviewed post-operatively, at
four years (2 to 8) and then at 12 years (10 to 15). All patients
had pre-operative knee radiographs and Cox and Insall knee scores. Superolateral
portal arthroscopy was performed per-operatively to document chondral
damage and after the osteotomy to assess the stability of the patellofemoral
joint. A total of 28 knees (82%) had a varying degree of damage
to the articular surface. At final follow-up 25 patients (28 knees)
were available for review and underwent clinical examination, radiographs
of the knee, and Cox and Insall scoring. Six patients who had no
arthroscopic chondral abnormality showed no or only early signs
of osteoarthritis on final radiographs; while 12 patients with lower
grade chondral damage (grade 1 to 2) showed early to moderate signs
of osteoarthritis and six out of ten knees with higher grade chondral
damage (grade 3 to 4) showed marked evidence of osteoarthritis;
four of these had undergone a knee replacement. In the 22 patients
(24 knees) with complete follow-up, 19 knees (79.2%) were reported
to have a good or excellent outcome at four years, while 15 knees
(62.5%) were reported to have the same at long-term follow-up. The
functional and radiological results show that the extent of pre-operatively
sustained chondral damage is directly related to the subsequent
development of patellofemoral osteoarthritis. Cite this article:
We evaluated the top 13 journals in trauma and
orthopaedics by impact factor and looked at the longer-term effect regarding
citations of their papers. All 4951 papers published in these journals during 2007 and 2008
were reviewed and categorised by their type, subspecialty and super-specialty.
All citations indexed through Google Scholar were reviewed to establish
the rate of citation per paper at two, four and five years post-publication.
The top five journals published a total of 1986 papers. Only three
(0.15%) were on operative orthopaedic surgery and none were on trauma.
Most (n = 1084, 54.5%) were about experimental basic science. Surgical
papers had a lower rate of citation (2.18) at two years than basic science
or clinical medical papers (4.68). However, by four years the rates
were similar (26.57 for surgery, 30.35 for basic science/medical),
which suggests that there is a considerable time lag before clinical
surgical research has an impact. We conclude that high impact journals do not address clinical
research in surgery and when they do, there is a delay before such
papers are cited. We suggest that a rate of citation at five years
post-publication might be a more appropriate indicator of importance
for papers in our specialty. Cite this article:
The February 2014 Spine Roundup360 looks at: single posterior approach for severe kyphosis; risk factors for recurrent disc herniation; dysphagia and cervical disc replacement or fusion; hang on to your topical antibiotics; cost-effective lumbar disc replacement; anxiolytics no role to play in acute lumbar back pain; and surgery best for lumbar disc herniation.
In this study, we evaluated patient-reported
outcomes, the rate of revision and the indications for revision
following resurfacing hemiarthroplasty of the shoulder in patients
with osteoarthritis. All patients with osteoarthritis who underwent primary resurfacing
hemiarthroplasty and reported to the Danish Shoulder Arthroplasty
Registry (DSR), between January 2006 and December 2010 were included.
There were 772 patients (837 arthroplasties) in the study. The Western
Ontario Osteoarthritis of the Shoulder (WOOS) index was used to
evaluate patient-reported outcome 12 months (10 to 14) post-operatively.
The rates of revision were calculated from the revisions reported
to the DSR up to December 2011 and by checking deaths with the Danish National
Register of Persons. A complete questionnaire was returned by 688 patients (82.2%).
The mean WOOS was 67 (0 to 100). A total of 63 hemiarthroplasties
(7.5%) required revision; the cumulative five-year rate of revision
was 9.9%. Patients aged <
55 years had a statistically significant
inferior WOOS score, which exceeded the minimal clinically important
difference, compared with older patients (mean difference 14.2 (8.8;
95% CI 19.6; p <
0.001), but with no increased risk of revision.
There was no significant difference in the mean WOOS or the risk
of revision between designs of resurfacing hemiarthroplasty. Cite this article:
In 1999, we developed a technique for biological
reconstruction after excision of a bone tumour, which involved using
autografts of the bone containing the tumour treated with liquid
nitrogen. We have previously reported the use of this technique
in 28 patients at a mean follow up of 27 months (10 to 54). In this study, we included 72 patients who underwent reconstruction
using this technique. A total of 33 patients died and three were
lost to follow-up, at a mean of 23 months (2 to 56) post-operatively,
leaving 36 patients available for a assessment at a mean of 101
months 16 to 163) post-operatively. The methods of reconstruction included
an osteo-articular graft in 16, an intercalary in 13 and, a composite
graft with prosthesis in seven. Post-operative function was excellent in 26 patients (72.2%),
good in seven (19.4%), and fair in three (8.3%) according to the
functional evaluation system of Enneking. No recurrent tumour occurred
within the grafts. The autografts survived in 29 patients (80.6%),
and the rates of survival at five and ten years were 86.1% and 80.6
%, respectively. Seven of 16 osteo-articular grafts (44%) failed
because of fracture or infection, but all the composite and intercalary
grafts survived. The long-term outcomes of frozen autografting, particularly using
composite and intercalary grafts, are satisfactory and thus represent
a good method of treatment for patients with a sarcoma of bone or
soft tissue. Cite this article:
The purpose of this study was to evaluate and
compare the effect of short segment pedicle screw instrumentation and
an intermediate screw (SSPI+IS) on the radiological outcome of type
A thoracolumbar fractures, as judged by the load-sharing classification,
percentage canal area reduction and remodelling. We retrospectively evaluated 39 patients who had undergone hyperlordotic
SSPI+IS for an AO-Magerl Type-A thoracolumbar fracture. Their mean
age was 35.1 (16 to 60) and the mean follow-up was 22.9 months (12
to 36). There were 26 men and 13 women in the study group. In total,
18 patients had a load-sharing classification score of seven and
21 a score of six. All radiographs and CT scans were evaluated for
sagittal index, anterior body height compression (%ABC), spinal
canal area and encroachment. There were no significant differences
between the low and high score groups with respect to age, duration
of follow-up, pre-operative sagittal index or pre-operative anterior
body height compression (p = 0.217, 0.104, 0.104, and 0.109 respectively).
The mean pre-operative sagittal index was 19.6° (12° to 28°) which
was corrected to -1.8° (-5° to 3°) post-operatively and 2.4° (0°
to 8°) at final follow-up (p = 0.835 for sagittal deformity). No
patient needed revision for loss of correction or failure of instrumentation. Hyperlordotic reduction and short segment pedicle screw instrumentation
and an intermediate screw is a safe and effective method of treating
burst fractures of the thoracolumbar spine. It gives excellent radiological
results with a very low rate of failure regardless of whether the
fractures have a high or low load-sharing classification score. Cite this article
Osteochondral injuries, if not treated adequately, often lead
to severe osteoarthritis. Possible treatment options include refixation
of the fragment or replacement therapies such as Pridie drilling,
microfracture or osteochondral grafts, all of which have certain
disadvantages. Only refixation of the fragment can produce a smooth
and resilient joint surface. The aim of this study was the evaluation
of an ultrasound-activated bioresorbable pin for the refixation of
osteochondral fragments under physiological conditions. In 16 Merino sheep, specific osteochondral fragments of the medial
femoral condyle were produced and refixed with one of conventional
bioresorbable pins, titanium screws or ultrasound-activated pins.
Macro- and microscopic scoring was undertaken after three months. Objectives
Methods
There have been differing descriptions of the
anterolateral structures of the knee, and not all have been named
or described clearly. The aim of this study was to provide a clear
anatomical interpretation of these structures. We dissected 40 fresh-frozen
cadaveric knees to view the relevant anatomy and identified a consistent
structure in 33 knees (83%); we termed this the anterolateral ligament
of the knee. This structure passes antero-distally from an attachment
proximal and posterior to the lateral femoral epicondyle to the
margin of the lateral tibial plateau, approximately midway between
Gerdy’s tubercle and the head of the fibula. The ligament is superficial
to the lateral (fibular) collateral ligament proximally, from which
it is distinct, and separate from the capsule of the knee. In the
eight knees in which it was measured, we observed that the ligament
was isometric from 0° to 60° of flexion of the knee, then slackened
when the knee flexed further to 90° and was lengthened by imposing
tibial internal rotation. Cite this article:
The zona conoidea comprises the area of the lateral
trochlear ridge of the humerus. The purpose of this study is to reintroduce
this term ‘zona conoidea’ to the discussion of the human elbow and
to investigate its significance in the development of osteoarthritis
of the elbow. The upper extremities of 12 cadavers were prepared. With the
forearm in neutral, pronation and supination, the distance between
the bevel of the radial head and zona conoidea was inspected. A
total of 12 healthy volunteers had a CT scan. The distance between
the zona conoidea and the bevelled rim of the radial head was measured
in these positions. In the anatomical specimens, early osteo-arthritic changes were
identified in the posteromedial bevelled rim of the radial head,
and the corresponding zona conoidea in supination. Measurement in
the CT study showed that in full supination, the distance between
the bevel of the radial head and the zona conoidea was at a minimum. This study suggests that the significant contact between the
bevel of the radial head and the zona conoidea in supination is
associated with the initiation of osteoarthritis of the elbow in
this area.