We investigated changes in the axial alignment of the ipsilateral
hip and knee after total hip arthroplasty (THA). We reviewed 152 patients undergoing primary THA (163 hips; 22
hips in men, 141 hips in women) without a pre-operative flexion
contracture. The mean age was 64 years (30 to 88). The diagnosis
was osteoarthritis (OA) in 151 hips (primary in 18 hips, and secondary
to dysplasia in 133) and non-OA in 12 hips. A posterolateral approach
with repair of the external rotators was used in 134 hips and an
anterior approach in 29 hips. We measured changes in leg length
and offset on radiographs, and femoral anteversion, internal rotation
of the hip and lateral patellar tilt on CT scans, pre- and post-operatively. Aims
Patients and Methods
The April 2015 Shoulder &
Elbow Roundup360 looks at: Distal clavicular resection not indicated in cuff repair?; Platelet-rich plasma in rotator cuff repair; Radial head geometry: time to change?; Heterotopic ossification in elbow trauma; Another look at heterotopic ossification in the humerus; Triceps on for total elbow arthroplasty?; Predicting outcomes in rotator cuff repair; Deltoid fatty infiltration and reverse shoulder arthroplasty
Unlinked, linked and convertible total elbow
arthroplasties (TEAs) are currently available. This study is the
first to report the clinical results of the convertible Latitude
TEA. This was a retrospective study of a consecutive cohort of 63
patients (69 primary TEAs) with a mean age of 60 years (23 to 87).
Between 2006 and 2008 a total of 19 men and 50 women underwent surgery.
The mean follow-up was 43 months (8 to 84). The range of movement,
function and pain all improved six months post-operatively and either
continued to improve slightly or reached a plateau thereafter. The
complication rate is similar to that reported for other TEA systems.
No loosening was seen. Remarkable is the disengagement of the radial
head component in 13 TEAs (31%) with a radial head component implanted. Implantation of both the linked and the unlinked versions of
the Latitude TEA results in improvement of function and decreased
pain, and shows high patient satisfaction at mid-term follow-up. Cite this article:
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. In this prospective case-control study, PB and SF were obtained from 22 patients (23 hips) undergoing revision of MoM (n = 14) and MoP (n = 9) hip arthroplasties, with eight controls provided from primary hip osteoarthritis cases awaiting arthroplasty. Lymphocyte subtypes in samples were analysed using flow cytometry.Objectives
Methods
Oxidised zirconium was introduced as a material for femoral components
in total knee arthroplasty (TKA) as an attempt to reduce polyethylene
wear. However, the long-term survival of this component is not known. We performed a retrospective review of a prospectively collected
database to assess the ten year survival and clinical and radiological
outcomes of an oxidised zirconium total knee arthroplasty with the
Genesis II prosthesis. The Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS)
and a patient satisfaction scale were used to assess outcome.Aims
Methods
Dislocation of the acromioclavicular joint is
a relatively common injury and a number of surgical interventions
have been described for its treatment. Recently, a synthetic ligament
device has become available and been successfully used, however,
like other non-native solutions, a compromise must be reached when
choosing non-anatomical locations for their placement. This cadaveric
study aimed to assess the effect of different clavicular anchorage points
for the Lockdown device on the reduction of acromioclavicular joint
dislocations, and suggest an optimal location. We also assessed
whether further stability is provided using a coracoacromial ligament
transfer (a modified Neviaser technique). The acromioclavicular
joint was exposed on seven fresh-frozen cadaveric shoulders. The
joint was reconstructed using the Lockdown implant using four different
clavicular anchorage points and reduction was measured. The coracoacromial
ligament was then transferred to the lateral end of the clavicle,
and the joint re-assessed. If the Lockdown ligament was secured
at the level of the conoid tubercle, the acromioclavicular joint
could be reduced anatomically in all cases. If placed medial or
2 cm lateral, the joint was irreducible. If the Lockdown was placed
1 cm lateral to the conoid tubercle, the joint could be reduced
with difficulty in four cases. Correct placement of the Lockdown
device is crucial to allow anatomical joint reduction. Even when the
Lockdown was placed over the conoid tubercle, anterior clavicle
displacement remained but this could be controlled using a coracoacromial
ligament transfer. Cite this article:
Obesity is a global epidemic of 2.1 billion people and a well known cause of osteoarthritis. Joint replacement in the obese attracts more complications, poorer outcomes and higher revision rates. It is a reversible condition and the fundamental principles of dealing with reversible medical conditions prior to elective total joint replacement should apply to obesity. The dilemma for orthopaedic surgeons is when to offer surgery in the face of a reversible condition, which if treated may obviate joint replacement and reduce the risk and severity of obesity related disease in both the medical arena and the field of orthopaedics.
If a modular convertible total shoulder system
is used as a primary implant for an anatomical total shoulder arthroplasty,
failure of the prosthesis or the rotator cuff can be addressed by
converting it to a reverse shoulder arthroplasty (RSA), with retention
of the humeral stem and glenoid baseplate. This has the potential
to reduce morbidity and improve the results. In a retrospective study of 14 patients (15 shoulders) with a
mean age of 70 years (47 to 83) we reviewed the clinical and radiological
outcome of converting an anatomical shoulder arthroplasty (ASA)
to a RSA using a convertible prosthetic system (SMR system, Lima,
San Daniele, Italy). The mean operating time was 64 minutes (45 to 75). All humeral
stems and glenoid baseplates were found to be well-fixed and could
be retained. There were no intra-operative or early post-operative
complications and no post-operative infection. The mean follow-up was 43 months (21 to 83), by which time the
mean visual analogue scale for pain had decreased from 8 pre-operatively
to 1, the mean American Shoulder and Elbow Surgeons Score from 12
to 76, the mean Oxford shoulder score from 3 to 39, the mean Western
Ontario Osteoarthritis of the Shoulder Score from 1618 to 418 and
the mean Subjective shoulder value from 15 to 61. On radiological review, one patient had a lucency around the
humeral stem, two had stress shielding. There were no fatigue fractures
of the acromion but four cases of grade 1 scapular notching. The use of a convertible prosthetic system to revise a failed
ASA reduces morbidity and minimises the rate of complications. The
mid-term clinical and radiological results of this technique are
promising. Cite this article:
The February 2015 Wrist &
Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures.
Total knee arthroplasty (TKA) is a cost effective
and extremely successful operation. As longevity increases, the demand
for primary TKA will continue to rise. The success and survivorship
of TKAs are dependent on the demographics of the patient, surgical
technique and implant-related factors. Currently the risk of failure of a TKA requiring revision surgery
ten years post-operatively is 5%. The most common indications for revision include aseptic loosening
(29.8%), infection (14.8%), and pain (9.5%). Revision surgery poses
considerable clinical burdens on patients and financial burdens
on healthcare systems. We present a current concepts review on the epidemiology of failed
TKAs using data from worldwide National Joint Registries. Cite this article:
The primary purpose of this study of metal-on-metal
(MoM) hip resurfacing was to compare the effect of using a cementless
or cemented femoral component on the subsequent bone mineral density
(BMD) of the femoral neck. This was a single-centre, prospective, double-blinded control
trial which randomised 120 patients (105 men and 15 women) with
a mean age of 49.4 years (21 to 68) to receive either a cemented
or cementless femoral component. Follow-up was to two years. Outcome
measures included total and six-point region-of-interest BMD of
the femoral neck, radiological measurements of acetabular inclination,
neck-shaft and stem-shaft angles, and functional outcome scores
including the Harris hip score, the Western Ontario and McMaster
Universities Osteoarthritis Index and the University of California
at Los Angeles activity scale. In total, 17 patients were lost to follow-up leaving 103 patients
at two years. There were no revisions in the cementless group and
three revisions (5%) in the cemented group (two because of hip pain
and one for pseudotumour). The total BMD was significantly higher in the cementless group
at six months (p <
0.001) and one year (p = 0.01) than in the
cemented group, although there was a loss of statistical significance
in the difference at two years (p = 0.155). All patient outcomes improved significantly: there were no significant
differences between the two groups. The results show better preservation of femoral neck BMD with
a cementless femoral component after two years of follow-up. Further
investigation is needed to establish whether this translates into
improved survivorship. Cite this article:
Total hip replacement causes a short-term increase
in the risk of mortality. It is important to quantify this and to identify
modifiable risk factors so that the risk of post-operative mortality
can be minimised. We performed a systematic review and critical
evaluation of the current literature on the topic. We identified
32 studies published over the last 10 years which provide either
30-day or 90-day mortality data. We estimate the pooled incidence
of mortality during the first 30 and 90 days following hip replacement
to be 0.30% (95% CI 0.22 to 0.38) and 0.65% (95% CI 0.50 to 0.81),
respectively. We found strong evidence of a temporal trend towards
reducing mortality rates despite increasingly co-morbid patients.
The risk factors for early mortality most commonly identified are
increasing age, male gender and co-morbid conditions, particularly
cardiovascular disease. Cardiovascular complications appear to have
overtaken fatal pulmonary emboli as the leading cause of death after
hip replacement. Cite this article:
The aim of this randomised controlled study was
to compare functional and radiological outcomes between modern cemented
and uncemented hydroxyapatite coated stems after one year in patients
treated surgically for a fracture of the femoral neck. A total of
141 patients aged >
65 years were included. Patients were randomised
to be treated with a cemented Exeter stem or an uncemented Bimetric
stem. The patients were reviewed at four and 12 months. The cemented group performed better than the uncemented group
for the Harris hip score (78 In conclusion, our data do not support the use of an uncemented
hydroxyapatite coated stem for the treatment of displaced fractures
of the femoral neck in the elderly. Cite this article:
Little information is available about several
important aspects of the treatment of melioidosis osteomyelitis
and septic arthritis. We undertook a retrospective review of 50 patients with these
conditions in an attempt to determine the effect of location of
the disease, type of surgical intervention and duration of antibiotic
treatment on outcome, particularly complications and relapse. We found that there was a 27.5% risk of osteomyelitis of the
adjacent bone in patients with septic arthritis in the lower limb.
Patients with septic arthritis and osteomyelitis of an adjacent
bone were in hospital significantly longer (p = 0.001), needed more
operations (p = 0.031) and had a significantly higher rate of complications
and re-presentation (p = 0.048). More than half the patients (61%), most particularly those with
multifocal bone and joint involvement, and those with septic arthritis
and osteomyelitis of an adjacent bone who were treated operatively,
needed more visits to theatre. Cite this article:
Total knee arthroplasty (TKA) is a major orthopaedic
intervention. The length of a patient's stay has been progressively
reduced with the introduction of enhanced recovery protocols: day-case
surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case
TKA. These constraints may be social, linked to patient’s comorbidities,
or due to surgery-related adverse events (e.g. pain, post-operative
nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and
multimodal opioid-sparing analgesia, day-case TKA might be achievable
in a limited group of patients. The younger, male patient without
comorbidities and with an excellent social network around him might
be a candidate. Demographic changes, effective recovery programmes and less invasive
surgical techniques such as unicondylar knee arthroplasty, may increase
the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced
against any increase in morbidity and mortality and the cost of
advanced follow-up at a distance with new technology. These factors
need to be evaluated before adopting this ultimate ‘fast-track’
approach. Cite this article:
Dunkin Hartley guinea pigs, a commonly used animal model of osteoarthritis,
were used to determine if high frequency ultrasound can ensure intra-articular
injections are accurately positioned in the knee joint. A high-resolution small animal ultrasound system with a 40 MHz
transducer was used for image-guided injections. A total of 36 guinea
pigs were anaesthetised with isoflurane and placed on a heated stage.
Sterile needles were inserted directly into the knee joint medially,
while the transducer was placed on the lateral surface, allowing
the femur, tibia and fat pad to be visualised in the images. B-mode
cine loops were acquired during 100 µl. We assessed our ability
to visualise 1) important anatomical landmarks, 2) the needle and
3) anatomical changes due to the injection. Objective
Methods
Unicompartmental knee arthroplasty (UKA) has
advantages over total knee arthroplasty but national joint registries report
a significantly higher revision rate for UKA. As a result, most
surgeons are highly selective, offering UKA only to a small proportion
(up to 5%) of patients requiring arthroplasty of the knee, and consequently
performing few each year. However, surgeons with large UKA practices
have the lowest rates of revision. The overall size of the practice
is often beyond the surgeon’s control, therefore case volume may
only be increased by broadening the indications for surgery, and
offering UKA to a greater proportion of patients requiring arthroplasty
of the knee. The aim of this study was to determine the optimal UKA usage
(defined as the percentage of knee arthroplasty practice comprised
by UKA) to minimise the rate of revision in a sample of 41 986 records
from the for National Joint Registry for England and Wales (NJR). UKA usage has a complex, non-linear relationship with the rate
of revision. Acceptable results are achieved with the use of 20%
or more. Optimal results are achieved with usage between 40% and
60%. Surgeons with the lowest usage (up to 5%) have the highest
rates of revision. With optimal usage, using the most commonly used
implant, five-year survival is 96% (95% confidence interval (CI)
94.9 to 96.0), compared with 90% (95% CI 88.4 to 91.6) with low
usage (5%) previously considered ideal. The rate of revision of UKA is highest with low usage, implying
the use of narrow, and perhaps inappropriate, indications. The widespread
use of broad indications, using appropriate implants, would give
patients the advantages of UKA, without the high rate of revision. Cite this article:
The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method. In this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who underwent 19 Ilizarov tibial lengthenings were retrospectively matched to the LON group.Objectives
Methods