The aim of this study was to review the early outcome of the Femoro-Patella Vialla (FPV) joint replacement. A total of 48 consecutive FPVs were implanted between December 2007 and June 2011. Case-note analysis was performed to evaluate the indications, operative histology, operative findings, post-operative complications and reasons for revision. The mean age of the patients was 63.3 years (48.2 to 81.0) and the mean follow-up was 25.0 months (6.1 to 48.9). Revision was performed in seven (14.6%) at a mean of 21.7 months, and there was one re-revision. Persistent pain was observed in three further patients who remain unrevised. The reasons for revision were pain due to progressive tibiofemoral disease in five, inflammatory arthritis in one, and patellar fracture following trauma in one. No failures were related to the implant or the technique. Trochlear dysplasia was associated with a significantly lower rate of revision (5.9% vs 35.7%, p = 0.017) and a lower incidence of revision or persistent pain (11.8% vs 42.9%, p = 0.045).

Focal patellofemoral osteoarthritis secondary to trochlear dysplasia should be considered the best indication for patellofemoral replacement. Standardised radiological imaging, with MRI to exclude overt tibiofemoral disease should be part of the pre-operative assessment, especially for the non-dysplastic knee.

Cite this article: Bone Joint J 2013;95-B:793–7.

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5).

A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity.

Cite this article: Bone Joint J 2013;95-B:660–3.

Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis.

We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

Cite this article: Bone Joint J 2013;95-B:694–98.

This study prospectively compared the efficacy of kyphoplasty using a Jack vertebral dilator and balloon kyphoplasty to treat osteoporotic compression fractures between T10 and L5. Between 2004 and 2009, two groups of 55 patients each underwent vertebral dilator kyphoplasty and balloon kyphoplasty, respectively. Pain, function, the Cobb angle, and the anterior and middle height of the vertebral body were assessed before and after operation. Leakage of bone cement was recorded. The post-operative change in the Cobb angle was significantly greater in the dilator kyphoplasty group than in the balloon kyphoplasty group (−9.51° (sd 2.56) vs −7.78° (sd 1.19), p < 0.001)). Leakage of cement was less in the dilator kyphoplasty group. No other significant differences were found in the two groups after operation, and both procedures gave equally satisfactory results in terms of all other variables assessed. No serious complications occurred in either group.

These findings suggest that vertebral dilator kyphoplasty can facilitate better correction of kyphotic deformity and may ultimately be a safer procedure in reducing leakage of bone cement.

The April 2013 Hip & Pelvis Roundup³⁶⁰ looks at: hip cartilage and magnets; labral repair or resection; who benefits from injection; rotational osteotomy for osteonecrosis; whether ceramic implants risk fracture; dual articulation; and hydroxyapatite.

The April 2013 Research Roundup³⁶⁰ looks at: when the ‘residency cake’ is done; steroids, stem cells and tendons; what exactly is osteoarthritis; platelet-rich plasma; CRPS; d-Dimer for DVT; reducing bacterial adhesion; and fin or limb?

The April 2013 Foot & Ankle Roundup³⁶⁰ looks at: whether arthroscopic arthrodesis is advantageous; osteochondral autografts; suture button associated fractures; an ultrasound solution to Achilles tendinopathy; the safety of the tendo Achilles in men; charcot and antibiotic-coated nails; and botox and Policeman’s Heel.

Aims

We performed a systematic review of the literature to determine whether earlier surgical repair of acute rotator cuff tear (ARCT) leads to superior post-operative clinical outcomes.

The April 2013 Trauma Roundup³⁶⁰ looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction.

The April 2013 Wrist & Hand Roundup³⁶⁰ looks at: whether botox is just for Hollywood; supercharging nerve repairs; YouTube research; options for Keinbock’s disease; volar plates; driving and plasters; symptomatic radial malunion; and MRI and acute scaphoid fractures.

Endoprosthetic replacement of the pelvis is one of the most challenging types of limb-salvage surgery, with a high rate of complications. In an attempt to reduce this and build greater versatility into the reconstruction process, a new type of pelvic endoprosthesis was developed in 2003, based on the old McKee-Farrar prosthesis. This study reviews the outcomes in 27 patients who had an ice-cream cone pelvic prosthesis inserted at two different specialist bone tumour centres in the United Kingdom over the past six years. The indications for treatment included primary bone tumours in 19 patients and metastatic disease in two, and six implants were inserted following failure of a previous pelvic reconstruction. Most of the patients had a P2+P3 resection as classified by Enneking, and most had resection of the ilium above the sciatic notch. The mean age of the patients at operation was 49 years (13 to 81). Complications occurred in ten patients (37.0%), of which dislocation was the most common, affecting four patients (14.8%). A total of three patients (11.1%) developed a deep infection around the prosthesis but all were successfully controlled by early intervention and two patients (7.4%) developed a local recurrence, at the same time as widespread metastases appeared. In one patient the prosthesis was removed for severe pain.

This method of treatment is still associated with high morbidity, but early results are promising. Complications are diminishing with increasing experience.

Mesenchymal stem-cell based therapies have been proposed as novel treatments for intervertebral disc degeneration, a prevalent and disabling condition associated with back pain. The development of these treatment strategies, however, has been hindered by the incomplete understanding of the human nucleus pulposus phenotype and by an inaccurate interpretation and translation of animal to human research. This review summarises recent work characterising the nucleus pulposus phenotype in different animal models and in humans and integrates their findings with the anatomical and physiological differences between these species. Understanding this phenotype is paramount to guarantee that implanted cells restore the native functions of the intervertebral disc.

Cite this article: Bone Joint Res 2013;2:169–78.

We compared six patients with a mean age of 70 years (49 to 80) with severe bilateral, painful glenohumeral joint destruction who underwent a single-stage bilateral total shoulder replacement, with eight patients of mean age 61 years (22 to 89) who underwent bilateral total shoulder replacement in two stages, at a mean interval of 18 months (6 to 43).

The overall function, pain and strength improved significantly in both groups. The subjective shoulder value, relative Constant score, active external rotation and the strength were improved significantly more in the single-stage group. Active elevation, abduction and overall function improved, significantly more in the single-stage group. Both the total duration of hospitalisation and the time off work per shoulder were substantially shorter in the single-stage group. The overall rate of complication was lower in the single-stage group.

Our findings indicated that single-stage bilateral total shoulder replacement yielded significantly better clinical results with shorter hospitalisation and rehabilitation than staged replacement, and was not associated with any increase in complications.

This is the first study to use the English Indices of Multiple Deprivation 2007, the Government’s official measure of multiple deprivation, to analyse the effect of socioeconomic status on the incidence of fractures of the hip and their outcome and mortality. Our sample consisted of all patients admitted to hospital with a fracture of the hip (n = 7511) in Nottingham between 1999 and 2009.

The incidence was 1.3 times higher (p = 0.038) in the most deprived populations than in the least deprived; the most deprived suffered a fracture, on average, 1.1 years earlier (82.0 years versus 83.1 years, p < 0.001). The mortality rate proved to be significantly higher in the most deprived population (log-rank test, p = 0.033), who also had a higher number of comorbidities (p = 0.001).

This study has shown an increase in the incidence of fracture of the hip in the most deprived population, but no association between socioeconomic status and mortality at 30 days. Preventative programmes aimed at reducing the risk of hip fracture should be targeted towards the more deprived if they are to make a substantial impact.

In this paper, we will consider the current role of simultaneous-bilateral TKA. Based on available evidence, it is our opinion that bilateral one stage TKR is a safe and efficacious treatment for patients with severe bilateral arthritic knee disease but should be reserved for selected patients without significant medical comorbidities.

We compared the intracompartmental pressures (ICPs) of open and closed tibial fractures with the same injury pattern in a rabbit model. In all, 20 six-month-old New Zealand White male rabbits were used. They were randomised into two equal groups of ten rabbits; an open fracture group (group 1) and a closed fracture group (group 2). Each anaesthetised rabbit was subjected to a standardised fracture of the proximal half of the right tibia using a custom-made device. In order to create a grade II open fracture in group 1, a 10 mm segment of fascia and periosteum was excised. The ICP in the anterior compartment was monitored at six-hourly intervals for 48 hours. Although there was a statistically significant difference in ICP values within each group (both p < 0.001), there was no significant difference between the groups for all measurements (all p ≥ 0.089). In addition, in both groups there was a statistically significant increase in ICP within the first 24 hours, whereas there was a statistically significant decrease within the second 24 hours (p < 0.001 for both groups). We conclude that open tibial fractures should be monitored for the development of acute compartment syndrome to the same extent as closed fractures.

Cite this paper: Bone Joint J 2013;95-B:111–14.

We present an illustrative case using a modification of the Gaines procedure for the surgical management of patients with spondyloptosis. It involves excision of the inferior half of the body of L5 anteriorly combined with posterior reduction and fusion.

We set out to determine the impact of surgery on quality of life and function in patients who had undergone surgery for symptomatic peri-acetabular metastases. From a prospective database we retrospectively reviewed 46 consecutive patients who had been treated operatively between June 2003 and June 2009. The mean age of the patients was 56.4 years (20 to 73) and the mean post-operative follow-up was 19.2 months (4 to 70). Functional evaluation and quality-of-life assessments were performed. At the most recent follow-up, 26 patients (56.5%) were alive. Their median survival time was 25.0 months. Ten major postoperative complications had occurred in eight patients (17.4%). The mean post-operative Musculoskeletal Tumor Society score (MSTS 93) was 56.3% (6.7% to 90.0%). Improvement in the Eastern Cooperative Oncology Group (ECOG) performance status was seen in 32 patients (69.6%). On the European Organisation for Research and Treatment of Cancer core quality-of-life questionnaire (QLQ-C30) measure of global health status there was a statistically significant improvement from the patients’ pre-operative status (42.8 (sd 13.7)) to that found at the latest follow-up (58.0 (sd 12.5)) (p = 0.001). The only statistically significant change in the nine symptom domains of the QLQ-C30 was a reduction in the mean level of pain (from 59.1 to 29.5 (out of 100)) (p < 0.001).

Surgery for patients with peri-acetabular metastases reduces pain and improves their quality of life, and has a low rate of surgical complications.

This is a case series of prospectively gathered data characterising the injuries, surgical treatment and outcomes of consecutive British service personnel who underwent a unilateral lower limb amputation following combat injury. Patients with primary, unilateral loss of the lower limb sustained between March 2004 and March 2010 were identified from the United Kingdom Military Trauma Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire. A total of 48 patients were identified: 21 had a trans-tibial amputation, nine had a knee disarticulation and 18 had an amputation at the trans-femoral level. The median New Injury Severity Score was 24 (mean 27.4 (9 to 75)) and the median number of procedures per residual limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were completed by 39 patients (81%) at a mean follow-up of 40 months (25 to 75). The physical component of the SF-36 varied significantly between different levels of amputation (p = 0.01). Mental component scores did not vary between amputation levels (p = 0.114). Pain (p = 0.332), use of prosthesis (p = 0.503), rate of re-admission (p = 0.228) and mobility (p = 0.087) did not vary between amputation levels.

These findings illustrate the significant impact of these injuries and the considerable surgical burden associated with their treatment. Quality of life is improved with a longer residual limb, and these results support surgical attempts to maximise residual limb length.

Cite this article: Bone Joint J 2013;95-B:224–9.

The December 2012 Wrist & Hand Roundup³⁶⁰ looks at: the imaging of scaphoid fractures; splinting to help Dupuytren’s disease; quality of life after nerve transfers; early failure of Moje thumbs; electra CMCJ arthroplasty; proximal interphalangeal joint replacement; pronator quadratus repair in distal radius fractures; and osteoporosis and wrist fractures.