The April 2013 Spine Roundup360 looks at: smuggling spinal implants; local bone graft and PLIF; predicting disability with slipped discs; mortality and spinal surgery; spondyloarthropathy; brachytherapy; and fibrin mesh and BMP.
Ventral screw osteosynthesis is a common surgical
method for treating fractures of the odontoid peg, but there is still
no consensus about the number and diameter of the screws to be used.
The purpose of this study was to develop a more accurate measurement
technique for the morphometry of the odontoid peg (dens axis) and
to provide a recommendation for ventral screw osteosynthesis. Images of the cervical spine of 44 Caucasian patients, taken
with a 64-line CT scanner, were evaluated using the measuring software
MIMICS. All measurements were performed by two independent observers.
Intraclass correlation coefficients were used to measure inter-rater
variability. The mean length of the odontoid peg was 39.76 mm ( The cross-section of the odontoid peg is not circular but slightly
elliptical, with a 10% greater diameter in the sagittal plane. In
the majority of cases (70.5%) the odontoid peg offers enough room
for two 3.5 mm cannulated cortical screws. Cite this article:
The reported prevalence of an asymptomatic slip
of the contralateral hip in patients operated on for unilateral slipped
capital femoral epiphysis (SCFE) is as high as 40%. Based on a population-based
cohort of 2072 healthy adolescents (58% women) we report on radiological
and clinical findings suggestive of a possible previous SCFE. Common
threshold values for Southwick’s lateral head–shaft angle (≥ 13°)
and Murray’s tilt index (≥ 1.35) were used. New reference intervals
for these measurements at skeletal maturity are also presented. At follow-up the mean age of the patients was 18.6 years (17.2
to 20.1). All answered two questionnaires, had a clinical examination
and two hip radiographs. There was an association between a high head–shaft angle and
clinical findings associated with SCFE, such as reduced internal
rotation and increased external rotation. Also, 6.6% of the cohort
had Southwick’s lateral head–shaft angle ≥ 13°, suggestive of a
possible slip. Murray’s tilt index ≥ 1.35 was demonstrated in 13.1%
of the cohort, predominantly in men, in whom this finding was associated
with other radiological findings such as pistol-grip deformity or
focal prominence of the femoral neck, but no clinical findings suggestive
of SCFE. This study indicates that 6.6% of young adults have radiological
findings consistent with a prior SCFE, which seems to be more common
than previously reported. Cite this article:
It is important to be able to identify patients
with an increased risk of venous thromboembolism (VTE) in order
to minimise the risk of an event. We investigated the incidence
and risk factors for post-operative VTE in 168 consecutive patients
with a malignancy of the lower limb. The period of study included
ten months before and 12 months after the introduction of chemical
thromboprophylaxis. All data about the potential risk factors were identified
and classified into three groups (patient-, surgery- and tumour-related).
The outcome measure was a thromboembolic event within 90 days of
surgery. Of the 168 patients, eight (4.8%) had a confirmed symptomatic
deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism.
Of the 28 variables tested, age >
60 years, higher American Society
of Anesthesiologists grade and metastatic tumour were independent
risk factors for VTE. The overall rate of symptomatic VTE was not significantly
different between patients who received chemical thromboprophylaxis
and those who did not. Knowledge of these risk factors may be of
value in improving the surgical outcome of patients with a malignancy
of the lower limb. Cite this article:
Redisplacement is the most common complication
of immobilisation in a cast for the treatment of diaphyseal fractures
of the forearm in children. We have previously shown that the three-point
index (TPI) can accurately predict redisplacement of fractures of
the distal radius. In this prospective study we applied this index
to assessment of diaphyseal fractures of the forearm in children
and compared it with other cast-related indices that might predict
redisplacement. A total of 76 children were included. Their ages,
initial displacement, quality of reduction, site and level of the
fractures and quality of the casting according to the TPI, Canterbury
index and padding index were analysed. Logistic regression analysis
was used to investigate risk factors for redisplacement. A total
of 18 fractures (24%) redisplaced in the cast. A TPI value of >
0.8 was the only significant risk factor for redisplacement (odds
ratio 238.5 (95% confidence interval 7.063 to 8054.86); p <
0.001). The TPI was far superior to other radiological indices, with
a sensitivity of 84% and a specificity of 97% in successfully predicting
redisplacement. We recommend it for routine use in the management
of these fractures in children. Cite this article:
Surgical repair of posterosuperior rotator cuff
tears has a poorer outcome and a higher rate of failure compared
with repairs of supraspinatus tears. In this prospective cohort
study 28 consecutive patients with an irreparable posterosuperior
rotator cuff tear after failed conservative or surgical treatment
underwent teres major tendon transfer. Their mean age was 60 years
(48 to 71) and the mean follow-up was 25 months (12 to 80). The
mean active abduction improved from 79° (0° to 150°) pre-operatively
to 105° (20° to 180°) post-operatively (p = 0.011). The mean active
external rotation in 90° abduction improved from 25° (0° to 70°)
pre-operatively to 55° (0° to 90°) post-operatively (p <
0.001).
The mean Constant score improved from 43 (18 to 78) pre-operatively
to 65 (30 to 86) post-operatively (p <
0.001). The median post-operative
VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to
5 (0 to 56) post-operatively (p <
0.001). In conclusion, teres major transfer effectively restores function
and relieves pain in patients with irreparable posterosuperior rotator
cuff tears and leads to an overall clinical improvement in a relatively
young and active patient group with limited treatment options. Cite this article:
There is conflicting evidence about the merits
of mobile bearings in total knee replacement, partly because most randomised
controlled trials (RCTs) have not been adequately powered. We report
the results of a multicentre RCT of mobile There was no significant difference between the groups pre-operatively:
mean OKS was 17.18 ( In this appropriately powered RCT, over the first five years
after total knee replacement functional outcomes, re-operation rates
and healthcare costs appear to be the same irrespective of whether
a mobile or fixed bearing is used. Cite this article:
The April 2013 Children’s orthopaedics Roundup360 looks at: improving stress distribution in dysplastic hips; the dangers of fashion; the natural history of supracondylar fractures; ankles that perform well as knees; intra-articular hip pathology at osteotomy; the safe removal of flexible nails; supracondylar fracture fixation; and talipes.
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 investigated whether an asymmetric extension
gap seen on routine post-operative radiographs after primary total
knee replacement (TKR) is associated with pain at three, six, 12
and 24 months’ follow-up. On radiographs of 277 patients after primary
TKR we measured the distance between the tibial tray and the femoral
condyle on both the medial and lateral sides. A difference was defined
as an asymmetric extension gap. We considered three groups (no asymmetric
gap, medial-opening and lateral-opening gap) and calculated the
associations with the Western Ontario and McMaster Universities
osteoarthritis index pain scores over time. Those with an asymmetric extension gap of ≥ 1.5 mm had a significant
association with pain scores at three months’ follow-up; patients
with a medial-opening extension gap reported more pain and patients
with a lateral-opening extension gap reported less pain (p = 0.036).
This effect was still significant at six months (p = 0.044), but had
lost significance by 12 months (p = 0.924). When adjusting for multiple
cofounders the improvement in pain was more pronounced in patients
with a lateral-opening extension gap than in those with a medial-opening extension
gap at three (p = 0.037) and six months’ (p = 0.027) follow-up. Cite this article:
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 lateral compartment is predominantly affected
in approximately 10% of patients with osteoarthritis of the knee. The
anatomy, kinematics and loading during movement differ considerably
between medial and lateral compartments of the knee. This in the
main explains the relative protection of the lateral compartment
compared with the medial compartment in the development of osteoarthritis.
The aetiology of lateral compartment osteoarthritis can be idiopathic,
usually affecting the femur, or secondary to trauma commonly affecting
the tibia. Surgical management of lateral compartment osteoarthritis
can include osteotomy, unicompartmental knee replacement and total
knee replacement. This review discusses the biomechanics, pathogenesis
and development of lateral compartment osteoarthritis and its management. Cite this article:
Cut-off values with highest sensitivity and specificity
for the synovial fluid white cell and differential count will facilitate
the accurate diagnosis of infection in total knee (TKR) and total
hip replacement (THR). All patients undergoing revision TKR or THR
for suspected prosthetic joint infection between 2009 and 2011 at
two hospitals were identified. A total of 75 patients were included
with a mean age of 70.3 years (38 to 89). Synovial fluid was aspirated
pre-operatively and peri-prosthetic tissue samples were taken intra-operatively
for histological and microbiological examination. Receiver operating characteristic (ROC) plots were constructed
for white cell and differential counts in aspirated fluid. The optimal
cut-off for TKR and THR was 1590 white cells/µl and 65% neutrophilia.
The white cell count cut-off value identified for THR was notably
lower than previously quoted in the literature. A cut-off value
for white cell count in synovial aspirate in suspected prosthetic
joint infection of between 1100 and 1700 white cells/µl is likely
to be applicable to both THR and TKR. Cite this article:
We conducted a randomised controlled trial to
determine whether active intense pulsed light (IPL) is an effective treatment
for patients with chronic mid-body Achilles tendinopathy. A total
of 47 patients were randomly assigned to three weekly therapeutic
or placebo IPL treatments. The primary outcome measure was the Victorian
Institute of Sport Assessment – Achilles (VISA-A) score. Secondary
outcomes were a visual analogue scale for pain (VAS) and the Lower
Extremity Functional Scale (LEFS). Outcomes were recorded at baseline,
six weeks and 12 weeks following treatment. Ultrasound assessment
of the thickness of the tendon and neovascularisation were also
recorded before and after treatment. There was no significant difference between the groups for any
of the outcome scores or ultrasound measurements by 12 weeks, showing
no measurable benefit from treatment with IPL in patients with Achilles tendinopathy. Cite this article:
This study provides recommendations on the position
of the implant in reverse shoulder replacement in order to minimise
scapular notching and osteophyte formation. Radiographs from 151
patients who underwent primary reverse shoulder replacement with
a single prosthesis were analysed at a mean follow-up of 28.3 months
(24 to 44) for notching, osteophytes, the position of the glenoid
baseplate, the overhang of the glenosphere, and the prosthesis scapular
neck angle (PSNA). A total of 20 patients (13.2%) had a notch (16 Grade 1 and four
Grade 2) and 47 (31.1%) had an osteophyte. In patients without either
notching or an osteophyte the baseplate was found to be positioned
lower on the glenoid, with greater overhang of the glenosphere and
a lower PSNA than those with notching and an osteophyte. Female patients
had a higher rate of notching than males (13.3% Based on these findings we make recommendations on the placement
of the implant in both male and female patients to avoid notching
and osteophyte formation. Cite this article:
The April 2013 Oncology Roundup360 looks at: the margin for error; new money for old risks; hindquarter amputation; custom tumour jigs; preserving the tibial epiphysis; how long is long enough?; genomics and radiation-induced bone tumours; and India ink.
Severe hallux valgus deformity is conventionally
treated with proximal metatarsal osteotomy. Distal metatarsal osteotomy
with an associated soft-tissue procedure can also be used in moderate
to severe deformity. We compared the clinical and radiological outcomes
of proximal and distal chevron osteotomy in severe hallux valgus deformity
with a soft-tissue release in both. A total of 110 consecutive female
patients (110 feet) were included in a prospective randomised controlled
study. A total of 56 patients underwent a proximal procedure and
54 a distal operation. The mean follow-up was 39 months (24 to 54)
in the proximal group and 38 months (24 to 52) in the distal group.
At follow-up the hallux valgus angle, intermetatarsal angle, distal
metatarsal articular angle, tibial sesamoid position, American Orthopaedic
Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal
score, patient satisfaction level, and complications were similar
in each group. Both methods showed significant post-operative improvement
and high levels of patient satisfaction. Our results suggest that
the distal chevron osteotomy with an associated distal soft-tissue
procedure provides a satisfactory method for correcting severe hallux
valgus deformity. Cite this article:
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.
Lower limb muscle power is thought to influence outcome following
total knee replacement (TKR). Post-operative deficits in muscle
strength are commonly reported, although not explained. We hypothesised
that post-operative recovery of lower limb muscle power would be
influenced by the number of satellite cells in the quadriceps muscle at
time of surgery. Biopsies were obtained from 29 patients undergoing TKR. Power
output was assessed pre-operatively and at six and 26 weeks post-operatively
with a Leg Extensor Power Rig and data were scaled for body weight.
Satellite cell content was assessed in two separate analyses, the
first cohort (n = 18) using immunohistochemistry and the second
(n = 11) by a new quantitative polymerase chain reaction (q-PCR)
protocol for Pax-7 (generic satellite cell marker) and Neural Cell
Adhesion Molecule (NCAM; marker of activated cells).Objectives
Methods
There is currently limited information available
on the benefits and risks of extended thromboprophylaxis after hip fracture
surgery. SAVE-HIP3 was a randomised, double-blind study conducted
to evaluate the efficacy and safety of extended thromboprophylaxis
with the ultra-low molecular-weight heparin semuloparin compared
with placebo in patients undergoing hip fracture surgery. After
a seven- to ten-day open-label run-in phase with semuloparin (20
mg once daily subcutaneously, initiated post-operatively), patients
were randomised to once-daily semuloparin (20 mg subcutaneously)
or placebo for 19 to 23 additional days. The primary efficacy endpoint
was a composite of any venous thromboembolism (VTE; any deep-vein
thrombosis and non-fatal pulmonary embolism) or all-cause death until
day 24 of the double-blind period. Safety parameters included major
and clinically relevant non-major bleeding, laboratory data, and
treatment-emergent adverse events (TEAEs). Extended thromboprophylaxis
with semuloparin demonstrated a relative risk reduction of 79% in
the rate of any VTE or all-cause death compared with placebo (3.9% Cite this article:
In a retrospective cohort study we compared the
clinical outcome and complications, including dysphagia, following
anterior cervical fusion for the treatment of cervical spondylosis
using either a zero-profile (Zero-P; Synthes) implant or an anterior
cervical plate and cage. A total of 83 patients underwent fusion
using a Zero-P and 107 patients underwent fusion using a plate and
cage. The mean follow-up was 18.6 months ( When compared with the traditional anterior cervical plate and
cage, the Zero-P implant is a safe and convenient procedure giving
good results in patients with symptomatic cervical spondylosis with
a reduced incidence of dysphagia post-operatively. Cite this article:
Latissimus dorsi tendon transfer (LDTT) is technically
challenging. In order to clarify the local structural anatomy, we undertook
a morphometric study using six complete cadavers (12 shoulders).
Measurements were made from the tendon to the nearby neurovascular
structures with the arm in two positions: flexed and internally
rotated, and adducted in neutral rotation. The tendon was then transferred
and measurements were taken from the edge of the tendon to a reference
point on the humeral head in order to assess the effect of a novel
two-stage release on the excursion of the tendon. With the shoulder flexed and internally rotated, the mean distances
between the superior tendon edge and the radial nerve, brachial
artery, axillary nerve and posterior circumflex artery were 30 mm
(26 to 34), 28 mm (17 to 39), 21 mm (12 to 28) and 15 mm (10 to
21), respectively. The mean distance between the inferior tendon
edge and the radial nerve, brachial artery and profunda brachii
artery was 18 mm (8 to 27), 22 mm (15 to 32) and 14 mm (7 to 21), respectively.
Moving the arm to a neutral position reduced these distances. A
mean of 15 mm (8 to 21) was gained from a standard soft-tissue release,
and 32 mm (20 to 45) from an extensile release. These figures help to define further the structural anatomy of
this region and the potential for transfer of the latissimus dorsi
tendon. Cite this article:
Matrix metalloproteinases (MMPs), responsible
for extracellular matrix remodelling and angiogenesis, might play
a major role in the response of the growth plate to detrimental
loads that lead to overuse injuries in young athletes. In order
to test this hypothesis, human growth plate chondrocytes were subjected
to mechanical forces equal to either physiological loads, near detrimental
or detrimental loads for two hours. In addition, these cells were
exposed to physiological loads for up to 24 hours. Changes in the
expression of MMPs -2, -3 and -13 were investigated. We found that expression of MMPs in cultured human growth plate
chondrocytes increases in a linear manner with increased duration
and intensity of loading. We also showed for the first time that
physiological loads have the same effect on growth plate chondrocytes
over a long period of time as detrimental loads applied for a short
period. These findings confirm the involvement of MMPs in overuse injuries
in children. We suggest that training programmes for immature athletes
should be reconsidered in order to avoid detrimental stresses and
over-expression of MMPs in the growth plate, and especially to avoid
physiological loads becoming detrimental. Cite this article:
We report a systematic review and meta-analysis
of published randomised and quasi-randomised trials evaluating the
efficacy of pre-operative skin antisepsis and cleansing techniques
in reducing foot and ankle skin flora. The post-preparation culture
number (Post-PCN) was the primary outcome. The data were evaluated
using a modified version of the Cochrane Collaboration’s tool. We
identified eight trials (560 participants, 716 feet) that met the inclusion
criteria. There was a significant difference in the proportions
of Post-PCN between hallux nailfold (HNF) and toe web spaces (TWS)
sites: 0.47 Meta-analyses showed that alcoholic chlorhexidine had better
efficacy than alcoholic povidone-iodine (PI) at HNF sites (risk
difference 0.19 (95% CI 0.08 to 0.30); p = 0.0005); a two-step intervention
using PI scrub and paint (S&
P) followed by alcohol showed significantly
better efficacy over PI (S&
P) alone at TWS sites (risk difference
0.13 (95% CI 0.02 to 0.24); p = 0.0169); and a two-step intervention
using chlorhexidine scrub followed by alcohol showed significantly
better efficacy over PI (S&
P) alone at the combined (HNF with
TWS) sites (risk difference 0.27 (95% CI 0.13 to 0.40); p <
0.0001).
No significant difference was found between cleansing techniques. Cite this article:
Slipped capital femoral epiphysis (SCFE) is relatively
common in adolescents and results in a complex deformity of the
hip that can lead to femoroacetabular impingement (FAI). FAI may
be symptomatic and lead to the premature development of osteoarthritis
(OA) of the hip. Current techniques for managing the deformity include
arthroscopic femoral neck osteochondroplasty, an arthroscopically
assisted limited anterior approach to the hip, surgical dislocation,
and proximal femoral osteotomy. Although not a routine procedure
to treat FAI secondary to SCFE deformity, peri-acetabular osteotomy
has been successfully used to treat FAI caused by acetabular over-coverage. These
procedures should be considered for patients with symptoms due to
a deformity of the hip secondary to SCFE. Cite this article:
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 Knee Roundup360 looks at: graft tension and outcome; chondrocytes at the midterm; pre-operative deformity and failure; the designer effect; whether chondroitin sulphate really does work; whether ACL reconstruction is really required; analgesia after TKR; and degenerative meniscus.
Ancient Egypt was a highly developed agrarian society with a massive civil engineering capability. Trauma and skeletal disease were common and vestiges of the evidence for that survive, largely in the form of hieratic images and papyri dedicated to the practice of medicine. The earliest treatise on trauma is the
Clinicians are often asked by patients, “When
can I drive again?” after lower limb injury or surgery. This question
is difficult to answer in the absence of any guidelines. This review
aims to collate the currently available evidence and discuss the
factors that influence the decision to allow a patient to return
to driving. There is currently insufficient evidence for any authoritative
body to determine fitness to drive. The lack of guidance could result
in patients being withheld from driving for longer than is necessary,
or returning to driving while still unsafe. Cite this article:
Patient-specific cutting guides (PSCGs) are designed
to improve the accuracy of alignment of total knee replacement (TKR).
We compared the accuracy of limb alignment and component positioning
after TKR performed using PSCGs or conventional instrumentation.
A total of 80 patients were randomised to undergo TKR with either of
the different forms of instrumentation, and radiological outcomes
and peri-operative factors such as operating time were assessed.
No significant difference was observed between the groups in terms
of tibiofemoral angle or femoral component alignment. Although the
tibial component in the PSCGs group was measurably closer to neutral
alignment than in the conventional group, the size of the difference
was very small (89.8° ( Cite this article:
Between 1999 and 2001, 90 patients underwent
total hip replacement using the same uncemented acetabular and femoral
components with a 28 mm metallic femoral head but with prospective
randomisation of the acetabular liner to either Durasul highly cross-linked
polyethylene or nitrogen-sterilised Sulene polyethylene. We assessed
83 patients at a minimum follow-up of ten years. Linear penetration
of the femoral head was estimated at six weeks, six and 12 months
and annually thereafter, using the Dorr method, given the non-spherical
shape of the acetabular component. There was no loosening of any component; only one hip in the
Sulene group showed proximal femoral osteolysis. The mean penetration
of the femoral head at six weeks was 0.08 mm (0.02 to 0.15) for
the Durasul group and 0.16 mm (0.05 to 0.28) for the Sulene group
(p = 0.001). The mean yearly linear penetration was 64.8% lower
for the Durasul group at 0.05 mm/year ( Cite this article:
The FRCS (Tr &
Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into four sections comprising Basic Science, Adult Pathology, Hands and Children’s Orthopaedics and Trauma. The Clinical Examination section is divided into Upper and Lower limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.
We evaluated the impact of pre-coating the tibial
component with polymethylmethacrylate (PMMA) on implant survival
in a cohort of 16 548 primary NexGen total knee replacements (TKRs)
in 14 113 patients. In 13 835 TKRs a pre-coated tray was used while
in 2713 TKRs the non-pre-coated version of the same tray was used.
All the TKRs were performed between 2001 and 2009 and were cemented.
TKRs implanted with a pre-coated tibial component had a lower cumulative
survival than those with a non-pre-coated tibial component (p =
0.01). After adjusting for diagnosis, age, gender, body mass index,
American Society of Anesthesiologists grade, femoral coupling design, surgeon
volume and hospital volume, pre-coating was an independent risk
factor for all-cause aseptic revision (hazard ratio 2.75, p = 0.006).
Revision for aseptic loosening was uncommon for both pre-coated
and non-pre-coated trays (rates of 0.12% and 0%, respectively).
Pre-coating with PMMA does not appear to be protective of revision
for this tibial tray design at short-term follow-up. Cite this article:
The optimum cementing technique for the tibial
component in cemented primary total knee replacement (TKR) remains
controversial. The technique of cementing, the volume of cement
and the penetration are largely dependent on the operator, and hence
large variations can occur. Clinical, experimental and computational
studies have been performed, with conflicting results. Early implant
migration is an indication of loosening. Aseptic loosening is the
most common cause of failure in primary TKR and is the product of
several factors. Sufficient penetration of cement has been shown
to increase implant stability. This review discusses the relevant literature regarding all aspects
of the cementing of the tibial component at primary TKR. Cite this article:
Focal femoral inlay resurfacing has been developed
for the treatment of full-thickness chondral defects of the knee. This
technique involves implanting a defect-sized metallic or ceramic
cap that is anchored to the subchondral bone through a screw or
pin. The use of these experimental caps has been advocated in middle-aged
patients who have failed non-operative methods or biological repair
techniques and are deemed unsuitable for conventional arthroplasty
because of their age. This paper outlines the implant design, surgical
technique and biomechanical principles underlying their use. Outcomes
following implantation in both animal and human studies are also reviewed. Cite this article:
Deficiency of the abductor mechanism is a well-recognised
cause of pain and limping after total hip replacement (THR). This
can be found incidentally at the time of surgery, or it may arise
as a result of damage to the superior gluteal nerve intra-operatively,
or after surgery owing to mechanical failure of the abductor muscle
repair or its detachment from the greater trochanter. The incidence
of abductor failure has been reported as high as 20% in some studies.
The management of this condition remains a dilemma for the treating
surgeon. We review the current state of knowledge concerning post-THR
abductor deficiency, including the aetiology, diagnosis and management,
and the outcomes of surgery for this condition. Cite this article:
This is a prospective randomised study comparing
the clinical and radiological outcomes of uni- and bipedicular balloon
kyphoplasty for the treatment of osteoporotic vertebral compression
fractures. A total of 44 patients were randomised to undergo either
uni- or bipedicular balloon kyphoplasty. Self-reported clinical
assessment using the Oswestry Disability Index, the Roland-Morris
Disability questionnaire and a visual analogue score for pain was undertaken
pre-operatively, and at three and twelve months post-operatively.
The vertebral height and kyphotic angle were measured from pre-
and post-operative radiographs. Total operating time and the incidence
of cement leakage was recorded for each group. Both uni- and bipedicular kyphoplasty groups showed significant
within-group improvements in all clinical outcomes at three months
and twelve months after surgery. However, there were no significant
differences between the groups in all clinical and radiological
outcomes. Operating time was longer in the bipedicular group (p <
0.001). The incidence of cement leakage was not significantly different
in the two groups (p = 0.09). A unipedicular technique yielded similar clinical and radiological
outcomes as bipedicular balloon kyphoplasty, while reducing the
length of the operation. We therefore encourage the use of a unipedicular
approach as the preferred surgical technique for the treatment of
osteoporotic vertebral compression fractures. Cite this article:
Achieving arthrodesis of the ankle can be difficult
in the presence of infection, deformity, poor soft tissues and bone loss.
We present a series of 48 patients with complex ankle pathology,
treated with the Ilizarov technique. Infection was present in 30
patients and 30 had significant deformity before surgery. Outcome
was assessed clinically and with patient-reported outcome measures
(Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and
the Short-Form (SF-36)). Arthrodesis was achieved in 40 patients with the Ilizarov technique
alone and in six further patients with additional surgery. Infection
was eradicated in all patients at a mean follow-up of 46.6 months
(13 to 162). Successful arthrodesis was less likely in those with
comorbidities and in tibiocalcaneal fusion compared with tibiotalar
fusion. These patients had poor general health scores compared with the
normal population before surgery. The mean MAOFAS score improved
significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to
90) post-operatively, but there was only a modest improvement in
general health; the mean SF-36 improved from 44.8 (19 to 66) to
50.1 (21 to 76). There was a major benefit in terms of pain relief. Arthrodesis using the Ilizarov technique is an effective treatment
for complex ankle pathology, with good clinical outcomes and eradication
of infection. However, even after successful arthrodesis general
health scores remain limited. Cite this article:
With greater numbers of younger patients undergoing
total hip replacement (THR), the effect of patient age on the diameter
of the femoral canal may become more relevant. This study aimed
to investigate the relationship between the diameter of the diaphysis
of the femoral canal with increasing age in a large number of patients
who underwent THR. A total of 1685 patients scheduled for THR had
their femoral dimensions recorded from calibrated radiographs. There
were 736 males and 949 females with mean ages of 67.1 years (34
to 92) and 70.2 years (29 to 92), respectively. The mean diameter
of the femoral canal was 13.3 mm (8.0 to 23.0) for males and 12.7
mm (6.0 to 26.0) for females. There was a poor correlation between
age and the diameter of the canal in males (r = 0.071, p = 0.05)
but a stronger correlation in females (r = 0.31, p <
0.001). The diameter of the femoral canal diameter of a female patient
undergoing THR could be predicted to increase by 3.2 mm between
the ages of 40 and 80 years, in contrast a male would be expected
to experience only a 0.6 mm increase during the same period. This
increase in the diameter of the canal with age might affect the
long-term survival of the femoral component in female patients. Cite this article:
The practice of removing a well-fixed cementless
femoral component is associated with high morbidity. Ceramic bearing
couples are low wearing and their use minimises the risk of subsequent
further revision due to the production of wear debris. A total of
165 revision hip replacements were performed, in which a polyethylene-lined acetabular
component was revised to a new acetabular component with a ceramic
liner, while retaining the well-fixed femoral component. A titanium
sleeve was placed over the used femoral trunnion, to which a ceramic
head was added. There were 100 alumina and 65 Delta bearing couples
inserted. The mean Harris hip score improved significantly from 71.3 (9.0
to 100.0) pre-operatively to 91.0 (41.0 to 100.0) at a mean follow
up of 4.8 years (2.1 to 12.5) (p <
0.001). No patients reported
squeaking of the hip. There were two fractures of the ceramic head, both in alumina
bearings. No liners were seen to fracture. No fractures were observed
in components made of Delta ceramic. At 8.3 years post-operatively
the survival with any cause of failure as the endpoint was 96.6%
(95% confidence interval (CI) 85.7 to 99.3) for the acetabular component and
94.0% (95% CI 82.1 to 98.4) for the femoral component. The technique of revising the acetabular component in the presence
of a well-fixed femoral component with a ceramic head placed on
a titanium sleeve over the used trunnion is a useful adjunct in
revision hip practice. The use of Delta ceramic is recommended. Cite this article:
Neurogenic heterotopic ossification (NHO) is
a disorder of aberrant bone formation affecting one in five patients sustaining
a spinal cord injury or traumatic brain injury. Ectopic bone forms
around joints in characteristic patterns, causing pain and limiting
movement especially around the hip and elbow. Clinical sequelae
of neurogenic heterotopic ossification include urinary tract infection,
pressure injuries, pneumonia and poor hygiene, making early diagnosis
and treatment clinically compelling. However, diagnosis remains
difficult with more investigation needed. Our pathophysiological
understanding stems from mechanisms of basic bone formation enhanced
by evidence of systemic influences from circulating humor factors
and perhaps neurological ones. This increasing understanding guides
our implementation of current prophylaxis and treatment including
the use of non-steroidal anti-inflammatory drugs, bisphosphonates,
radiation therapy and surgery and, importantly, should direct future, more
effective ones.
McFarland fractures of the medial malleolus in
children, also classified as Salter–Harris Type III and IV fractures,
are associated with a high incidence of premature growth plate arrest.
In order to identify prognostic factors for the development of complications
we reviewed 20 children with a McFarland fracture that was treated
surgically, at a mean follow-up of 8.9 years (3.5 to 17.4). Seven
children (35%) developed premature growth arrest with angular deformity.
The mean American Orthopaedic Foot and Ankle Society Ankle-Hindfoot
Scale for all patients was 98.3 (87 to 100) and the mean modified
Weber protocol was 1.15 (0 to 5). There was a significant correlation
between initial displacement (p = 0.004) and operative delay (p
= 0.007) with premature growth arrest. Both risk factors act independently
and additively, such that all children with both risk factors developed
premature arrest whereas children with no risk factor did not. We
recommend that fractures of the medial malleolus in children should
be treated by anatomical reduction and screw fixation within one
day of injury. Cite this article:
We report the incidence and intensity of persistent
pain in patients with an otherwise uncomplicated total ankle replacement
(TAR). Arthroscopic debridement was performed in selected cases
and the clinical outcome was analysed. Among 120 uncomplicated TARs, there was persistent pain with
a mean visual analogue scale (VAS) of 2.7 (0 to 8). The intensity
of pain decreased in 115 ankles (95.8%). Exercise or walking for
more than 30 minutes was the most common aggravating factor (62
ankles, 68.1%). The character of the pain was most commonly described
as dull (50 ankles, 54.9%) and located on the medial aspect of the
joint (43 ankles, 47.3%). A total of seven ankles (5.8%) underwent subsequent arthroscopy.
These patients had local symptoms and a VAS for pain ≥ 7 on exertion.
Impingement with fibrosis and synovitis was confirmed. After debridement,
the median VAS decreased from 7 to 3 and six patients were satisfied.
The median VAS for pain and the American Orthopaedic Foot and Ankle
Society score of the ankles after debridement was similar to that
of the uncomplicated TARs (p = 0.496 and p = 0.066, respectively). Although TAR reduces the intensity of pain, residual pain is
not infrequent even in otherwise uncomplicated TARs and soft-tissue
impingement is the possible cause. Cite this article:
We have recently shown that waste heat from forced-air
warming blankets can increase the temperature and concentration
of airborne particles over the surgical site. The mechanism for
the increased concentration of particles and their site of origin
remained unclear. We therefore attempted to visualise the airflow
in theatre over a simulated total knee replacement using neutral-buoyancy
helium bubbles. Particles were created using a Rocket PS23 smoke
machine positioned below the operating table, a potential area of
contamination. The same theatre set-up, warming devices and controls
were used as in our previous study. This demonstrated that waste
heat from the poorly insulated forced-air warming blanket increased
the air temperature on the surgical side of the drape by >
5°C.
This created convection currents that rose against the downward
unidirectional airflow, causing turbulence over the patient. The
convection currents increased the particle concentration 1000-fold
(2 174 000 particles/m3 for forced-air warming Cite this article:
The aim of this study was to determine whether
the level of circulating C-reactive protein (CRP) before treatment predicted
overall disease-specific survival and local tumour control in patients
with a sarcoma of bone. We retrospectively reviewed 318 patients who presented with a
primary sarcoma of bone between 2003 and 2010. Those who presented
with metastases and/or local recurrence were excluded. Elevated CRP levels were seen in 84 patients before treatment;
these patients had a poorer disease-specific survival (57% at five
years) than patients with a normal CRP (79% at five years) (p <
0.0001). They were also less likely to be free of recurrence (71%
at five years) than patients with a normal CRP (79% at five years)
(p = 0.04). Multivariate analysis showed the pre-operative CRP level
to be an independent predictor of survival and local control. Patients
with a Ewing’s sarcoma or chondrosarcoma who had an elevated CRP
before their treatment started had a significantly poorer disease-specific
survival than patients with a normal CRP (p = 0.02 and p <
0.0001, respectively).
Patients with a conventional osteosarcoma and a raised CRP were
at an increased risk of poorer local control. We recommend that CRP levels are measured routinely in patients
with a suspected sarcoma of bone as a further prognostic indicator
of survival. Cite this article:
There have been only a few small studies of patients
with an infected shoulder replacement treated with a single-stage
exchange procedure. We retrospectively reviewed 35 patients (19 men
and 16 women) with a peri-prosthetic infection of the shoulder who
were treated in this way. A total of 26 were available for clinical
examination; three had died, two were lost to follow-up and four
patients had undergone revision surgery. The mean follow-up time was
4.7 years (1.1 to 13.25), with an infection-free survival of 94%. The organisms most commonly isolated intra-operatively were Single-stage exchange is a successful and practical treatment
for patients with peri-prosthetic infection of the shoulder. Cite this article:
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:
We present our experience of the modified Dunn
procedure in combination with a Ganz surgical dislocation of the hip
to treat patients with severe slipped capital femoral epiphysis
(SCFE). The aim was to prospectively investigate whether this technique
is safe and reproducible. We assessed the degree of reduction, functional
outcome, rate of complications, radiological changes and range of
movement in the hip. There were 28 patients with a mean follow-up
of 38.6 months (24 to 84). The lateral slip angle was corrected
by a mean of 50.9° (95% confidence interval 44.3 to 57.5). The mean
modified Harris hip score at the final follow-up was 89.1 ( Cite this article:
We examined the relationship between the size
of the femoral cam in femoroacetabular impingement (FAI) and acetabular
pathomorphology to establish if pincer impingement exists in patients
with a femoral cam. CT scans of 37 symptomatic impinging hips with a femoral cam
were analysed in a three-dimensional study and were compared with
34 normal hips. The inclination and version of the acetabulum as
well as the acetabular rim angle and the bony acetabular coverage
were calculated. These measurements were correlated with the size
and shape of the femoral cams. While the size of the femoral cam varied characteristically,
the acetabular morphology of the two groups was similar in terms
of version (normal mean 23° ( We found no correlation between acetabular morphology and the
severity of cam lesion and no evidence of either global or focal
over-coverage to support the diagnosis of ‘mixed’ FAI. The femoral
cam may provoke edge loading but removal of any acetabular bearing
surface when treating cam FAI might induce accelerated wear. Cite this article:
The purpose of this study was to evaluate the
risk of late displacement after the treatment of distal radial fractures with
a locking volar plate, and to investigate the clinical and radiological
factors that might correlate with re-displacement. From March 2007
to October 2009, 120 of an original cohort of 132 female patients
with unstable fractures of the distal radius were treated with a
volar locking plate, and were studied over a follow-up period of
six months. In the immediate post-operative and final follow-up
radiographs, late displacement was evaluated as judged by ulnar
variance, radial inclination, and dorsal angulation. We also analysed
the correlation of a variety of clinical and radiological factors
with re-displacement. Ulnar variance was significantly overcorrected
(p <
0.001) while radial inclination and dorsal angulation were
undercorrected when compared statistically (p <
0.001) with the unaffected
side in the immediate post-operative stage. During follow-up, radial
shortening and dorsal angulation progressed statistically, but none
had a value beyond the acceptable range. Bone mineral density measured
at the proximal femur and the position of the screws in the subchondral
region, correlated with slight progressive radial shortening, which
was not clinically relevant. Volar locking plating of distal radial fractures is a reliable
form of treatment without substantial late displacement. Cite this article:
Pigmented villonodular synovitis (PVNS) is a
rare benign disease of the synovium of joints and tendon sheaths, which
may be locally aggressive. We present 18 patients with diffuse-type
PVNS of the foot and ankle followed for a mean of 5.1 years (2 to
11.8). There were seven men and 11 women, with a mean age of 42
years (18 to 73). A total of 13 patients underwent open or arthroscopic
synovectomy, without post-operative radiotherapy. One had surgery
at the referring unit before presentation with residual tibiotalar
PVNS. The four patients who were managed non-operatively remain
symptomatically controlled and under clinical and radiological surveillance.
At final follow-up the mean Musculoskeletal Tumour Society score
was 93.8% (95% confidence interval (CI) 85 to 100), the mean Toronto
Extremity Salvage Score was 92 (95% CI 82 to 100) and the mean American
Academy of Orthopaedic Surgeons foot and ankle score was 89 (95%
CI 79 to 100). The lesion in the patient with residual PVNS resolved radiologically
without further intervention six years after surgery. Targeted synovectomy
without adjuvant radiotherapy can result in excellent outcomes,
without recurrence. Asymptomatic patients can be successfully managed
non-operatively. This is the first series to report clinical outcome
scores for patients with diffuse-type PVNS of the foot and ankle. Cite this article:
The systemic use of steroids and habitual alcohol
intake are two major causative factors in the development of idiopathic
osteonecrosis of the femoral head (ONFH). To examine any interaction
between oral corticosteroid use and alcohol intake on the risk of
ONFH, we conducted a hospital-based case-control study of 71 cases
with ONFH (mean age 45 years (20 to 79)) and 227 matched controls
(mean age 47 years (18 to 79)). Alcohol intake was positively associated
with ONFH among all subjects: the adjusted odds ratio (OR) of subjects
with ≥ 3032 drink-years was 3.93 (95% confidence interval (CI) 1.18
to 13.1) compared with never-drinkers. When stratified by steroid use,
the OR of such drinkers was 11.1 (95% CI 1.30 to 95.5) among those
who had never used steroids, but 1.10 (95% CI 0.21 to 4.79) among
those who had. When we assessed any interaction based on a two-by-two
table of alcohol and steroid use, the OR of those non-drinkers who
did use steroids was markedly elevated (OR 31.5) compared with users
of neither. However, no further increase in OR was noted for the
effect of using both (OR 31.6). We detected neither a multiplicative
nor an additive interaction (p for multiplicative interaction 0.19;
synergy index 0.95), suggesting that the added effect of alcohol
may be trivial compared with the overwhelming effect of steroids
in the development of ONFH. Cite this article:
The incidence of acute and chronic conditions
of the tendo Achillis appear to be increasing. Causation is multifactorial
but the role of inherited genetic elements and the influence of
environmental factors altering gene expression are increasingly
being recognised. Certain individuals’ tendons carry specific variations
of genetic sequence that may make them more susceptible to injury.
Alterations in the structure or relative amounts of the components
of tendon and fine control of activity within the extracellular
matrix affect the response of the tendon to loading with failure
in certain cases. This review summarises present knowledge of the influence of
genetic patterns on the pathology of the tendo Achillis, with a
focus on the possible biological mechanisms by which genetic factors
are involved in the aetiology of tendon pathology. Finally, we assess
potential future developments with both the opportunities and risks
that they may carry. Cite this article:
To review the current best surgical practice and detail a multi-disciplinary
approach that could further reduce joint replacement infection. Review of relevant literature indexed in PubMed.Objectives
Methods
The aim of this study was to examine the loading
of the other joints of the lower limb in patients with unilateral osteoarthritis
(OA) of the knee. We recruited 20 patients with no other symptoms
or deformity in the lower limbs from a consecutive cohort of patients
awaiting knee replacement. Gait analysis and electromyographic recordings were
performed to determine moments at both knees and hips, and contraction
patterns in the medial and lateral quadriceps and hamstrings bilaterally.
The speed of gait was reduced in the group with OA compared with
the controls, but there were only minor differences in stance times
between the limbs. Patients with OA of the knee had significant
increases in adduction moment impulse at both knees and the contralateral
hip (adjusted p-values: affected knee: p <
0.01, unaffected knee
p = 0.048, contralateral hip p = 0.03), and significantly increased
muscular co-contraction bilaterally compared with controls (all
comparisons for co-contraction, p <
0.01). The other major weight-bearing joints are at risk from abnormal
biomechanics in patients with unilateral OA of the knee. Cite this article:
Although the Western Ontario and McMaster Universities
(WOMAC) osteoarthritis index was originally developed for the assessment
of non-operative treatment, it is commonly used to evaluate patients
undergoing either total hip (THR) or total knee replacement (TKR).
We assessed the importance of the 17 WOMAC function items from the perspective
of 1198 patients who underwent either THR (n = 704) or TKR (n =
494) in order to develop joint-specific short forms. After these
patients were administered the WOMAC pre-operatively and at three,
six, 12 and 24 months’ follow-up, they were asked to nominate an
item of the function scale that was most important to them. The
items chosen were significantly different between patients undergoing
THR and those undergoing TKR (p <
0.001), and there was a shift
in the priorities after surgery in both groups. Setting a threshold
for prioritised items of ≥ 5% across all follow-up, eight items
were selected for THR and seven for TKR, of which six items were
common to both. The items comprising specific WOMAC-THR and TKR
function short forms were found to be equally responsive compared
with the original WOMAC function form. Cite this article:
The Ponseti and French taping methods have reduced
the incidence of major surgery in congenital idiopathic clubfoot
but incur a significant burden of care, including heel-cord tenotomy.
We developed a non-operative regime to reduce treatment intensity
without affecting outcome. We treated 402 primary idiopathic clubfeet
in patients aged <
three months who presented between September
1991 and August 2008. Their Harrold and Walker grades were 6.0%
mild, 25.6% moderate and 68.4% severe. All underwent a dynamic outpatient
taping regime over five weeks based on Ponseti manipulation, modified
Jones strapping and home exercises. Feet with residual equinus (six
feet, 1.5%) or relapse within six months (83 feet, 20.9%) underwent
one to three additional tapings. Correction was maintained with
below-knee splints, exercises and shoes. The clinical outcome at
three years of age (385 feet, 95.8% follow-up) showed that taping
alone corrected 357 feet (92.7%, ‘good’). Late relapses or failure
of taping required limited posterior release in 20 feet (5.2%, ‘fair’)
or posteromedial release in eight feet (2.1%, ‘poor’). The long-term
(>
10 years) outcomes in 44 feet (23.8% follow-up) were assessed
by the Laaveg–Ponseti method as excellent (23 feet, 52.3%), good
(17 feet, 38.6%), fair (three feet, 6.8%) or poor (one foot, 2.3%).
These compare favourably with published long-term results of the
Ponseti or French methods. This dynamic taping regime is a simple
non-operative method that delivers improved medium-term and promising
long-term results. Cite this article:
The FRCS (Tr &
Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into four sections comprising Basic Science, Adult Pathology, Hands and Children’s Orthopaedics and Trauma. The Clinical Examination section is divided into Upper and Lower limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.
Noise generation has been reported with ceramic-on-ceramic
articulations in total hip replacement (THR). This study evaluated
208 consecutive Delta Motion THRs at a mean follow-up of 21 months
(12 to 35). There were 141 women and 67 men with a mean age of 59
years (22 to 84). Patients were reviewed clinically and radiologically,
and the incidence of noise was determined using a newly described
assessment method. Noise production was examined against range of
movement, ligamentous laxity, patient-reported outcome scores, activity
level and orientation of the acetabular component. There were 143
silent hips (69%), 22 (11%) with noises other than squeaking, 17
(8%) with unreproducible squeaking and 26 (13%) with reproducible
squeaking. Hips with reproducible squeaking had a greater mean range
of movement (p <
0.001) and mean ligament laxity (p = 0.004), smaller
median head size (p = 0.01) and decreased mean acetabular component
inclination (p = 0.02) and anteversion angle (p = 0.02) compared
with the other groups. There was no relationship between squeaking
and age (p = 0.13), height (p = 0.263), weight (p = 0.333), body
mass index (p = 0.643), gender (p = 0.07) or patient outcome score
(p = 0.422). There were no revisions during follow-up. Despite the
surprisingly high incidence of squeaking, all patients remain satisfied
with their hip replacement. Cite this article:
The February 2013 Hip &
Pelvis Roundup360 looks at: amazing alumina; dual mobility; white cells and periprosthetic infection; cartilage and impingement surgery; acetabulum in combination; cementless ceramic prosthesis; metal-on-metal hips; and whether size matters in failure.
Van Nes rotationplasty may be used for patients
with congenital proximal focal femoral deficiency (PFFD). The lower
limb is rotated to use the ankle and foot as a functional knee joint
within a prosthesis. A small series of cases was investigated to
determine the long-term outcome. At a mean of 21.5 years (11 to
45) after their rotationplasty, a total of 12 prosthetic patients
completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris
hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires,
as did 12 age- and gender-matched normal control participants. A
physical examination and gait analysis, computerised dynamic posturography
(CDP), and timed ‘Up &
Go’ testing was also completed. Wilcoxon
Signed rank test was used to compare each PFFD patient with a matched
control participant with false discovery rate of 5%. There were no differences between the groups in overall health
and well-being on the SF-36. Significant differences were seen in
gait parameters in the PFFD group. Using CDP, the PFFD group had
reduced symmetry in stance, and reduced end point and maximum excursions. Patients who had undergone Van Nes rotationplasty had a high
level of function and quality of life at long-term follow-up, but
presented with significant differences in gait and posture compared
with the control group. 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.
Recent studies have shown that modulating inflammation-related
lipid signalling after a bone fracture can accelerate healing in
animal models. Specifically, decreasing 5-lipoxygenase (5-LO) activity
during fracture healing increases cyclooxygenase-2 (COX-2) expression
in the fracture callus, accelerates chondrogenesis and decreases
healing time. In this study, we test the hypothesis that 5-LO inhibition
will increase direct osteogenesis. Bilateral, unicortical femoral defects were used in rats to measure
the effects of local 5-LO inhibition on direct osteogenesis. The
defect sites were filled with a polycaprolactone (PCL) scaffold
containing 5-LO inhibitor (A-79175) at three dose levels, scaffold
with drug carrier, or scaffold only. Drug release was assessed Objectives
Methods
The February 2013 Wrist &
Hand Roundup360 looks at: to splint or not to splint; salvage of the unsalvageable; a close shave for malunions; a classic approach to malunion; diabetic carpal tunnel; capsulodesis; a wrist from a fibula; thumb-based osteoarthritis - a further opinion from the Editor-in-Chief.
Recent guidance recommends the use of a well-proven
cemented femoral stem for hemiarthroplasty in the management of
fractures of the femoral neck, and the Exeter Trauma Stem (ETS)
has been suggested as an example of such an implant. The design
of this stem was based on the well-proven Exeter Total Hip Replacement
stem (ETHRS). This study assessed the surface finish of the ETS
in comparison with the ETHRS. Two ETSs and two ETHRSs were examined
using a profilometer with a precision of 1 nm and compared with
an explanted Exeter Matt stem. The mean roughness average (RA) of
the ETSs was approximately ten times higher than that of the ETHRSs (0.235 μm
(0.095 to 0.452) Cite this article:
Stem cells are a key component of regenerative medicine strategies. Particular areas of musculoskeletal application include cartilage and bone regeneration in arthritis and trauma. There are several types of stem cell and this article will focus on the adult derived cells. The review includes current issues and future developments.
Local recurrence along the biopsy track is a
known complication of percutaneous needle biopsy of malignant musculoskeletal
tumours. In order to completely excise the track with the tumour
its identification is essential, but this becomes increasingly difficult
over time. In an initial prospective study, 22 of 45 patients (48.8%)
identified over a three-month period, treated by resection of a
musculoskeletal tumour, had an unidentifiable biopsy site at operation,
with identification statistically more difficult after 50 days.
We therefore introduced the practice of marking the biopsy site
with India ink. In all 55 patients undergoing this procedure, the
biopsy track was identified pre-operatively (100%); this difference
was statistically significant. We recommend this technique as a
safe, easy and accurate means of ensuring adequate excision of the
biopsy track.
Cite this article:
Several authors have suggested that the final
five weeks of gestation are a critical period for the development
of the hip. In order to test the hypothesis that gestational age
at birth may influence the development of the hip joint, we analysed
the sonographic findings in 1992 hips (in 996 term newborns) with
no risk factor for developmental dysplasia of the hip. The 996 infants
were born at a mean gestational age of 39 weeks (37 to 41). The mean bony roof angle (α), cartilage roof angle (β) and the
distribution of the type of hip were compared between the 37th,
38th, 39th, 40th and 41st birth week groups. There was a significant
difference in the distribution of type of hip between the different
birth week groups (p <
0.001), but no significant difference
between the α angles of all groups (p = 0.32). There was no correlation
between birth week and roof angle (p = 0.407 and p = 0.291, respectively)
and no significant correlation between birth weight and roof angle
(p = 0.735 and p = 0.132, respectively). The maturity of the infant hip, as assessed sonographically,
does not appear to be affected by gestational age, and the fetal
development of the acetabular roof appears to plateau from 37 weeks. Cite this article:
Most fractures of the radial head are stable
undisplaced or minimally displaced partial fractures without an associated
fracture of the elbow or forearm or ligament injury, where stiffness
following non-operative management is the primary concern. Displaced
unstable fractures of the radial head are usually associated with other
fractures or ligament injuries, and restoration of radiocapitellar
contact by reconstruction or prosthetic replacement of the fractured
head is necessary to prevent subluxation or dislocation of the elbow
and forearm. In fractures with three or fewer fragments (two articular
fragments and the neck) and little or no metaphyseal comminution,
open reduction and internal fixation may give good results. However,
fragmented unstable fractures of the radial head are prone to early
failure of fixation and nonunion when fixed. Excision of the radial
head is associated with good long-term results, but in patients
with instability of the elbow or forearm, prosthetic replacement
is preferred. This review considers the characteristics of stable and unstable
fractures of the radial head, as well as discussing the debatable
aspects of management, in light of the current best evidence. Cite this article:
The February 2013 Knee Roundup360 looks at: mobile-bearing TKRs; arthroscopic ACL reconstruction; the use of chondrocytes for osteochondral defects; ACL reconstruction and the return to pivoting sports; ACLs and the MOON study; the benefit of knee navigation; and trabecular metal.
The number of surgical procedures performed each year to treat
femoroacetabular impingement (FAI) continues to rise. Although there
is evidence that surgery can improve symptoms in the short-term,
there is no evidence that it slows the development of osteoarthritis
(OA). We performed a feasibility study to determine whether patient
and surgeon opinion was permissive for a Randomised Controlled Trial
(RCT) comparing operative with non-operative treatment for FAI. Surgeon opinion was obtained using validated questionnaires at
a Specialist Hip Meeting (n = 61, 30 of whom stated that they routinely
performed FAI surgery) and patient opinion was obtained from clinical
patients with a new diagnosis of FAI (n = 31).Objectives
Methods
We evaluated the efficacy of Cite this article:
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:
In Norway total joint replacement after hip dysplasia
is reported more commonly than in neighbouring countries, implying
a higher prevalence of the condition. We report on the prevalence
of radiological features associated with hip dysplasia in a population
of
2081 19-year-old Norwegians. The radiological measurements used
to define hip dysplasia were Wiberg’s centre-edge (CE) angle at
thresholds of <
20° and <
25°, femoral head extrusion index
<
75%, Sharp’s angle >
45°, an acetabular depth to width ratio
<
250 and the sourcil shape assessed subjectively. The whole
cohort underwent clinical examination of their range of hip movement,
body mass index (BMI), and Beighton hypermobility score, and were
asked to complete the EuroQol (EQ-5D) and Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC). The prevalence of hip
dysplasia in the cohort varied from 1.7% to 20% depending on the
radiological marker used. A Wiberg’s CE angle <
20° was seen
in 3.3% of the cohort: 4.3% in women and 2.4% in men. We found no
association between subjects with multiple radiological signs indicative
of dysplasia and BMI, Beighton score, EQ-5D or WOMAC. Although there
appears to be a high prevalence of hip dysplasia among 19-year-old
Norwegians, this is dependent on the radiological parameters applied. Cite this article:
Like athletes, musicians are vulnerable to musculoskeletal
injuries that can be career ending or have a severe negative financial
impact. All ages are affected, with a peak incidence in the third
and fourth decades. Women are slightly more likely to be affected
than men. It is incumbent upon orthopaedic surgeons to be able to
complete a thorough physical assessment, be aware of the risk factors
associated with musculoskeletal symptoms in musicians, and have
a detailed knowledge of the specific syndromes they suffer and their
appropriate treatment. In this paper we review the common hand injuries that afflict
musicians and discuss their treatment. Cite this article:
The February 2013 Oncology Roundup360 looks at: proximal fibular tumours; radiotherapy-induced chondrosarcoma; mega-prosthesis; CRP predictions of sarcoma survival; predicting survival in metastatic disease; MRI for recurrence in osteoid osteoma; and a sarcoma refresher
Modern athletes are constantly susceptible to performance-threatening injury as they push their bodies to greater limits and endure higher physical stresses. Loss of performance and training time can adversely and permanently affect a sportsperson’s career. Now more than ever with advancing medical technology the answer may lie in biologic therapy. We have been using peripheral blood stem cells (PBSC) clinically and have been able to demonstrate that stem cells differentiate into target cells to enable regenerative repair. The potential of this technique as a regenerative agent can be seen in three broad applications: 1) articular cartilage, 2) bone and 3) soft tissue. This article highlights the successful cases, among many, in all three of these applications.
The February 2013 Children’s orthopaedics Roundup360 looks at: ABC treated with suction and curettage; peri-acetabular osteotomy; cast index; Perthes’ disease associated with accidental injury; brachial plexus birth palsy; MRI assessment of DDH; total meniscectomy; and paediatric septic arthritis.
We analysed retrospectively the risk factors
leading to femoral overgrowth after flexible intramedullary nailing
in 43 children (mean age 7.1 years (3.6 to 12.0)) with fractures
of the shaft of the femur. We reviewed their demographic data, mechanism
of injury, associated injuries, the type and location of the fractures,
the nail–canal diameter (NCD) ratios and femoral overgrowth at a
mean follow-up of 40.7 months (25.2 to 92.7). At that time, the
children were divided into two groups, those with femoral overgrowth
of <
1 cm (Group 1), and those with overgrowth of ≥ 1 cm (Group
2). The mean femoral overgrowth of all patients was 0.6 cm at final
follow-up. Overgrowth of ≥ 1 cm was noted in 11 children (25.6%).
The NCD ratio was significantly lower in Group 2 than in Group 1,
with an odds ratio of 30.0 (p = 0.003). We believe that a low NCD ratio is an indicator of an unstable
configuration with flexible intramedullary nailing, and have identified
an association between a low NCD ratio and femoral overgrowth resulting
in leg-length discrepancy after flexible intramedullary nailing
in paediatric femoral shaft fractures. Cite this article:
The Cementless Oxford Unicompartmental Knee Replacement
(OUKR) was developed to address problems related to cementation,
and has been demonstrated in a randomised study to have similar
clinical outcomes with fewer radiolucencies than observed with the
cemented device. However, before its widespread use it is necessary
to clarify contraindications and assess the complications. This
requires a larger study than any previously published. We present a prospective multicentre series of 1000 cementless
OUKRs in 881 patients at a minimum follow-up of one year. All patients
had radiological assessment aligned to the bone–implant interfaces
and clinical scores. Analysis was performed at a mean of 38.2 months
(19 to 88) following surgery. A total of 17 patients died (comprising
19 knees (1.9%)), none as a result of surgery; there were no tibial
or femoral loosenings. A total of 19 knees (1.9%) had significant
implant-related complications or required revision. Implant survival
at six years was 97.2%, and there was a partial radiolucency at
the bone–implant interface in 72 knees (8.9%), with no complete radiolucencies.
There was no significant increase in complication rate compared
with cemented fixation (p = 0.87), and no specific contraindications
to cementless fixation were identified. Cementless OUKR appears to be safe and reproducible in patients
with end-stage anteromedial osteoarthritis of the knee, with radiological
evidence of improved fixation compared with previous reports using
cemented fixation. Cite this article:
The February 2013 Shoulder &
Elbow Roundup360 looks at: whether we should replace fractured shoulders; the limited evidence for shoulder fractures; cuffs and early physio; matrix proteins and cuff tears; long-term SLAP tear outcomes; suture anchors; recurrent Bankart repairs; and acromial morphology and calcific tendonitis.
The revised Tokuhashi, Tomita and modified Bauer
scores are commonly used to make difficult decisions in the management
of patients presenting with spinal metastases. A prospective cohort
study of 199 consecutive patients presenting with spinal metastases,
treated with either surgery and/or radiotherapy, was used to compare
the three systems. Cox regression, Nagelkerke’s R2 and
Harrell’s concordance were used to compare the systems and find their
best predictive items. The three systems were equally good in terms
of overall prognostic performance. Their most predictive items were
used to develop the Oswestry Spinal Risk Index (OSRI), which has
a similar concordance, but a larger coefficient of determination
than any of these three scores. A bootstrap procedure was used to
internally validate this score and determine its prediction optimism. The OSRI is a simple summation of two elements: primary tumour
pathology (PTP) and general condition (GC): OSRI = PTP + (2 – GC). This simple score can predict life expectancy accurately in patients
presenting with spinal metastases. It will be helpful in making
difficult clinical decisions without the delay of extensive investigations. 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
We reviewed the long-term radiological outcome,
complications and revision operations in 19 children with quadriplegic
cerebral palsy and hip dysplasia who underwent combined peri-iliac
osteotomy and femoral varus derotation osteotomy. They had a mean
age of 7.5 years (1.6 to 10.9) and comprised 22 hip dislocations
and subluxations. We also studied the outcome for the contralateral
hip. At a mean follow-up of 11.7 years (10 to 15.1) the Melbourne
cerebral palsy (CP) hip classification was grade 2 in 16 hips, grade
3 in five, and grade 5 in one. There were five complications seen
in four hips (21%, four patients), including one dislocation, one
subluxation, one coxa vara with adduction deformity, one subtrochanteric
fracture and one infection. A recurrent soft-tissue contracture occurred
in five hips and ten required revision surgery. In pre-adolescent children with quadriplegic cerebral palsy good
long-term outcomes can be achieved after reconstruction of the hip;
regular follow-up is required.
Cite this article: