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.
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:
We examined the association of graft type with
the risk of early revision of primary anterior cruciate ligament reconstruction
(ACLR) in a community-based sample. A retrospective analysis of
a cohort of 9817 ACLRs recorded in an ACLR Registry was performed.
Patients were included if they underwent primary ACLR with bone–patellar tendon–bone
autograft, hamstring tendon autograft or allograft tissue. Aseptic
failure was the main endpoint of the study. After adjusting for
age, gender, ethnicity, and body mass index, allografts had a
3.02 times (95% confidence interval (CI) 1.93 to 4.72) higher risk
of aseptic revision than bone–patellar tendon–bone autografts (p
<
0.001). Hamstring tendon autografts had a 1.82 times (95% CI
1.10 to 3.00) higher risk of revision compared with bone–patellar
tendon–bone autografts (p = 0.019). For each year increase in age,
the risk of revision decreased by 7% (95% CI 5 to 9). In gender-specific
analyses a 2.26 times (95% CI 1.15 to 4.44) increased risk of hamstring
tendon autograft revision in females was observed compared with
bone–patellar tendon–bone autograft. We conclude that allograft
tissue, hamstring tendon autografts, and younger age may all increase
the risk of early revision surgery after ACLR. 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.
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.
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 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.
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:
We
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 sternoclavicular joint (SCJ) is a pivotal
articulation in the linked system of the upper limb girdle, providing
load-bearing in compression while resisting displacement in tension
or distraction at the manubrium sterni. The SCJ and acromioclavicular
joint (ACJ) both have a small surface area of contact protected
by an intra-articular fibrocartilaginous disc and are supported
by strong extrinsic and intrinsic capsular ligaments. The function
of load-sharing in the upper limb by bulky periscapular and thoracobrachial
muscles is extremely important to the longevity of both joints.
Ligamentous and capsular laxity changes with age, exposing both
joints to greater strain, which may explain the rising incidence
of arthritis in both with age. The incidence of arthritis in the
SCJ is less than that in the ACJ, suggesting that the extrinsic
ligaments of the SCJ provide greater stability than the coracoclavicular
ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish
from medial clavicular physeal or metaphyseal fracture-separation:
cross-sectional imaging is often required. The distinction is important
because the treatment options and outcomes of treatment are dissimilar,
whereas the treatment and outcomes of ACJ separation and fracture
of the lateral clavicle can be similar. Proper recognition and treatment
of traumatic instability is vital as these injuries may be life-threatening.
Instability of the SCJ does not always require surgical intervention.
An accurate diagnosis is required before surgery can be considered,
and we recommend the use of the Stanmore instability triangle. Most
poor outcomes result from a failure to recognise the underlying
pathology. There is a natural reluctance for orthopaedic surgeons to operate
in this area owing to unfamiliarity with, and the close proximity
of, the related vascular structures, but the interposed sternohyoid
and sternothyroid muscles are rarely injured and provide a clear
boundary to the medial retroclavicular space, as well as an anatomical
barrier to unsafe intervention. This review presents current concepts of instability of the SCJ,
describes the relevant surgical anatomy, provides a framework for
diagnosis and management, including physiotherapy, and discusses
the technical challenges of operative intervention. Cite this article:
The popularity of cementless total hip replacement
(THR) has surpassed cemented THR in England and Wales. This retrospective
cohort study records survival time to revision following primary
cementless THR with the most common combination (accounting for
almost a third of all cementless THRs), and explores risk factors independently
associated with failure, using data from the National Joint Registry
for England and Wales. Patients with osteoarthritis who had a DePuy
Corail/Pinnacle THR implanted between the establishment of the registry
in 2003 and 31 December 2010 were included within analyses. There
were 35 386 procedures. Cox proportional hazard models were used
to analyse the extent to which the risk of revision was related
to patient, surgeon and implant covariates. The overall rate of
revision at five years was 2.4% (99% confidence interval 2.02 to
2.79). In the final adjusted model, we found that the risk of revision
was significantly higher in patients receiving metal-on-metal (MoM:
hazard ratio (HR) 1.93, p <
0.001) and ceramic-on-ceramic bearings
(CoC: HR 1.55, p = 0.003) compared with the best performing bearing
(metal-on-polyethylene). The risk of revision was also greater for
smaller femoral stems (sizes 8 to 10: HR 1.82, p <
0.001) compared
with mid-range sizes. In a secondary analysis of only patients where body
mass index (BMI) data were available (n = 17 166), BMI ≥ 30 kg/m2 significantly
increased the risk of revision (HR 1.55, p = 0.002). The influence
of the bearing on the risk of revision remained significant (MoM:
HR 2.19, p <
0.001; CoC: HR 2.09,
p = 0.001). The risk of revision was independent of age, gender,
head size and offset, shell, liner and stem type, and surgeon characteristics. We found significant differences in failure between bearing surfaces
and femoral stem size after adjustment for a range of covariates
in a large cohort of single-brand cementless THRs. In this study
of procedures performed since 2003, hard bearings had significantly
higher rates of revision, but we found no evidence that head size
had an effect. Patient characteristics, such as BMI and American
Society of Anesthesiologists grade, also influence the survival
of cementless components. Cite this article:
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 October 2012 Hip &
Pelvis Roundup360 looks at: diagnosing the infected hip replacement; whether tranexamic acid has a low complication rate; the relationship between poor cementing technique and early failure of resurfacing; debridement and retention for the infected replacement; triple-tapered stems and bone mineral density; how early discharge can be bad for your sleep; an updated QFracture algorithm to predict the risk of an osteoporotic fracture; and local infiltration analgesia and total hip replacement.
In 2006, approximately 1.3 million peer-reviewed scientific articles were published, aided by a large rise in the number of available scientific journals from 16 000 in 2001 to 23 750 by 2006. Is this evidence of an explosion in scientific knowledge or just the accumulation of wasteful publications and junk science? Data show that only 45% of the articles published in the 4500 top scientific journals are cited within the first five years of publication, a figure that is dropping steadily. Only 42% receive more than one citation. For better or for worse, “Publish or Perish” appears here to stay as the number of published papers becomes the basis for selection to academic positions, for tenure and promotions, a criterion for the awarding of grants and also the source of funding for salaries. The high pressure to publish has, however, ushered in an era where scientists are increasingly conducting and publishing data from research performed with ‘questionable research practices’ or even committing outright fraud. The few cases which are reported will in fact be the tip of an iceberg and the scientific community needs to be vigilant against this corruption of science.
The August 2012 Research Roundup360 looks at: PRP and chondrogenic differentiation; basic fibroblast growth factor; whether glucosamine works; randomised trials; ossification of the ligamentum flavum; treadmill running; inhibiting BMP antagonists; and whether NSAIDs delay union after all.
The August 2012 Trauma Roundup360 looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China.
The use of pulsed electromagnetic fields (PEMF)
to stimulate bone growth has been recommended as an alternative to
the surgical treatment of ununited scaphoid fractures, but has never
been examined in acute fractures. We hypothesised that the use of
PEMF in acute scaphoid fractures would accelerate the time to union
by 30% in a randomised, double-blind, placebo-controlled, multicentre
trial. A total of 53 patients in three different medical centres
with a unilateral undisplaced acute scaphoid fracture were randomly
assigned to receive either treatment with PEMF (n = 24) or a placebo
(n = 29). The clinical and radiological outcomes were assessed at
four, six, nine, 12, 24 and 52 weeks. A log-rank analysis showed that neither time to clinical and
radiological union nor the functional outcome differed significantly
between the groups. The clinical assessment of union indicated that
at six weeks tenderness in the anatomic snuffbox (p = 0.03) as well
as tenderness on longitudinal compression of the scaphoid (p = 0.008) differed
significantly in favour of the placebo group. We conclude that stimulation of bone growth by PEMF has no additional
value in the conservative treatment of acute scaphoid fractures.