The aim of this study was to evaluate the risk
factors for dislocation of the bearing after a mobile-bearing Oxford medial
unicompartmental knee replacement (UKR) and to test the hypothesis
that surgical factors, as measured from post-operative radiographs,
are associated with its dislocation From a total of 480 UKRs performed between 2001 and 2012, in
391 patients with a mean age of 66.5 years (45 to 82) (316 female,
75 male), we identified 17 UKRs where bearing dislocation occurred.
The post-operative radiological measurements of the 17 UKRs and
51 matched controls were analysed using conditional logistic regression analysis.
The post-operative radiological measurements included post-operative
change in limb alignment, the position of the femoral and tibial
components, the resection depth of the proximal tibia, and the femoral component-posterior
condyle classification. We concluded that a post-operative decrease in the posterior
tibial slope relative to the pre-operative value was the only significant
determinant of dislocation of the bearing after medial Oxford UKR
(odds ratio 1.881; 95% confidence interval 1.272 to 2.779). A post-operative
posterior tibial slope <
8.45° and a difference between the pre-operative
and post-operative posterior tibial slope of >
2.19° may increase
the risk of dislocation. Cite this article:
We report our experience of using a computer
navigation system to aid resection of malignant musculoskeletal tumours
of the pelvis and limbs and, where appropriate, their subsequent
reconstruction. We also highlight circumstances in which navigation
should be used with caution. We resected a musculoskeletal tumour from 18 patients (15 male,
three female, mean age of 30 years (13 to 75) using commercially
available computer navigation software (Orthomap 3D) and assessed
its impact on the accuracy of our surgery. Of nine pelvic tumours,
three had a biological reconstruction with extracorporeal irradiation,
four underwent endoprosthetic replacement (EPR) and two required
no bony reconstruction. There were eight tumours of the bones of
the limbs. Four diaphyseal tumours underwent biological reconstruction.
Two patients with a sarcoma of the proximal femur and two with a
sarcoma of the proximal humerus underwent extra-articular resection
and, where appropriate, EPR. One soft-tissue sarcoma of the adductor
compartment which involved the femur was resected and reconstructed
using an EPR. Computer navigation was used to aid reconstruction
in eight patients. Histological examination of the resected specimens revealed tumour-free
margins in all patients. Post-operative radiographs and CT showed
that the resection and reconstruction had been carried out as planned
in all patients where navigation was used. In two patients, computer
navigation had to be abandoned and the operation was completed under
CT and radiological control. The use of computer navigation in musculoskeletal oncology allows
accurate identification of the local anatomy and can define the
extent of the tumour and proposed resection margins. Furthermore,
it helps in reconstruction of limb length, rotation and overall
alignment after resection of an appendicular tumour. Cite this article:
The aim of this study was to evaluate the feasibility
of using the intact S1 nerve root as a donor nerve to repair an avulsion
of the contralateral lumbosacral plexus. Two cohorts of patients
were recruited. In cohort 1, the L4–S4 nerve roots of 15 patients
with a unilateral fracture of the sacrum and sacral nerve injury
were stimulated during surgery to establish the precise functional
distribution of the S1 nerve root and its proportional contribution
to individual muscles. In cohort 2, the contralateral uninjured
S1 nerve root of six patients with a unilateral lumbosacral plexus
avulsion was transected extradurally and used with a 25 cm segment
of the common peroneal nerve from the injured leg to reconstruct
the avulsed plexus. The results from cohort 1 showed that the innervation of S1 in
each muscle can be compensated for by L4, L5, S2 and S3. Numbness
in the toes and a reduction in strength were found after surgery
in cohort 2, but these symptoms gradually disappeared and strength
recovered. The results of electrophysiological studies of the donor
limb were generally normal. Severing the S1 nerve root does not appear to damage the healthy
limb as far as clinical assessment and electrophysiological testing
can determine. Consequently, the S1 nerve can be considered to be
a suitable donor nerve for reconstruction of an avulsed contralateral
lumbosacral plexus. Cite this article:
The aim of this study was to perform a cost–utility
analysis of total hip (THR) and knee replacement (TKR). Arthritis is
a disabling condition that leads to long-term deterioration in quality
of life. Total joint replacement, despite being one of the greatest
advances in medicine of the modern era, has recently come under
scrutiny. The National Health Service (NHS) has competing demands,
and resource allocation is challenging in times of economic restraint. Patients
who underwent THR (n = 348) or TKR (n = 323) between January and
July 2010 in one Scottish region were entered into a prospective
arthroplasty database. A health–utility score was derived from the
EuroQol (EQ-5D) score pre-operatively and at one year, and was combined
with individual life expectancy to derive the quality-adjusted life years
(QALYs) gained. Two-way analysis of variance was used to compare
QALYs gained between procedures, while controlling for baseline
differences. The number of QALYs gained was higher after THR than
after TKR (6.5 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 aims of this study were to evaluate the incidence
of local argyria in patients with silver-coated megaprostheses and
to identify a possible association between argyria and elevated
levels of silver both locally and in the blood. Between 2004 and
2011, 32 megaprostheses with silver coatings were implanted in 20
female and 12 male patients following revision arthroplasty for
infection or resection of a malignant tumour, and the levels of
silver locally in drains and seromas and in the blood were determined.
The mean age of the patients was 46 years (10 to 81); one patient
died in the immediate post-operative period and was excluded. Seven patients (23%) developed local argyria after a median of
25.7 months (interquartile range 2 to 44.5). Patients with and without
local argyria had comparable levels of silver in the blood and aspiration
fluids. The length of the implant did not influence the development
of local argyria. Patients with clinical evidence of local argyria
had no neurological symptoms and no evidence of renal or hepatic
failure. Thus, we conclude that the short-term surveillance of blood
silver levels in these patients is not required. Cite this article:
We present the validation of a translation into
Danish of the Oxford ankle foot questionnaire (OxAFQ). We followed the
Isis Pros guidelines for translation and pilot-tested the questionnaire
on ten children and their parents. Following modifications we tested
the validity of the final questionnaire on 82 children (36 boys
and 45 girls) with a mean age of 11.7 years (5.5 to 16.0) and their
parents. We tested the reliability (repeatability (test–retest),
child–parent agreement, internal consistency), feasibility (response
rate, time to completion, floor and ceiling effects) and construct
validity. The generic child health questionnaire was used for comparison.
We found good internal consistency for the physical and the school
and play domains, but lower internal consistency for the emotional domain.
Overall, good repeatability was found within children and parents
as well as agreement between children and parents. The OxAFQ was
fast and easy to complete, but we observed a tendency towards ceiling
effects in the school and play and emotional domains. To our knowledge
this is the first independent validation of the OxAFQ in any language.
We found it valid and feasible for use in the clinic to assess the
impact on children’s lives of foot and/or ankle disorders. It is
a valuable research tool. Cite this article:
We describe 13 patients with cerebral palsy and
lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior
spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve
sitting posture and relieve pain. The mean follow-up was 3.3 years
(2.2 to 6.2). The mean pre-operative lumbar lordosis was 108° (80
to 150°) and was corrected to 62° (43° to
85°); the mean thoracic kyphosis from 17° (-23° to
35°) to 47° (25° to 65°);
the mean scoliosis from 82° (0° to 125°)
to 22° (0° to 40°); the mean pelvic
obliquity from 21° (0° to 38°)
to 3° (0° to 15°); the mean sacral
slope from 79° (54° to 90°) to
50° (31° to 66°). The mean pre-operative
coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to
0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm
to 7.8 cm) was corrected to -1.6 cm
(-4 cm to 2.5 cm). The mean operating time was 250 minutes (180
to 360 minutes) and intra-operative blood loss 0.8 of estimated
blood volume (0.3 to 2 estimated blood volume). The mean intensive
care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10
to 27), respectively. Three patients lost a significant amount of
blood intra-operatively and subsequently developed chest or urinary
infections and superior mesenteric artery syndrome. An increased pre-operative lumbar lordosis and sacral slope were
associated with increased peri-operative morbidity: scoliosis and
pelvic obliquity were not. A reduced lumbar lordosis and increased
thoracic kyphosis correlated with better global sagittal balance
at follow-up. All patients and their parents reported excellent
surgical outcomes. Lordoscoliosis and hyperlordosis are associated with significant
morbidity in quadriplegic patients. They are rare deformities and
their treatment is challenging. Sagittal imbalance is the major
component: it can be corrected by posterior fusion of the spine
with excellent functional results. Cite this article:
The aim of this study was to determine if a change
in antibiotic prophylaxis for routine hip and knee replacement was
associated with an increased risk of acute renal impairment. We identified 238 patients (128 knees and 110 hips) who had received
a single prophylactic dose of 1.5 g cefuroxime before joint replacement.
We compared them with prospectively collected data from 254 patients
(117 knees and 137 hips) who received a single prophylactic dose
of 2 g flucloxacillin and a height- and gender-determined dose of
gentamicin. The primary outcome measure was any new renal impairment
as graded by clinically validated criteria. We identified four patients (1.69%) in the cefuroxime group who
developed renal impairment. All four had mild impairment and all
renal function was normal by the third post-operative day. The incidence
of new-onset renal impairment was significantly higher in the flucloxacillin-and-gentamicin
group at 9.45% (24 patients) (p <
0.001). Three of these patients
remained with acute renal impairment after a week, although the
serum creatinine levels in all subsequently returned to normal. Cite this article:
In a randomised controlled pragmatic trial we
investigated whether local infiltration analgesia would result in earlier
readiness for discharge from hospital after total knee replacement
(TKR) than patient-controlled epidural analgesia (PCEA) plus femoral
nerve block. A total of 45 patients with a mean age of 65 years
(49 to 81) received a local infiltration with a peri-articular injection
of bupivacaine, morphine and methylprednisolone, as well as adjuvant
analgesics. In 45 PCEA+femoral nerve blockade patients with a mean
age of 67 years (50 to 84), analgesia included a bupivacaine nerve
block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics.
The mean time until ready for discharge was 3.2 days (1 to 14) in
the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral
nerve blockade group. The mean pain scores for patients receiving
local infiltration were higher when walking (p = 0.0084), but there
were no statistically significant differences at rest. The mean
opioid consumption was higher in those receiving local infiltration. The choice between these two analgesic pathways should not be
made on the basis of time to discharge after surgery. Most secondary
outcomes were similar, but PCEA+femoral nerve blockade patients
had lower pain scores when walking and during continuous passive
movement. If PCEA+femoral nerve blockade is not readily available, local
infiltration provides similar length of stay and similar pain scores
at rest following TKR. Cite this article:
Perthes’ disease is an osteonecrosis of the juvenile
hip, the aetiology of which is unknown. A number of comorbid associations
have been suggested that may offer insights into aetiology, yet
the strength and validity of these are unclear. This study explored
such associations through a case control study using the United
Kingdom General Practice Research database. Associations investigated
were those previously suggested within the literature. Perthes’ disease has a significant association with congenital
genitourinary and inguinal anomalies, suggesting that intra-uterine
factors may be critical to causation. Other comorbid associations
may offer insight to support or refute theories of pathogenesis.
Total knee arthroplasty (TKA) is known to lead
to a reduction in periprosthetic bone mineral density (BMD). In theory,
this may lead to migration, instability and aseptic loosening of
the prosthetic components. Bisphosphonates inhibit bone resorption
and may reduce this loss in BMD. We hypothesised that treatment
with bisphosphonates and calcium would lead to improved BMD and
clinical outcomes compared with treatment with calcium supplementation
alone following TKA. A total of 26 patients, (nine male and 17 female,
mean age 67 years) were prospectively randomised into two study
groups: alendronate and calcium (bisphosphonate group, n = 14) or calcium
only (control group, n = 12). Dual energy X-ray absorptiometry (DEXA)
measurements were performed post-operatively, and at three months,
six months, one, two, four, and seven years post-operatively. Mean femoral metaphyseal BMD was significantly higher in the
bisphosphonate group compared with controls, up to four years following
surgery in some areas of the femur (p = 0.045). BMD was observed
to increase in the lateral tibial metaphysis in the bisphosphonate
group until seven years (p = 0.002), and was significantly higher than
that observed in the control group throughout (p = 0.024). There
were no significant differences between the groups in the central
femoral metaphyseal, tibial medial metaphyseal or diaphyseal regions
of interest (ROI) of either the femur or tibia. Bisphosphonate treatment after TKA may be of benefit for patients
with poor bone quality. However, further studies with a larger number
of patients are necessary to assess whether this is clinically beneficial. Cite this article:
A poor response to chemotherapy (≤ 90% necrosis)
for osteosarcomas leads to poorer survival and an increased risk of
local recurrence, particularly if there is a close margin of excision.
We evaluated whether amputation confers any survival benefit over
limb salvage surgery (LSS) with narrow margins in patients who respond
poorly to chemotherapy. We only analysed patients with an osteosarcoma of the limb, a
poor response to chemotherapy and close margins on LSS (marginal/intralesional)
or primary amputation: 360 patients (36 LSS (intralesional margins),
197 LSS (marginal margins) and 127 amputations) were included. Local
recurrence developed in 13 (36%) following LSS with intralesional
margins, and 39 (20%) following LSS with marginal margins. There
was no local recurrence in patients who underwent amputation. The
five-year survival for all patients was 41% (95% confidence interval
(CI) 35 to 46), but for those treated by LSS with marginal margins
was 46.2% (95% CI 38 to 53), 36.3% (95% CI 27 to 45) for those treated
by amputation, and 28% (95 CI 14 to 44) for those treated by LSS
with intralesional margins. Patients who had LSS and then developed
local recurrence as a first event had the same survival as those
who had primary amputation without local recurrence. Prophylactic
adjuvant radiotherapy was used in 40 patients but had no discernible
effect in preventing local recurrence. Although amputation offered better local control, it conferred
no clear survival benefit over LSS with marginal margins in these
patients with a poor overall prognosis. Cite this article:
Obesity is a risk factor for complications following
many orthopaedic procedures. The purpose of this study was to investigate
whether obesity was an independent risk factor increasing the rate
of complications following periacetabular osteotomy (PAO) and to
determine whether radiographic correction after PAO was affected
by obesity. We retrospectively collected demographic, clinical and radiographic
data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were
followed for a mean of 48 months (12 to 60) after PAO. A total of
65 patients (23.2%) were obese (body mass index (BMI) >
30 kg/m2).
Univariate and multivariate analysis demonstrated that BMI was an independent
risk factor associated with the severity of the complications. The
average probability of a patient developing a major complication
was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese
patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient
The odds of a patient developing a major complication were 11 times
higher (95% CI 4.71 to 17.60, p <
0.0001) for an obese compared
with a non-obese patient. Following PAO surgery, there was no difference in radiographic
correction between obese and non-obese patients. PAO procedures
in obese patients correct the deformity effectively but are associated
with an increased rate of complications. Cite this article:
The December 2014 Children’s orthopaedics Roundup360 looks at: predicting drift in supracondylar fractures; do normal hips dislocate?; the burden of trampoline fractures; muscle eversion activity is strongly predictive of outcome in CTEV; the modified Dunn osteotomy; plaster and moulded casts; and psychology and fractures.
Resection of malignant bony tumours of the pelvis
creates large bone and soft-tissue defects, and is frequently associated
with complications such as wound dehiscence and deep infection.
We present the results of six patients in whom a rectus abdominis
myocutaneous (RAM) flap was used following resection of a malignant
tumour of the pelvis. Bony reconstruction was performed using a
constrained hip tumour prosthesis in three patients, vascularised
fibular graft in two and frozen autograft in one. At a mean follow-up
of 63 months (16 to 115), no patients had a problem with the wound. Immediate reconstruction using a RAM flap may be used after resection
of a malignant tumour of the pelvis to provide an adequate volume
of tissue to eliminate the dead space, cover the exposed bone or
implants with well-vascularised soft tissue and to reduce the risk
of complications. Cite this article:
We report the outcomes of 20 patients (12 men,
8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction
of deformities of the ankle and hindfoot using retrograde intramedullary
nail arthrodesis. The mean age of the patients was 62.6 years (46
to 83); their mean BMI was 32.7 (15 to 47) and their median American
Society of Anaesthetists score was 3 (2 to 4). All presented with
severe deformities and 15 had chronic ulceration. All were treated
with reconstructive surgery and seven underwent simultaneous midfoot
fusion using a bolt, locking plate or a combination of both. At
a mean follow-up of 26 months (8 to 54), limb salvage was achieved
in all patients and 12 patients (80%) with ulceration achieved healing
and all but one patient regained independent mobilisation. There was
failure of fixation with a broken nail requiring revision surgery
in one patient. Migration of distal locking screws occurred only
when standard screws had been used but not with hydroxyapatite-coated
screws. The mean American Academy of Orthopaedic Surgeons Foot and
Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22
to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical
Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7
to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved
from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary
hindfoot arthrodesis nail is a good form of treatment for patients
with severe Charcot hindfoot deformity, ulceration and instability
provided a multidisciplinary care plan is delivered. Cite this article:
Dislocation remains among the most common complications
of, and reasons for, revision of both primary and revision total
hip replacements (THR). Hence, there is great interest in maximising
stability to prevent this complication. Head size has been recognised
to have a strong influence on the risk of dislocation post-operatively.
As femoral head size increases, stability is augmented, secondary
to an increase in impingement-free range of movement. Larger head
sizes also greatly increase the ‘jump distance’ required for the
head to dislocate in an appropriately positioned cup. Level-one
studies support the use of larger diameter heads as they decrease
the risk of dislocation following primary and revision THR. Highly cross-linked
polyethylene has allowed us to increase femoral head size, without
a marked increase in wear. However, the thin polyethylene liners
necessary to accommodate larger heads may increase the risk of liner
fracture and larger heads have also been implicated in causing soft-tissue
impingement resulting in groin pain. Larger diameter heads also
impart larger forces on the femoral trunnion, which may contribute
to corrosion, metal release, and adverse local tissue reactions.
Alternative large bearings including large ceramic heads and dual
mobility bearings may mitigate some of these risks, and several
of these devices have been used with clinical success. Cite this article:
There is controversy whether congenital foot
abnormalities are true risk factors for pathological dysplasia of
the hip. Previous United Kingdom screening guidelines considered
congenital talipes equinovarus (CTEV) to be a risk factor for hip
dysplasia, but present guidelines do not. We assessed the potential
relationship between pathological dysplasia of the hip and fixed
idiopathic CTEV. We present a single-centre 21-year prospective longitudinal observational
study. All fixed idiopathic CTEV cases were classified (Harrold
and Walker Types 1 to 3) and the hips clinically and sonographically
assessed. Sonographic Graf Type III, IV and radiological irreducible
hip dislocation were considered to be pathological hip dysplasia. Over 21 years there were 139 children with 199 cases of fixed
idiopathic CTEV feet. Sonographically, there were 259 normal hips,
18 Graf Type II hips, 1 Graf Type III hip and 0 Graf Type IV hip.
There were no cases of radiological or sonographic irreducible hip
dislocation. Fixed idiopathic CTEV should not be considered as a significant
risk factor for pathological hip dysplasia. This conclusion is in
keeping with the current newborn and infant physical examination
guidelines in which the only risk factors routinely screened are
family history and breech presentation. Our findings suggest CTEV
should not be considered a significant risk factor in pathological
dysplasia of the hip. Cite this article:
To determine the morbidity and mortality outcomes of patients
presenting with a fractured neck of femur in an Australian context.
Peri-operative variables related to unfavourable outcomes were identified
to allow planning of intervention strategies for improving peri-operative
care. We performed a retrospective observational study of 185 consecutive
adult patients admitted to an Australian metropolitan teaching hospital
with fractured neck of femur between 2009 and 2010. The main outcome
measures were 30-day and one-year mortality rates, major complications
and factors influencing mortality. Objectives
Methods