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 best method of reconstruction after resection of malignant tumours of the tibial diaphysis is unknown. In the absence of any long-term studies analysing the results of intercalary endoprosthetic replacement, we present a retrospective review of 18 patients who underwent limb salvage using a tibial diaphyseal endoprosthetic replacement following excision of a malignant bone tumour. There were ten men and eight women with a mean age of 42.5 years (16 to 76). Mean follow-up was 58.5 months (20 to 141) for all patients and 69.3 months (20 to 141) for the 12 patients still alive. Cumulative patient survival was 59% (95% confidence interval (CI) 32 to 84) at five years. Implant survival was 63% (95% CI 35 to 90) at ten years. Four patients required revision to a proximal tibial replacement at a mean follow-up of 29 months (10 to 54). Complications included metastases in five patients, aseptic loosening in four, peri-prosthetic fracture in two, infection in one and local recurrence in one. The mean Musculoskeletal Tumor Society score and the mean Toronto Extremity Salvage Score were 23 (17 to 28) and 74% (53 to 91), respectively. Although rates of complication and revision were high, custom-made tibial diaphyseal replacement following resection of malignant bone tumours enables early return to function and provides an attractive alternative to other surgical options, without apparent compromise of patient survival.
Most problems encountered in complex revision
total knee arthroplasty can be managed with the wide range of implant
systems currently available. Modular metaphyseal sleeves, metallic
augments and cones provide stability even with significant bone
loss. Hinged designs substitute for significant ligamentous deficiencies.
Catastrophic failure that precludes successful reconstruction can
be encountered. The alternatives to arthroplasty in such drastic
situations include knee arthrodesis, resection arthroplasty and
amputation. The relative indications for the selection of these
alternatives are recurrent deep infection, immunocompromised host,
and extensive non-reconstructible bone or soft-tissue defects.
A total of 157 hindquarter amputations were carried
out in our institution during the last 30 years. We have investigated
the reasons why this procedure is still required and the outcome.
This operation was used as treatment for 13% of all pelvic bone
sarcomas. It was curative in 140 and palliative in 17, usually to
relieve pain. There were 90 primary procedures (57%) with the remaining
67 following the failure of previous operations to control the disease
locally. The indication for amputation in primary disease was for
large tumours for which limb-salvage surgery was no longer feasible.
The peri-operative mortality was 1.3% (n = 2) and major complications
of wound healing or infection arose in 71 (45%) patients. The survival
at five years after hindquarter amputation with the intent to cure
was 45%, and at ten years 38%. Local recurrence occurred in 23 patients
(15%). Phantom pain was a significant problem, and only 20% used
their prosthesis regularly. Functional scores were a mean of 57%.
With careful patient selection the oncological results and functional outcomes
of hindquarter amputation justify its continued use. Cite this article:
Antibiotic impregnated articulating spacers are
used in two-stage revision total knee arthroplasty to deliver local antibiotic
therapy while preserving function. We have observed infection control
in greater than 95% of cases with functional outcomes approaching
those seen in revision for aseptic loosening. Higher failure has
been observed with methicillin resistant organisms.
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 set out to determine the impact of surgery on quality of life and function in patients who had undergone surgery for symptomatic peri-acetabular metastases. From a prospective database we retrospectively reviewed 46 consecutive patients who had been treated operatively between June 2003 and June 2009. The mean age of the patients was 56.4 years (20 to 73) and the mean post-operative follow-up was 19.2 months (4 to 70). Functional evaluation and quality-of-life assessments were performed. At the most recent follow-up, 26 patients (56.5%) were alive. Their median survival time was 25.0 months. Ten major postoperative complications had occurred in eight patients (17.4%). The mean post-operative Musculoskeletal Tumor Society score (MSTS 93) was 56.3% (6.7% to 90.0%). Improvement in the Eastern Cooperative Oncology Group (ECOG) performance status was seen in 32 patients (69.6%). On the European Organisation for Research and Treatment of Cancer core quality-of-life questionnaire (QLQ-C30) measure of global health status there was a statistically significant improvement from the patients’ pre-operative status (42.8 ( Surgery for patients with peri-acetabular metastases reduces pain and improves their quality of life, and has a low rate of surgical complications.
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:
The results of hip and knee replacement surgery
are generally regarded as positive for patients. Nonetheless, they are
both major operations and have recognised complications. We present
a review of relevant claims made to the National Health Service
Litigation Authority. Between 1995 and 2010 there were 1004 claims
to a value of £41.5 million following hip replacement surgery and
523 claims to a value of £21 million for knee replacement. The most common
complaint after hip surgery was related to residual neurological
deficit, whereas after knee replacement it was related to infection.
Vascular complications resulted in the highest costs per case in
each group. Although there has been a large increase in the number of operations
performed, there has not been a corresponding relative increase
in litigation. The reasons for litigation have remained largely
unchanged over time after hip replacement. In the case of knee replacement,
although there has been a reduction in claims for infection, there
has been an increase in claims for technical errors. There has also
been a rise in claims for non-specified dissatisfaction. This information
is of value to surgeons and can be used to minimise the potential
mismatch between patient expectation, informed consent and outcome. Cite this article:
Venous thromboembolism (VTE) remains an immediate
threat to patients following total hip and knee replacement. While
there is a strong consensus that steps should be taken to minimise
the risk to patients by utilising some forms of prophylaxis for
the vast majority of patients, the methods utilised have been extremely
variable. Clinical practice guidelines (CPGs) have been published
by various professional organisations for over 25 years to provide recommendations
to standardise VTE prophylaxis. Historically, these recommendations
have varied widely depending in underlying assumptions, goals, and
methodology of the various groups. This effort has previously been
exemplified by the American College of Chest Physicians (ACCP) and
the American Academy of Orthopaedic Surgeons (AAOS). The former
group of medical specialists targeted minimising venographically
proven deep vein thrombosis (DVT) (the vast majority of which are
asymptomatic) as their primary goal prior to 2012. The latter group of
surgeons targeted minimising symptomatic VTE. As a result prior
to 2012, the recommendations of the two groups were widely divergent.
In the past year, both groups have reassessed the current literature
with the principal goals of minimising symptomatic VTE events and
bleeding complications. As a result, for the first time the CPGs
of these two major subspecialty organisations are in close agreement.
Fractures of the femoral neck in children are
rare, high-energy injuries with high complication rates. Their treatment has
become more interventional but evidence of the efficacy of such
measures is limited. We performed a systematic review of studies
examining different types of treatment and their outcomes, including
avascular necrosis (AVN), nonunion, coxa vara, premature physeal
closure (PPC), and Ratliff’s clinical criteria. A total of 30 studies
were included, comprising 935 patients. Operative treatment and
open reduction were associated with higher rates of AVN. Delbet
types I and II fractures were most likely to undergo open reduction
and internal fixation. Coxa vara was reduced in the operative group,
whereas nonunion and PPC were not related to surgical intervention. Nonunion
and coxa vara were unaffected by the method of reduction. Capsular
decompression had no effect on AVN. Although surgery allows a more
anatomical union, it is uncertain whether operative treatment or
the type of reduction affects the rate of AVN, nonunion or PPC,
because more severe fractures were operated upon more frequently.
A delay in treatment beyond 24 hours was associated with a higher
incidence of AVN. Cite this article:
Matrix-assisted autologous chondrocyte transplantation (MACT)
has been developed and applied in the clinical practice in the last
decade to overcome most of the disadvantages of the first generation
procedures. The purpose of this systematic review is to document
and analyse the available literature on the results of MACT in the
treatment of chondral and osteochondral lesions of the knee. All studies published in English addressing MACT procedures were
identified, including those that fulfilled the following criteria:
1) level I-IV evidence, 2) measures of functional or clinical outcome,
3) outcome related to cartilage lesions of the knee cartilage.Objectives
Methods
The October 2012 Foot &
Ankle Roundup360 looks at: ankle arthrodesis in young active patients; the Bologna-Oxford total ankle replacements; significant failure and revision rates for total ankle arthroplasty; surgical treatment of Achilles tendon rupture; selective plantar fascia release; whether removal of metalwork can resolve foot pain; allografting of osteochondral lesions; distracting from osteoarthritis; and ultrasound-guided minimally invasive surgery.
In this paper, we consider wound healing after
total knee arthroplasty.
We present a comparison of patient-reported outcomes
(PROMs) in relation to patient age, in patients who had received
a total (TKR) or unicompartmental knee replacement (UKR). The outcome
was evaluated using the Oxford knee score (OKS), EuroQol (EQ-5D)
and satisfaction scores. Patients aged 65 to 84 years demonstrated
better pre-operative function scores than those aged <
65 years
(OKS, p = 0.03; EQ-5D, p = 0.048) and those aged
≥ 85 years (OKS, p = 0.03). Post-operative scores were comparable
across age groups, but a linear trend for greater post-operative
improvement in OKS and EQ-5D was seen with decreasing age (p <
0.033). The overall mean satisfaction score at six months was 84.9,
but those aged <
55 years exhibited a lower mean level of satisfaction (78.3)
compared with all other age groups (all p <
0.031). The cumulative
overall two-year revision rate was 1.3%. This study demonstrates
that good early outcomes, as measured by the OKS and EQ-5D, can
be anticipated following knee replacement regardless of the patient’s
age, although younger patients gain greater improvement. However,
the lower satisfaction in those aged
<
55 years is a concern, and suggests that outcome is not fully
encapsulated by the OKS and EQ-5D evaluation, and raises the question
whether the OKS alone is an appropriate measure of pain and function
in younger, more active individuals. Cite this article:
We live in troubled times. Increased opposition reliance on explosive devices, the widespread use of individual and vehicular body armour, and the improved survival of combat casualties have created many complex musculoskeletal injuries in the wars in Iraq and Afghanistan. Explosive mechanisms of injury account for 75% of all musculoskeletal combat casualties. Throughout all the echelons of care medical staff practice consistent treatment strategies of damage control orthopaedics including tourniquets, antibiotics, external fixation, selective amputations and vacuum-assisted closure. Complications, particularly infection and heterotopic ossification, remain frequent, and re-operations are common. Meanwhile, non-combat musculoskeletal casualties are three times more frequent than those derived from combat and account for nearly 50% of all musculoskeletal casualties requiring evacuation from the combat zone.
The aim of this study was first, to determine
whether CT scans undertaken to identify serious injury to the viscera were
of use in detecting clinically unrecognised fractures of the thoracolumbar
vertebrae, and second, to identify patients at risk of ‘missed injury’. We retrospectively analysed CT scans of the chest and abdomen
performed for blunt injury to the torso in 303 patients. These proved
to be positive for thoracic and intra-abdominal injuries in only
2% and 1.3% of cases, respectively. However, 51 (16.8%) showed a
fracture of the thoracolumbar vertebrae and these constituted our subset
for study. There were eight women and 43 men with mean age of 45.2
years (15 to 94). There were 29 (57%) stable and 22 (43%) unstable
fractures. Only 17 fractures (33.3%) had been anticipated after
clinical examination. Of the 22 unstable fractures, 11 (50%) were
anticipated. Thus, within the whole group of 303 patients, an unstable spinal
injury was missed in 11 patients (3.6%); no harm resulted as they
were all protected until the spine had been cleared. A subset analysis
revealed that patients with a high Injury Severity Score, a low
Glasgow Coma Scale and haemodynamic instability were most likely
to have a significant fracture in the absence of positive clinical
findings. This is the group at greatest risk. Clinical examination alone cannot detect significant fractures
of the thoracolumbar spine. It should be combined with CT imaging
to reduce the risk of missed injury.
No previous studies have examined the physical
characteristics of patients with cauda equina syndrome (CES). We compared
the anthropometric features of patients who developed CES after
a disc prolapse with those who did not but who had symptoms that
required elective surgery. We recorded the age, gender, height,
weight and body mass index (BMI) of 92 consecutive patients who
underwent elective lumbar discectomy and 40 consecutive patients who
underwent discectomy for CES. On univariate analysis, the mean BMI
of the elective discectomy cohort (26.5 kg/m2 (16.6 to
41.7) was very similar to that of the age-matched national mean
(27.6 kg/m2, p = 1.0). However, the mean BMI of the CES
cohort (31.1 kg/m2 (21.0 to 54.9)) was significantly
higher than both that of the elective group (p <
0.001) and the
age-matched national mean (p <
0.001). A similar pattern was
seen with the weight of the groups. Multivariate logistic regression
analysis was performed, adjusted for age, gender, height, weight
and BMI. Increasing BMI and weight were strongly associated with
an increased risk of CES (odds ratio (OR) 1.17, p <
0.001; and
OR 1.06, p <
0.001, respectively). However, increasing height
was linked with a reduced risk of CES (OR 0.9, p <
0.01). The
odds of developing CES were 3.7 times higher (95% confidence interval
(CI) 1.2 to 7.8, p = 0.016) in the overweight and obese (as defined
by the World Health Organization: BMI ≥ 25 kg/m2) than
in those of ideal weight. Those with very large discs (obstructing
>
75% of the spinal canal) had a larger BMI than those with small
discs (obstructing <
25% of the canal; p <
0.01). We therefore
conclude that increasing BMI is associated with CES.