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:
It is becoming increasingly common for a patient
to have ipsilateral hip and knee replacements. The inter-prosthetic (IP)
distance, the distance between the tips of hip and knee prostheses,
has been thought to be associated with an increased risk of IP fracture.
Small gap distances are generally assumed to act as stress risers,
although there is no real biomechanical evidence to support this. The purpose of this study was to evaluate the influence of IP
distance, cortical thickness and bone mineral density on the likelihood
of an IP femoral fracture. A total of 18 human femur specimens were randomised into three
groups by bone density and cortical thickness. For each group, a
defined IP distance of 35 mm, 80 mm or 160 mm was created by choosing
the appropriate lengths of component. The maximum fracture strength
was determined using a four-point bending test. The fracture force of all three groups was similar (p = 0.498).
There was a highly significant correlation between the cortical
area and the fracture strength (r = 0.804, p <
0.001), whereas
bone density showed no influence. This study suggests that the IP distance has little influence
on fracture strength in IP femoral fractures: the thickness of the
cortex seems to be the decisive factor. Cite this article:
The aim of this study was to evaluate the functional
and oncological outcome of extracorporeally irradiated autografts
used to reconstruct the pelvis after a P1/2 internal hemipelvectomy. The study included 18 patients with a primary malignant bone
tumour of the pelvis. There were 13 males and five females with
a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic
sarcoma, six a Ewing’s sarcoma, and five a chondrosarcoma. At a
mean follow-up of 51.6 months (4 to 185), nine patients had died
with metastatic disease while nine were free from disease. Local
recurrence occurred in three patients all of whom eventually died of
their disease. Deep infection occurred in three patients and required
removal of their graft in two while the third underwent a hindquarter
amputation for extensive flap necrosis. The mean Musculoskeletal Tumor Society functional score of the
16 patients who could be followed-up for at least 12 months was
77% (50 to 90). Those 15 patients who completed the Toronto Extremity
Salvage Score questionnaire had a mean score of 71% (53 to 85). Extracorporeal irradiation and re-implantation of bone is a valid
method of reconstruction after an internal hemipelvectomy. It has
an acceptable morbidity and a functional outcome that compares favourably
with other available reconstructive techniques. Cite this article:
We retrospectively reviewed the hospital records of 68 patients who had been referred with an injury to the posterolateral corner of the knee to a specialist knee surgeon between 2005 and 2009. These injuries were diagnosed based on a combination of clinical testing and imaging and arthroscopy when available. In all, 51 patients (75%) presented within 24 hours of their injury with a mean presentation at eight days (0 to 20) after the injury. A total of 63 patients (93%) had instability of the knee at presentation. There was a mean delay to the diagnosis of injury to the posterolateral corner of 30 months (0 to 420) from the time of injury. In all, the injuries in 49 patients (72%) were not identified at the time of the initial presentation, with the injury to the posterolateral corner only recognised in those patients who had severe multiple ligamentous injuries. The correct diagnosis, including injury to the posterolateral corner, had only been made in 34 patients (50%) at time of referral to a specialist knee clinic. MRI correctly identified 14 of 15 injuries when performed acutely (within 12 weeks of injury), but this was the case in only four of 15 patients in whom it was performed more than 12 weeks after the injury. Our study highlights a need for greater diligence in the examination and investigation of acute ligamentous injuries at the knee with symptoms of instability, in order to avoid failure to identify the true extent of the injury at the time when anatomical repair is most straightforward.
Most patients (95%) with fibular hemimelia have
an absent anterior cruciate ligament (ACL). The purpose of this study
was to assess the long-term outcome of such patients with respect
to pain and knee function. We performed a retrospective review of
patients with fibular hemimelia and associated ACL deficiency previously
treated at our institution. Of a possible 66 patients, 23 were sent
the Musculoskeletal Outcomes Data Evaluation and Management System
(MODEMS) questionnaire and Lysholm knee score to complete. In all,
11 patients completed the MODEMS and nine completed the Lysholm
score questionnaire. Their mean age was 37 years (27 to 57) at review.
Five patients had undergone an ipsilateral Symes amputation. There
was no significant difference in any subsections of the Short-Form
36 scores of our patients compared with age-matched controls. The
mean Lysholm knee score was 90.2 (82 to 100). A slight limp was
reported in six patients. No patients had episodes of locking of the
knee or required a supportive device for walking. Four had occasional
instability with sporting activities. These results suggest that patients with fibular hemimelia and
ACL deficiency can live active lives with a similar health status
to age-matched controls.
We investigated whether the extension gap in total knee replacement (TKR) would be changed when the femoral component was inserted. The extension gap was measured with and without the femoral component in place in 80 patients with varus osteoarthritis undergoing posterior-stabilised TKR. The effect of a post-operative increase in the size of the femoral posterior condyles was also evaluated. The results showed that placement of the femoral component significantly reduced the medial and lateral extension gaps by means of 1.0 mm and 0.9 mm, respectively (p <
0.0001). The extension gap was reduced when a larger femoral component was selected relative to the thickness of the resected posterior condyle. When the post-operative posterior lateral condyle was larger than that pre-operatively, 17 of 41 knees (41%) showed a decrease in the extension gap of >
2.0 mm. When a specially made femoral trial component with a posterior condyle enlarged by 4 mm was tested, the medial and lateral extension gaps decreased further by means of 2.1 mm and 2.8 mm, respectively. If the thickness of the posterior condyle is expected to be larger than that pre-operatively, it should be recognised that the extension gap is likely to be altered. This should be taken into consideration when preparing the extension gap.
The June 2012 Wrist &
Hand Roundup360 looks at; radial osteotomy and advanced Kienböck's disease; fixing the Bennett fracture; PEEK plates and four-corner arthrodesis,;carpal tunnel release and haemodialysis; degloved digits and the reverse radial forearm flap; occupational hand injuries; trapeziometacarpal osteoarthritis; fixing the fractured metacarpal neck and pyrocarbon implants for the destroyed PIPJ.
The relationship between post-operative bone
density and subsequent failure of total knee replacement (TKR) is
not known. This retrospective study aimed to determine the relationship
between bone density and failure, both overall and according to
failure mechanism. All 54 aseptic failures occurring in 50 patients
from 7760 consecutive primary cemented TKRs between 1983 and 2004
were matched with non-failing TKRs, and 47 failures in 44 patients
involved tibial failures with the matching characteristics of age
(65.1 for failed and 69.8 for non-failed), gender (70.2% female), diagnosis
(93.6% OA), date of operation, bilaterality, pre-operative alignment
(0.4 and 0.3 respectively), and body mass index (30.2 and 30.0 respectively).
In each case, the density of bone beneath the tibial component was assessed
at each follow-up interval using standardised, calibrated radiographs.
Failing knees were compared with controls both overall and, as a
subgroup analysis, by failure mechanism. Knees were compared with
controls using univariable linear regression. Significant and continuous elevation in tibial density was found
in knees that eventually failed by medial collapse (p <
0.001)
and progressive radiolucency (p <
0.001) compared with controls,
particularly in the medial region of the tibia. Knees failing due
to ligamentous instability demonstrated an initial decline in density
(p = 0.0152) followed by a non-decreasing density over time (p =
0.034 for equivalence). Non-failing knees reported a decline in
density similar to that reported previously using dual-energy x-ray
absorptiometry (DEXA). Differences between failing and non-failing
knees were observable as early as two months following surgery.
This tool may be used to identify patients at risk of failure following
TKR, but more validation work is needed. Cite this article:
Giant cell tumours (GCT) of the synovium and
tendon sheath can be classified into two forms: localised (giant
cell tumour of the tendon sheath, or nodular tenosynovitis) and
diffuse (diffuse-type giant cell tumour or pigmented villonodular
synovitis). The former principally affects the small joints. It
presents as a solitary slow-growing tumour with a characteristic
appearance on MRI and is treated by surgical excision. There is
a significant risk of multiple recurrences with aggressive diffuse
disease. A multidisciplinary approach with dedicated MRI, histological assessment
and planned surgery with either adjuvant radiotherapy or systemic
targeted therapy is required to improve outcomes in recurrent and
refractory diffuse-type GCT. Although arthroscopic synovectomy through several portals has
been advocated as an alternative to arthrotomy, there is a significant
risk of inadequate excision and recurrence, particularly in the
posterior compartment of the knee. For local disease partial arthroscopic
synovectomy may be sufficient, at the risk of recurrence. For both
local and diffuse intra-articular disease open surgery is advised
for recurrent disease. Marginal excision with focal disease will
suffice, not dissimilar to the treatment of GCT of tendon sheath.
For recurrent and extra-articular soft-tissue disease adjuvant therapy,
including intra-articular radioactive colloid or moderate-dose external
beam radiotherapy, should be considered.
A comprehensive study of osteology remains a cornerstone of current orthopaedic and traumatological education. Osteology was already established as an important part of surgical education by the 16th century. In order to teach anatomy and osteology, the corpses of executed criminals were dissected by the
We present detailed information about early morbidity
after aseptic revision knee replacement from a nationwide study.
All aseptic revision knee replacements undertaken between 1st October
2009 and 30th September 2011 were analysed using the Danish National
Patient Registry with additional information from the Danish Knee
Arthroplasty Registry. The 1218 revisions involving 1165 patients
were subdivided into total revisions, large partial revisions, partial
revisions and revisions of unicondylar replacements (UKR revisions).
The mean age was 65.0 years (27 to 94) and the median length of
hospital stay was four days (interquartile range: 3 to 5), with
a 90 days re-admission rate of 9.9%,
re-operation rate of 3.5% and mortality rate of 0.2%. The age ranges
of 51 to 55 years (p = 0.018), 76 to 80 years (p <
0.001) and ≥ 81
years (p <
0.001) were related to an increased risk of re-admission.
The age ranges of 76 to 80 years (p = 0.018) and the large partial
revision subgroup (p = 0.073) were related to an increased risk
of re-operation. The ages from 76 to 80 years (p <
0.001), age ≥ 81
years (p <
0.001) and surgical time >
120 min (p <
0.001)
were related to increased length of hospital stay, whereas the use
of a tourniquet (p = 0.008) and surgery in a low volume centre (p
= 0.013) were related to shorter length of stay. In conclusion, we found a similar incidence of early post-operative
morbidity after aseptic knee revisions as has been reported after
primary procedures. This suggests that a length of hospital stay ≤ four
days and discharge home at that time is safe following aseptic knee
revision surgery in Denmark. Cite this article:
Lateral clavicular physeal injuries in adolescents
are frequently misinterpreted as acromioclavicular dislocations. There
are currently no clear guidelines for the management of these relatively
rare injuries. Non-operative treatment can result in a cosmetic
deformity, warranting resection of the non-remodelled original lateral
clavicle. However, fixation with Kirschner (K)-wires may be associated
with infection and/or prominent metalwork. We report our experience
with a small series of such cases. Between October 2008 and October 2011 five patients with lateral
clavicular physeal fractures (types III, IV and V) presented to
our unit. There were four boys and one girl with a mean age of 12.8
years (9 to 14). Four fractures were significantly displaced and
treated operatively using a tension band suture technique. One grade
III fracture was treated conservatively. The mean follow-up was
26 months (6 to 42). All patients made an uncomplicated recovery. The mean time to
discharge was three months. The QuickDASH score at follow-up was
0 for each patient. No patient developed subsequent growth disturbances. We advocate the surgical treatment of significantly displaced
Grade IV and V fractures to avoid cosmetic deformity. A tension
band suture technique avoids the problems of retained metalwork
and the need for a secondary procedure. Excellent clinical and radiological
results were seen in all our patients. Cite this article:
We report the results of revision total knee
replacement (TKR) in 26 patients with major metaphyseal osteolytic defects
using 29 trabecular metal cones in conjunction with a rotating hinged
total knee prosthesis. The osteolytic defects were types II and
III (A or B) according to the Anderson Orthopaedic Research Institute
(AORI) classification. The mean age of the patients was 72 years
(62 to 84) and there were 15 men and 11 women. In this series patients had
undergone a mean of 2.34 previous total knee arthroplasties. The
main objective was to restore anatomy along with stability and function
of the knee joint to allow immediate full weight-bearing and active
knee movement. Outcomes were measured using Knee Society scores,
Oxford knee scores, range of movement of the knee and serial radiographs.
Patients were followed for a mean of 36 months (24 to 49). The mean
Oxford knee clinical scores improved from 12.83 (10 to 15) to 35.20
(32 to 38) (p <
0.001) and mean American Knee Society scores
improved from 33.24 (13 to 36) to 81.12 (78 to 86) (p <
0.001).
No radiolucent lines suggestive of loosening were seen around the trabecular
metal cones, and by one year all the radiographs showed good osteo-integration.
There was no evidence of any collapse or implant migration. Our
early results confirm the findings of others that trabecular metal
cones offer a useful way of managing severe bone loss in revision
TKR. Cite this article:
Aseptic loosening of the femoral component is
an important indication for revision surgery in unicompartmental knee
replacement (UKR). A new design of femoral component with an additional
peg was introduced for the cemented Oxford UKR to increase its stability.
The purpose of this study was to compare the primary stability of
the two designs of component. Medial Oxford UKR was performed in 12 pairs of human cadaver
knees. In each pair, one knee received the single peg and one received
the twin peg design. Three dimensional micromotion and subsidence
of the component in relation to the bone was measured under cyclical
loading at flexion of 40° and 70° using an optical measuring system.
Wilcoxon matched pairs signed-rank test was performed to detect
differences between the two groups. There was no significant difference in the relative micromotion
(p = 0.791 and 0.380, respectively) and subsidence (p = 0.301 and
0.176, respectively) of the component between the two groups at
both angles of flexion. Both designs of component offered good strength
of fixation in this cadaver study. Cite this article:
In this paper, we consider wound healing after
total knee arthroplasty.
The June 2013 Knee Roundup360 looks at: knee arthroplasty in diabetic patients; whether TKR is a timebomb; the use of antidepressants for knee OA; trochleoplasty; articulated spacers; mental health and joint replacement; and the use of physiotherapy for meniscal tear.
The biomechanical function of the anteromedial
(AM) and posterolateral (PL) bundles of the anterior cruciate ligament
(ACL) remains controversial. Some studies report that the AM bundle
stabilises the knee joint in anteroposterior (AP) translation and
rotational movement (both internal and external) to the same extent
as the PL bundle. Others conclude that the PL bundle is more important
than the AM in controlling rotational movement. The objective of this randomised cohort study involving 60 patients
(39 men and 21 women) with a mean age of 32.9 years (18 to 53) was
to evaluate the function of the AM and the PL bundles of the ACL
in both AP and rotational movements of the knee joint after single-bundle
and double-bundle ACL reconstruction using a computer navigation
system. In the double-bundle group the patients were also randomised
to have the AM or the PL bundle tensioned first, with knee laxity
measured after each stage of reconstruction. All patients had isolated
complete ACL tears, and the presence of a meniscal injury was the
only supplementary pathology permitted for inclusion in the trial.
The KT-1000 arthrometer was used to apply a constant load to evaluate
the AP translation and the rolimeter was used to apply a constant
rotational force. For the single-bundle group deviation was measured
before and after ACL reconstruction. In the double-bundle group
deviation was measured for the ACL-deficient, AM- or PL-reconstructed
first conditions and for the total reconstruction. We found that the AM bundle in the double-bundle group controlled
rotation as much as the single-bundle technique, and to a greater
extent than the PL bundle in the double-bundle technique. The double-bundle
technique increases AP translation and rotational stability in internal
rotation more than the single-bundle technique.
In distal fibular resection without reconstruction,
the stabilising effect of the lateral malleolus is lost. Thus, the ankle
may collapse into valgus and may be unstable in varus. Here, we
describe a child who underwent successful staged surgical correction
of a severe neglected valgus deformity after excision of the distal
fibula for a Ewing’s sarcoma.