The June 2014 Shoulder &
Elbow Roundup360 looks at: suprascapular nerve and rotator cuff pathology; anchors in Bankart repair: it’s not what you’ve got, but how you use it; not all shoulder PROMs are equal; reverse shoulder arthroplasty OK in trauma; not all in the mind: frozen shoulder personality debunked; open and arthroscopic repair equivalent in shoulder instability; natural history of olecranon fractures not so bleak?; and resurfacing of the shoulder: a Danish perspective.
Patient safety is a critical issue in elective
total joint replacement surgery. Identifying risk factors that might
predict complications and intensive care unit (ICU) admission proves instrumental
in reducing morbidity and mortality. The institution’s experience
with risk stratification and pre-operative ICU triage has resulted
in a reduction in unplanned ICU admissions and post-operative complications
after total hip replacement. The application of the prediction tools
to total knee replacement has proven less robust so far. This work
also reviews areas for future research in patient safety and cost
containment. Cite this article:
We have compared three different methods of treating
symptomatic non-traumatic tears of the supraspinatus tendon in patients
above 55 years of age. A total of 180 shoulders (173 patients) with
supraspinatus tendon tears were randomly allocated into one of three
groups (each of 60 shoulders); physiotherapy (group 1), acromioplasty and
physiotherapy (group 2) and rotator cuff repair, acromioplasty and
physiotherapy (group 3). The Constant score was assessed and followed
up by an independent observer pre-operatively and at three, six
and twelve months after the intervention. Of these, 167 shoulders were available for assessment at one
year (follow-up rate of 92.8%). There were 55 shoulders in group
1 (24 in males and 31 in females, mean age 65 years (55 to 79)),
57 in group 2 (29 male and 28 female, mean age 65 years (55 to 79))
and 55 shoulders in group 3 (26 male and 29 female, mean age 65
years (55 to 81)). There were no between-group differences in the
Constant score at final follow-up: 74.1 ( Cite this article:
The National Institute for Health and Clinical
Excellence (NICE) has thus far relied on historical data and predominantly
industry-sponsored trials to provide evidence for venous thromboembolic
(VTE) prophylaxis in joint replacement patients. We argue that the
NICE guidelines may be reliant on assumptions that are in need of
revision. Following the publication of large scale, independent
observational studies showing little difference between low-molecular-weight
heparins and aspirin, and recent changes to the guidance provided
by other international bodies, should NICE reconsider their recommendations? Cite this article:
We assessed the frequency and causes of neurological
deterioration in 59 patients with spinal cord injury on whom reports
were prepared for clinical negligence litigation. In those who deteriorated
neurologically we assessed the causes of the change in neurology
and whether that neurological deterioration was potentially preventable.
In all 27 patients (46%) changed neurologically, 20 patients (74%
of those who deteriorated) had no primary neurological deficit.
Of those who deteriorated, 13 (48%) became Frankel A. Neurological
deterioration occurred in 23 of 38 patients (61%) with unstable
fractures and/or dislocations; all 23 patients probably deteriorated
either because of failures to immobilise the spine or because of
inappropriate removal of spinal immobilisation. Of the 27 patients who
altered neurologically, neurological deterioration was, probably,
avoidable in 25 (excess movement in 23 patients with unstable injuries,
failure to evacuate an epidural haematoma in one patient and over-distraction following
manipulation of the cervical spine in one patient). If existing
guidelines and standards for the management of actual or potential
spinal cord injury had been followed, neurological deterioration
would have been prevented in 25 of the 27 patients (93%) who experienced
a deterioration in their neurological status. Cite this article:
The aim of this study was to assess the effect
of frictional torque and bending moment on fretting corrosion at
the taper interface of a modular femoral component and to investigate
whether different combinations of material also had an effect. The
combinations we examined were 1) cobalt–chromium (CoCr) heads on
CoCr stems 2) CoCr heads on titanium alloy (Ti) stems and 3) ceramic
heads on CoCr stems. In test 1 increasing torque was imposed by offsetting the stem
in the anteroposterior plane in increments of 0 mm, 4 mm, 6 mm and
8 mm when the torque generated was equivalent to 0 Nm, 9 Nm, 14
Nm and 18 Nm. In test 2 we investigated the effect of increasing the bending
moment by offsetting the application of axial load from the midline
in the mediolateral plane. Increments of offset equivalent to head
+ 0 mm, head + 7 mm and head + 14 mm were used. Significantly higher currents and amplitudes were seen with increasing
torque for all combinations of material. However, Ti stems showed
the highest corrosion currents. Increased bending moments associated
with using larger offset heads produced more corrosion: Ti stems
generally performed worse than CoCr stems. Using ceramic heads did
not prevent corrosion, but reduced it significantly in all loading
configurations. Cite this article:
The management of children’s fractures has evolved
as a result of better health education, changes in lifestyle, improved
implant technology and the changing expectations of society. This
review focuses on the changes seen in paediatric fractures, including
epidemiology, the increasing problems of obesity, the mechanisms
of injury, non-accidental injuries and litigation. We also examine
the changes in the management of fractures at three specific sites:
the supracondylar humerus, femoral shaft and forearm. There has
been an increasing trend towards surgical stabilisation of these
fractures. The reasons for this are multifactorial, including societal
expectations of a perfect result and reduced hospital stay. Reduced hospital
stay is beneficial to the social, educational and psychological
needs of the child and beneficial to society as a whole, due to
reduced costs. Cite this article:
We compared the length of hospitalisation, rate
of infection, dislocation of the hip and revision, and mortality following
primary hip and knee arthroplasty for osteoarthritis in patients
with Alzheimer’s disease (n = 1064) and a matched control group
(n = 3192). The data were collected from nationwide Finnish health
registers. Patients with Alzheimer’s disease had a longer peri-operative
hospitalisation (median 13 days Cite this article:
In this study, we describe a morphological classification
for greater tuberosity fractures of the proximal humerus. We divided
these fractures into three types: avulsion, split and depression.
We retrospectively reviewed all shoulder radiographs showing isolated
greater tuberosity fractures in a Level I trauma centre between
July 2007 and July 2012. We identified 199 cases where records and
radiographs were reviewed and included 79 men and 120 women with
a mean age of 58 years (23 to 96). The morphological classification
was applied to the first 139 cases by three reviewers on two occasions
using the Kappa statistic and compared with the AO and Neer classifications.
The inter- and intra-observer reliability of the morphological classification
was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior
to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59
to 0.65) classifications. The distribution of avulsion, split and
depression type fractures was 39%, 41%, and 20%, respectively. This
classification of greater tuberosity fractures is more reliable
than the Neer or AO classifications. These distinct fracture morphologies
are likely to have implications in terms of pathophysiology and
surgical technique. Cite this article:
The February 2015 Foot &
Ankle Roundup360 looks at: Syndesmosis screw removal in randomised controlled trial; Diagnostic value of Hawkins sign; Chevron rules supreme?; Diabetes and ankle replacement; Fixed-bearing ankle replacement; Fusion for osteomyelitis of the ankle; ‘Reformed’ fallers.
Femoral stem version has a major influence on
impingement and early post-operative stability after total hip arthroplasty
(THA). The main objective of this study was to evaluate the validity
of a novel radiological method for measuring stem version. Anteroposterior
(AP) radiographs and three-dimensional CT scans were obtained for
115 patients (female/male 63/72, mean age 62.5 years (50 to 75))
who had undergone minimally invasive, cementless THA. Stem version was
calculated from the AP hip radiograph by rotation-based change in
the projected prosthetic neck–shaft (NSA*) angle using the mathematical
formula ST = arcos [tan (NSA*) / tan (135)]. We used two independent
observers who repeated the analysis after a six-week interval. Radiological
measurements were compared with 3D-CT measurements by an independent,
blinded external institute. We found a mean difference of 1.2° ( We found that femoral tilt was associated with the mean radiological
measurement error (r = 0.22, p = 0.02). The projected neck–shaft angle is a reliable method for measuring
stem version on AP radiographs of the hip after a THA. However,
a highly standardised radiological technique is required for its
precise measurement. Cite this article:
This article provides an overview of the role of genomics in sarcomas and describes how new methods of analysis and comparative screening have provided the potential to progress understanding and treatment of sarcoma. This article reviews genomic techniques, the evolution of the use of genomics in cancer, the current state of genomic analysis, and also provides an overview of the medical, social and economic implications of recent genomic advances.
Over a 15-year prospective period, 201 infants
with a clinically unstable hip at neonatal screening were subsequently
reviewed in a ‘one stop’ clinic where they were assessed clinically
and sonographically. Their mean age was 1.62 weeks (95% confidence
interval (CI) 1.35 to 1.89). Clinical neonatal hip screening revealed
a sensitivity of 62% (mean, 62.6 95%CI 50.9 to 74.3), specificity
of 99.8% (mean, 99.8, 95% CI 99.7 to 99.8) and positive predictive value
(PPV) of 24% (mean, 26.2, 95% CI 19.3 to 33.0). Static and dynamic
sonography for Graf type IV dysplastic hips had a 15-year sensitivity
of 77% (mean, 75.8 95% CI 66.9 to 84.6), specificity of 99.8% (mean,
99.8, 95% CI 99.8 to 99.8) and a PPV of 49% (mean, 55.1, 95% CI
41.6 to 68.5). There were 36 infants with an irreducible dislocation
of the hip (0.57 per 1000 live births), including six that failed
to resolve with neonatal splintage. Most clinically unstable hips referred to a specialist clinic
are female and stabilise spontaneously. Most irreducible dislocations
are not identified from this neonatal instability group. There may
be a small subgroup of females with instability of the hip which
may be at risk of progression to irreducibility despite early treatment
in a Pavlik harness. A controlled study is required to assess the value of neonatal
clinical screening programmes. Cite this article:
The December 2012 Hip &
Pelvis Roundup360 looks at: swimming against the tide with resurfacing; hip impingement surgery; the relationship between obesity and co-morbidities and joint replacement infection; cemented hips; cross-linked polyethylene notching; whether cement is necessary in oncological arthroplasty; and how total hip replacement may result in weight gain.
Reported rates of dislocation in hip hemiarthroplasty
(HA) for the treatment of intra-capsular fractures of the hip, range
between 1% and 10%. HA is frequently performed through a direct
lateral surgical approach. The aim of this study is to determine
the contribution of the anterior capsule to the stability of a cemented
HA through a direct lateral approach. A total of five whole-body cadavers were thawed at room temperature,
providing ten hip joints for investigation. A Thompson HA was cemented
in place via a direct lateral approach. The cadavers were then positioned
supine, both knee joints were disarticulated and a digital torque
wrench was attached to the femur using a circular frame with three
half pins. The wrench applied an external rotation force with the
hip in extension to allow the hip to dislocate anteriorly. Each
hip was dislocated twice; once with a capsular repair and once without
repairing the capsule. Stratified sampling ensured the order in
which this was performed was alternated for the paired hips on each
cadaver. Comparing peak torque force in hips with the capsule repaired
and peak torque force in hips without repair of the capsule, revealed
a significant difference between the ‘capsule repaired’ (mean 22.96
Nm, standard deviation ( Cite this article:
The February 2014 Wrist &
Hand Roundup360 looks at: simple debridement and ulnar-sided wrist pain; needle fasciotomy or collagenase injection; joint replacement in osteoarthritic knuckles; the Mannerfelt arthrodesis; scaphoid union rates with conservative treatment; the benefits of atorvastatin for muscle re-innervation after sciatic nerve transection; and complications of trapeziectomy.
The use of robots in orthopaedic surgery is an
emerging field that is gaining momentum. It has the potential for significant
improvements in surgical planning, accuracy of component implantation
and patient safety. Advocates of robot-assisted systems describe
better patient outcomes through improved pre-operative planning
and enhanced execution of surgery. However, costs, limited availability,
a lack of evidence regarding the efficiency and safety of such systems
and an absence of long-term high-impact studies have restricted
the widespread implementation of these systems. We have reviewed
the literature on the efficacy, safety and current understanding of
the use of robotics in orthopaedics. Cite this article:
The December 2014 Wrist &
Hand Roundup360 looks at: ultrasound for carpal tunnel diagnosis; where we are at with management of undisplaced scaphoid fractures; ARPE for thumb metacarpals?; extravasation injuries in the hand and wrist; research and practice in hand surgery; and physio ineffective in hand osteoarthritis