There are no recent studies comparing cable with
wire for the fixation of osteotomies or fractures in total hip replacement
(THR). Our objective was to evaluate the five-year clinical and
radiological outcomes and complication rates of the two techniques.
We undertook a review including all primary and revision THRs performed
in one hospital between 1996 and 2005 using cable or wire fixation.
Clinical and radiological evaluation was performed five years post-operatively.
Cables were used in 51 THRs and wires in 126, and of these, 36 THRs
with cable (71%) and 101 with wire (80%) were evaluated at follow-up.
The five-year radiographs available for 33 cable and 91 wire THRs
revealed rates of breakage of fixation of 12 of 33 (36%) and 42
of 91 (46%), respectively. With cable there was a significantly
higher risk of metal debris (68% In conclusion, we found a higher incidence of complications and
a trend towards increased infection and foreign-body reaction with
the use of cables.
Blood loss during total knee replacement (TKR)
remains a significant concern. In this study, 114 patients underwent TKR,
and were divided into two groups based on whether they received
a new generation fibrin sealant intra-operatively, or a local infiltration
containing adrenaline. Groups were then compared for mean calculated
total blood volume (TBV) loss, transfusion rates, and knee range
of movement. Mean TBV loss was similar between groups: fibrin sealant
mean was 705 ml (281 to 1744), local adrenaline mean was 712 ml
(261 to 2308) (p = 0.929). Overall, significantly fewer units of
blood were transfused in the fibrin sealant group (seven units)
compared with the local adrenaline group (15 units) (p = 0.0479).
Per patient transfused, significantly fewer units of blood were transfused
in the fibrin sealant group (1.0 units) compared with the local
adrenaline group (1.67 units) (p = 0.027), suggesting that the fibrin
sealant may reduce the need for multiple unit transfusions. Knee
range of movement was similar between groups. From our results,
it appears that application of this newer fibrin sealant results
in blood loss and transfusion rates that are low and similar to
previously applied fibrin sealants. Cite this article:
We undertook a randomised controlled trial to
compare the piriformis-sparing approach with the standard posterior approach
used for total hip replacement (THR). We recruited 100 patients
awaiting THR and randomly allocated them to either the piriformis-sparing
approach or the standard posterior approach. Pre- and post-operative
care programmes and rehabilitation regimes were identical for both
groups. Observers were blinded to the allocation throughout; patients
were blinded until the two-week assessment. Follow-up was at six
weeks, three months, one year and two years. In all 11 patients
died or were lost to follow-up. There was no significant difference between groups for any of
the functional outcomes. However, for patients in the piriformis-sparing
group there was a trend towards a better six-minute walk test at
two weeks and greater patient satisfaction at six weeks. The acetabular
components were less anteverted (p = 0.005) and had a lower mean
inclination angle (p = 0.02) in the piriformis-sparing group. However,
in both groups the mean component positions were within Lewinnek’s
safe zone. Surgeons perceived the piriformis-sparing approach to
be significantly more difficult than the standard approach (p =
0.03), particularly in obese patients. In conclusion, performing THR through a shorter incision involving
sparing piriformis is more difficult and only provides short-term
benefits compared with the standard posterior approach.
The October 2013 Hip &
Pelvis Roundup360 looks at: Young and impinging; Clothes, weather and femoral heads?; Go long, go cemented; Surgical repair of the abductors?; Aspirin for DVT prophylaxis?; Ceramic-on-polyethylene: a low-wear solution?; ALVAL and ASR™: the story continues….; Salvaging Legg-Calve-Perthes’ disease
The outcome after total hip replacement has improved
with the development of surgical techniques, better pain management
and the introduction of enhanced recovery pathways. These pathways
require a multidisciplinary team to manage pre-operative education,
multimodal pain control and accelerated rehabilitation. The current economic
climate and restricted budgets favour brief hospitalisation while
minimising costs. This has put considerable pressure on hospitals
to combine excellent results, early functional recovery and shorter
admissions. In this review we present an evidence-based summary of some common
interventions and methods, including pre-operative patient education,
pre-emptive analgesia, local infiltration analgesia, pre-operative
nutrition, the use of pulsed electromagnetic fields, peri-operative
rehabilitation, wound dressings, different surgical techniques, minimally
invasive surgery and fast-track joint replacement units. Cite this article:
Tranexamic acid (TEA), an inhibitor of fibrinolysis,
reduces blood loss after routine total knee replacement (TKR). However,
controversy persists regarding the dosage and timing of administration
of this drug during surgery. We performed a prospective randomised
controlled study to examine the optimum blood-saving effect of TEA
in minimally invasive TKR. We randomly assigned 151 patients who underwent unilateral minimally
invasive TKR to three groups: 1) a placebo group (50 patients);
2) a one-dose TEA group (52 patients), who received one injection
of TEA (10 mg/kg) intra-operatively on deflation of the tourniquet;
and 3) a two-dose TEA group (49 patients), who received two injections
of TEA (10 mg/kg) given pre-operatively and intra-operatively. Total
blood loss was calculated from the maximum loss of haemoglobin.
All patients were followed clinically for the presence of venous
thromboembolism (VTE). The mean total blood loss was significantly higher in the placebo
group than in the other two groups (1222 ml (845 to 2043) Our prospective randomised controlled study showed that one intra-operative
injection of TEA is effective for blood conservation after minimally
invasive TKR.
We compared inflammation in the knee after total knee replacement (TKR) for primary osteoarthritis between two groups of patients undergoing joint replacement with and without synovectomy. A total of 67 patients who underwent unilateral TKR were randomly divided into group I, TKR without synovectomy, and group II, TKR with synovectomy. Clinical outcomes, serial serum inflammatory markers (including interleukin-6 (IL-6), CRP and ESR) and the difference in temperature of the skin of the knee, compared with the contralateral side, were sequentially evaluated until 26 weeks after surgery. Pre-operatively, there were no statistically different clinical parameters between groups I and II. At the 26-week follow-up, both groups had a similarly significantly improved American Knee Society clinical score (p <
0.001) and functional score (p <
0.001) with no differences between the groups. Similar changes in serial inflammatory markers were found in both groups, including mean peak levels of IL-6 (189 pg/ml ( We concluded that synovectomy at the time of TKR does not provide any benefit to the clinical outcome or shorten the duration of the inflammatory response after surgery.
The August 2013 Hip &
Pelvis Roundup360 looks at: are we getting it right first time?; tantalum augments in revision hip surgery; lower wear in dual mobility?; changing faces changes outcomes; synovial fluid aspiration in MOM hips; taper disease: the new epidemic of hip surgery; the super-obese and THR; and whether well fixed stems can remain in infected hips
We performed a systematic review and meta-analysis
of modern total ankle replacements (TARs) to determine the survivorship,
outcome, complications, radiological findings and range of movement,
in patients with end-stage osteoarthritis (OA) of the ankle who
undergo this procedure. We used the methodology of the Cochrane Collaboration,
which uses risk of bias profiling to assess the quality of papers
in favour of a domain-based approach. Continuous outcome scores
were pooled across studies using the generic inverse variance method
and the random-effects model was used to incorporate clinical and
methodological heterogeneity. We included 58 papers (7942 TARs)
with an interobserver reliability (Kappa) for selection, performance,
attrition, detection and reporting bias of between 0.83 and 0.98.
The overall survivorship was 89% at ten years with an annual failure
rate of 1.2% (95% confidence interval (CI) 0.7 to 1.6). The mean
American Orthopaedic Foot and Ankle Society score changed from 40 (95%
CI 36 to 43) pre-operatively to 80 (95% CI 76 to 84) at a mean follow-up
of 8.2 years (7 to 10) (p <
0.01). Radiolucencies were identified
in up to 23% of TARs after a mean of 4.4 years (2.3 to 9.6). The
mean total range of movement improved from 23° (95% CI 19 to 26)
to 34° (95% CI 26 to 41) (p = 0.01). Our study demonstrates that TAR has a positive impact on patients’
lives, with benefits lasting ten years, as judged by improvement
in pain and function, as well as improved gait and increased range
of movement. However, the quality of evidence is weak and fraught
with biases and high quality randomised controlled trials are required
to compare TAR with other forms of treatment such as fusion. Cite this article:
The osteoinductive properties of demineralised
bone matrix have been demonstrated in animal studies. However, its therapeutic
efficacy has yet to be proven in humans. The clinical properties
of AlloMatrix, an injectable calcium-based demineralised bone matrix
allograft, were studied in a prospective randomised study of 50
patients with an isolated unstable distal radial fracture treated
by reduction and Kirschner (K-) wire fixation. A total of 24 patients
were randomised to the graft group (13 men and 11 women, mean age
42.3 years (20 to 62)) and 26 to the no graft group (8 men and 18
women, mean age 45.0 years (17 to 69)). At one, three, six and nine weeks, and six and 12 months post-operatively,
patients underwent radiological evaluation, assessments for range
of movement, grip and pinch strength, and also completed the Disabilities
of Arm, Shoulder and Hand questionnaire. At one and six weeks and
one year post-operatively, bone mineral density evaluations of both
wrists were performed. No significant difference in wrist function and speed of recovery,
rate of union, complications or bone mineral density was found between
the two groups. The operating time was significantly higher in the
graft group (p = 0.004). Radiologically, the reduction parameters
remained similar in the two groups and all AlloMatrix extraosseous leakages
disappeared after nine weeks. This prospective randomised controlled trial did not demonstrate
a beneficial effect of AlloMatrix demineralised bone matrix in the
treatment of this category of distal radial fractures treated by
K-wire fixation. Cite this article:
Although the importance of lateral femoral wall
integrity is increasingly being recognised in the treatment of intertrochanteric
fracture, little attention has been put on the development of a
secondary post-operative fracture of the lateral wall. Patients
with post-operative fractures of the lateral wall were reported
to have high rates of re-operation and complication. To date, no
predictors of post-operative lateral wall fracture have been reported.
In this study, we investigated the reliability of lateral wall thickness
as a predictor of lateral wall fracture after dynamic hip screw
(DHS) implantation. A total of 208 patients with AO/OTA 31-A1 and -A2 classified
intertrochanteric fractures who received internal fixation with
a DHS between January 2003 and May 2012 were reviewed. There were
103 men and 150 women with a mean age at operation of
78 years (33 to 94). The mean follow-up was 23 months (6 to 83).
The right side was affected in 97 patients and the left side in
111. Clinical information including age, gender, side, fracture
classification, tip–apex distance, follow-up time, lateral wall
thickness and outcome were recorded and used in the statistical
analysis. Fracture classification and lateral wall thickness significantly
contributed to post-operative lateral wall fracture (both p <
0.001). The lateral wall thickness threshold value for risk of developing
a secondary lateral wall fracture was found to be 20.5 mm. To our knowledge, this is the first study to investigate the
risk factors of post-operative lateral wall fracture in intertrochanteric
fracture. We found that lateral wall thickness was a reliable predictor
of post-operative lateral wall fracture and conclude that intertrochanteric
fractures with a lateral wall thickness <
20.5 mm should not
be treated with DHS alone. Cite this article:
The period of post-operative treatment before surgical wounds
are completely closed remains a key window, during which one can
apply new technologies that can minimise complications. One such
technology is the use of negative pressure wound therapy to manage
and accelerate healing of the closed incisional wound (incisional
NPWT). We undertook a literature review of this emerging indication
to identify evidence within orthopaedic surgery and other surgical
disciplines. Literature that supports our current understanding
of the mechanisms of action was also reviewed in detail. Objectives
Methods
It is accepted that resurfacing hip replacement
preserves the bone mineral density (BMD) of the femur better than total
hip replacement (THR). However, no studies have investigated any
possible difference on the acetabular side. Between April 2007 and March 2009, 39 patients were randomised
into two groups to receive either a resurfacing or a THR and were
followed for two years. One patient’s resurfacing subsequently failed,
leaving 19 patients in each group. Resurfaced replacements maintained proximal femoral BMD and,
compared with THR, had an increased bone mineral density in Gruen
zones 2, 3, 6, and particularly zone 7, with a gain of 7.5% (95%
confidence interval (CI) 2.6 to 12.5) compared with a loss of 14.6%
(95% CI 7.6 to 21.6). Resurfacing replacements maintained the BMD
of the medial femoral neck and increased that in the lateral zones
between 12.8% (95% CI 4.3 to 21.4) and 25.9% (95% CI 7.1 to 44.6). On the acetabular side, BMD was similar in every zone at each
point in time. The mean BMD of all acetabular regions in the resurfaced
group was reduced to 96.2% (95% CI 93.7 to 98.6) and for the total
hip replacement group to 97.6% (95% CI 93.7 to 101.5) (p = 0.4863).
A mean total loss of 3.7% (95% CI 1.0 to 6.5) and 4.9% (95% CI 0.8
to 9.0) of BMD was found above the acetabular component in W1 and
10.2% (95% CI 0.9 to 19.4) and 9.1% (95% CI 3.8 to 14.4) medial
to the implant in W2 for resurfaced replacements and THRs respectively.
Resurfacing resulted in a mean loss of BMD of 6.7% (95% CI 0.7 to
12.7) in W3 but the BMD inferior to the acetabular component was
maintained in both groups. These results suggest that the ability of a resurfacing hip replacement
to preserve BMD only applies to the femoral side.
Our aim in this pilot study was to evaluate the fixation of, the bone remodelling around, and the clinical outcome after surgery of a new, uncemented, fully hydroxyapatite-coated, collared and tapered femoral component, designed specifically for elderly patients with a fracture of the femoral neck. We enrolled 50 patients, of at least 70 years of age, with an acute displaced fracture of the femoral neck in this prospective single-series study. They received a total hip replacement using the new component and were followed up regularly for two years. Fixation was evaluated by radiostereometric analysis and bone remodelling by dual-energy x-ray absorptiometry. Hip function and the health-related quality of life were assessed using the Harris hip score and the EuroQol-5D. Up to six weeks post-operatively there was a mean subsidence of 0.2 mm (−2.1 to +0.5) and a retroversion of a mean of 1.2° (−8.2° to +1.5°). No component migrated after three months. The patients had a continuous loss of peri-prosthetic bone which amounted to a mean of 16% (−49% to +10%) at two years. The mean Harris hip score was 82 (51 to 100) after two years. The two-year results from this pilot study indicate that this new, uncemented femoral component can be used for elderly patients with osteoporotic fractures of the femoral neck.
We compared the clinical and radiological outcomes
of two cementless femoral stems in the treatment of patients with
a Garden III or IV fracture of the femoral neck. A total of 70 patients At final follow-up there were no statistically significant differences
between the short anatomical and the conventional stems with regard
to the mean Harris hip score (85.7 (66 to 100) Our study demonstrated that despite the poor bone quality in
these elderly patients with a fracture of the femoral neck, osseo-integration
was obtained in all hips in both groups. However, the incidence
of thigh pain, pulmonary microemboli and peri-prosthetic fracture
was significantly higher in the conventional stem group than in
the short stem group.
We investigated factors that were thought to be associated with an increased incidence of squeaking of ceramic-on-ceramic total hip replacements. Between June 1997 and December 2008 the three senior authors implanted 2406 primary total hip replacements with a ceramic-on-ceramic bearing surface. The mean follow-up was 10.6 years. The diagnosis was primary osteoarthritis in each case, and no patient had undergone previous surgery to the hip. We identified 74 squeaking hips (73 patients) giving an incidence of 3.1% at a mean follow-up of 9.5 years (4.1 to 13.3). Taller, heavier and younger patients were significantly more likely to have hips that squeaked. Squeaking hips had a significantly higher range of post-operative internal (p = 0.001) and external rotation (p = 0.003) compared with silent hips. Patients with squeaking hips had significantly higher activity levels (p = 0.009). A squeaking hip was not associated with a significant difference in patient satisfaction (p = 0.24) or Harris hip score (p = 0.34). Four implant position factors enabled good prediction of squeaking. These were high acetabular component inclination, high femoral offset, lateralisation of the hip centre and either high or low acetabular component anteversion. This is the largest study to date to examine patient factors and implant position factors that predispose to squeaking of a ceramic-on-ceramic hip. The results suggest that factors which increase the mechanical forces across the hip joint and factors which increase the risk of neck-to-rim impingement, and therefore edge-loading, are those that predispose to squeaking.
The June 2013 Hip &
Pelvis Roundup360 looks at: failure in metal-on-metal arthroplasty; minimal hip approaches; whether bisphosphonates improve femoral bone stock following arthroplasty; whether more fat means more operative time; surgical infection; vascularised fibular graft for osteonecrosis; subclinical SUFE; and dentists, hips and antibiotics.
To investigate the differences of open reduction and internal
fixation (ORIF) of complex AO Type C distal radius fractures between
two different models of a single implant type. A total of 136 patients who received either a 2.4 mm (n = 61)
or 3.5 mm (n = 75) distal radius locking compression plate (LCP
DR) using a volar approach were followed over two years. The main
outcome measurements included motion, grip strength, pain, and the
scores of Gartland and Werley, the Short-Form 36 (SF-36) and the
Disabilities of the Arm, Shoulder, and Hand (DASH). Differences
between the treatment groups were evaluated using regression analysis
and the likelihood ratio test with significance based on the Bonferroni
corrected p-value of <
0.003.Objectives
Methods
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.
Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion. This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures. We retrospectively reviewed 279 patients (99 obese (BMI ≥ 30) and 180 non-obese (BMI <
30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function. These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.