The number of arthroplasties being undertaken
is expected to grow year on year, and periprosthetic joint infections will
be an increasing socioeconomic burden. The challenge to prevent
and eradicate these infections has resulted in the emergence of
several new strategies, which are discussed in this review. Cite this article:
This article presents an overview of mycetoma
and offers guidelines for orthopaedic surgeons who may be involved in
the care of patients with this condition. Cite this article:
This review examines the future of total hip arthroplasty, aiming to avoid past mistakes
The aim of this study was to report the incidence
of arthrofibrosis of the knee and identify risk factors for its development
following a fracture of the tibial plateau. We carried out a retrospective
review of 186 patients (114 male, 72 female) with a fracture of
the tibial plateau who underwent open reduction and internal fixation.
Their mean age was 46.4 years (19 to 83) and the mean follow-up
was16.0 months (6 to 80). A total of 27 patients (14.5%) developed arthrofibrosis requiring
a further intervention. Using multivariate regression analysis,
the use of a provisional external fixator (odds ratio (OR) 4.63,
95% confidence interval (CI) 1.26 to 17.7, p = 0.021) was significantly
associated with the development of arthrofibrosis. Similarly, the
use of a continuous passive movement (CPM) machine was associated
with significantly less development of arthrofibrosis (OR = 0.32,
95% CI 0.11 to 0.83, p = 0.024). The effect of time in an external
fixator was found to be significant, with each extra day of external
fixation increasing the odds of requiring manipulation under anaesthesia
(MUA) or quadricepsplasty by 10% (OR = 1.10, p = 0.030). High-energy
fracture, surgical approach, infection and use of tobacco were not
associated with the development of arthrofibrosis. Patients with
a successful MUA had significantly less time to MUA (mean 2.9 months; Based our results, CPM following operative fixation for a fracture
of the tibial plateau may reduce the risk of the development of
arthrofibrosis, particularly in patients who also undergo prolonged
provisional external fixation. Cite this article:
This article is a systematic review of the published
literature about the biomechanics, functional outcome and complications
of intramedullary nailing of fractures of the distal radius. We searched the Medline and EMBASE databases and included all
studies which reported the outcome of intramedullary (IM) nailing
of fractures of the distal radius. Data about functional outcome,
range of movement (ROM), strength and complications, were extracted.
The studies included were appraised independently by both authors
using a validated quality assessment scale for non-controlled studies
and the CONSORT statement for randomised controlled trials (RCTs). The search strategy revealed 785 studies, of which 16 were included
for full paper review. These included three biomechanical studies,
eight case series and five randomised controlled trials (RCTs). The biomechanical studies concluded that IM nails were at least
as strong as locking plates. The clinical studies reported that
IM nailing gave a comparable ROM, functional outcome and grip strength
to other fixation techniques. However, the mean complication rate of intramedullary nailing
was 17.6% (0% to 50%). This is higher than the rates reported in
contemporary studies for volar plating. It raises concerns about
the role of intramedullary nailing, particularly when comparative
studies have failed to show that it has any major advantage over
other techniques. Further adequately powered RCTs comparing the
technique to both volar plating and percutaneous wire fixation are needed. Cite this article:
Bone sarcomas are rare cancers and orthopaedic
surgeons come across them infrequently, sometimes unexpectedly during
surgical procedures. We investigated the outcomes of patients who
underwent a surgical procedure where sarcomas were found unexpectedly
and were subsequently referred to our unit for treatment. We identified
95 patients (44 intra-lesional excisions, 35 fracture fixations,
16 joint replacements) with mean age of 48 years (11 to 83); 60%
were males (n = 57). Local recurrence arose in 40% who underwent
limb salvage surgery Cite this article:
The December 2013 Wrist &
Hand Roundup360 looks at: Scapholunate instability; three-ligament tenodesis; Pronator quadratus; Proximal row carpectomy; FPL dysfunction after volar plate fixation; Locating the thenar branch of the median nerve; Metallosis CMCJ arthroplasties; and timing of flap reconstruction
The Unified Classification System (UCS) was introduced
because of a growing need to have a standardised universal classification
system of periprosthetic fractures. It combines and simplifies many
existing classification systems, and can be applied to any fracture
around any partial or total joint replacement occurring during or
after operation. Our goal was to assess the inter- and intra-observer
reliability of the UCS in association with knee replacement when
classifying fractures affecting one or more of the femur, tibia
or patella. We used an international panel of ten orthopaedic surgeons with
subspecialty fellowship training and expertise in adult hip and
knee reconstruction (‘experts’) and ten residents of orthopaedic
surgery in the last two years of training (‘pre-experts’). They
each received 15 radiographs for evaluation. After six weeks they
evaluated the same radiographs again but in a different order. The reliability was assessed using the Kappa and weighted Kappa
values. The Kappa values for inter-observer reliability for the experts
and the pre-experts were 0.741 (95% confidence interval (CI) 0.707
to 0.774) and 0.765 (95% CI 0.733 to 0.797), respectively. The weighted
Kappa values for intra-observer reliability for the experts and
pre-experts were 0.898 (95% CI 0.846 to 0.950) and 0.878 (95% CI
0.815 to 0.942) respectively. The UCS has substantial inter-observer reliability and ‘near
perfect’ intra-observer reliability when used for periprosthetic
fractures in association with knee replacement in the hands of experienced
and inexperienced users. Cite this article:
In this study we evaluated whether the Instability
Severity Index Score (ISIS) and the Western Ontario Shoulder Instability
Index (WOSI) could detect those patients at risk of failure following
arthroscopic Bankart repair. Between April 2008 and June 2010, the
ISIS and WOSI were recorded pre-operatively in 110 patients (87
male, 79%) with a mean age of 25.1 years (16 to 61) who underwent
this procedure for recurrent anterior glenohumeral instability. A telephone interview was performed two-years post-operatively
to determine whether patients had experienced a recurrent dislocation
and whether they had returned to pre-injury activity levels. In
all, six (5%) patients had an ISIS >
6 points (0 to 9). Of 100 (91%)
patients available two years post-operatively, six (6%) had a recurrent dislocation,
and 28 (28%) did not return to pre-injury activity. No patient who
dislocated had an ISIS >
6 (p = 1.0). There was no difference in
the mean pre-operative WOSI in those who had a re-dislocation and
those who did not (p = 0.99). The pre-operative WOSI was significantly
lower (p = 0.02) in those who did not return to pre-injury activity, whereas
the ISIS was not associated with return to pre-injury activity (p
= 0.13). In conclusion, neither the pre-operative ISIS nor WOSI predicted
recurrent dislocation within two years of arthroscopic Bankart repair.
Patients with a lower pre-operative WOSI were less likely to return
to pre-injury activity. Cite this article:
The December 2014 Oncology Roundup360 looks at: metaphyseal and diaphyseal osteosarcoma subtly different beasts; sports and endoprosthetic reconstruction of the knee; is curettage without tissue diagnosis sensible in cartilaginous tumours?; autoclaved autograft in bone tumour reconstruction; vascularised graft a step too far in bone defects?; interdigitated neoadjuvant chemoradiotherapy in high-grade sarcoma; predicting life expectancy in patients with painful metastasis; and osteolytic lesions of the hands and feet.
To prevent insufficiency of the triceps after
total elbow arthroplasty, we have, since 2008, used a triceps-sparing ulnar
approach. This study evaluates the clinical results and post-operative
alignment of the prosthesis using this approach. We reviewed 25 elbows in 23 patients. There were five men and
18 women with a mean age of 69 years (54 to 83). There were 18 elbows
with rheumatoid arthritis, six with a fracture or pseudoarthrosis
and one elbow with osteoarthritis. Post-operative complications included one intra-operative fracture,
one elbow with heterotopic ossification, one transient ulnar nerve
palsy, and one elbow with skin necrosis, but no elbow was affected
by insufficiency of the triceps. Patients were followed for a mean of 42 months (24 to 77). The
mean post-operative Japanese Orthopaedic Association Elbow Score
was 90.8 (51 to 100) and the mean Mayo Elbow Performance score 93.8
(65 to 100). The mean post-operative flexion/extension of the elbow
was 135°/-8°. The Manual Muscle Testing score of the triceps was
5 in 23 elbows and 2 in two elbows (one patient). The mean alignment
of the implants examined by 3D-CT was 2.8° pronation (standard deviation
( The triceps-sparing ulnar approach allows satisfactory alignment
of the implants, is effective in preventing post-operative triceps
insufficiency, and gives satisfactory short-term results. Cite this article: 2015;97-B:1096–1101.
We evaluated the outcome of treatment of nonunion
of an intracapsular fracture of the femoral neck in young patients
using two cannulated screws and a vascularised bone graft. A total
of 32 patients (15 women and 17 men, with a mean age of 36.5 years;
20 to 50) with failed internal fixation of an intracapsular fracture
were included in the study. Following removal of the primary fixation,
two cannulated compression screws were inserted with a vascularised
iliac crest bone graft based on the ascending branch of the lateral
femoral circumflex artery. At a mean follow-up of 6.8 years (4 to 10), union was achieved
in 27 hips (84%). A total of five patients with a mean age of 40.5
years (35 to 50) had a persistent nonunion and underwent total hip
arthroplasty as also did two patients whose fracture united but
who developed osteonecrosis of the femoral head two years post-operatively. Statistical
analysis showed that younger patients achieved earlier and more
reliable union (p <
0.001). The functional outcome, as assessed
by the Harris Hip score, was better in patients aged <
45 years
compared with those aged >
45 years (p <
0.001). These findings suggest that further fixation using two cannulated
compression screws and a vascularised iliac crest bone graft is
an effective salvage treatment in patients aged <
45 years, in
whom osteosynthesis of a displaced intracapsular fractures of the
femoral neck has failed. Cite this article:
Because there have been no standard methods to determine pre-operatively
the thickness of resection of the proximal tibia in unicompartmental
knee arthroplasty (UKA), information about the relationship between
the change of limb alignment and the joint line elevation would
be useful for pre-operative planning. The purpose of this study
was to clarify the correlation between the change of limb alignment
and the change of joint line height at the medial compartment after
UKA. A consecutive series of 42 medial UKAs was reviewed retrospectively.
These patients were assessed radiographically both pre- and post-operatively
with standing anteroposterior radiographs. The thickness of bone
resection at the proximal tibia and the distal femur was measured
radiographically. The relationship between the change of femorotibial
angle (δFTA) and the change of joint line height, was analysed.Objectives
Methods
We prospectively assessed the diagnostic accuracy
of the gravity stress test and clinical findings to evaluate the stability
of the ankle mortise in patients with supination–external rotation-type
fractures of the lateral malleolus without widening of the medial
clear space. The cohort included 79 patients with a mean age of
44 years (16 to 82). Two surgeons assessed medial tenderness, swelling
and ecchymosis and performed the external rotation (ER) stress test
(a reference standard). A diagnostic radiographer performed the
gravity stress test. For the gravity stress test, the positive likelihood ratio (LR)
was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and
the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate
change from the pre-test probability. Medial tenderness, both alone
and in combination with swelling and/or ecchymosis, indicated a
small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47),
whereas swelling and ecchymosis indicated only minimal changes (positive
LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). In conclusion, when gravity stress test results are in agreement
with clinical findings, the result is likely to predict stability
of the ankle mortise with an accuracy equivalent to ER stress test
results. When clinical examination suggests a medial-side injury,
however, the gravity stress test may give a false negative result. Cite this article:
The long term biological effects of wear products
following total hip arthroplasty (THA) are unclear. However, the indications
for THA are expanding, with increasingly younger patients undergoing
the procedure. This prospective, randomised study compared two groups of patients
undergoing THA after being randomised to receive one of two different
bearing surfaces: metal-on-polyethylene (MoP) n = 22 and metal-on-metal
(MoM) n = 23. We investigated the relationship between three variables:
bearing surface (MoP Our results demonstrated significantly higher mean cobalt and
chromium (Co and Cr) blood levels in the MoM group at all follow-up
points following surgery (p <
0.01), but there were no significant
differences in the chromosomal aberration indices between MoM and
MoP at two or five years (two years: p = 0.56, p = 0.08, p = 0.91, p
= 0.51 and five years: p = 0.086, p = 0.73, p = 0.06, p = 0.34)
for translocations, breaks, loss and gain of chromosomes respectively.
Regression analysis showed a strong linear relationship between
Cr levels and the total chromosomal aberration indices in the MoM
group (R2 = 0.90016), but this was not as strong for
Co (R2 = 0.68991). In the MoP group, the analysis revealed
a poor relationship between Cr levels and the total chromosomal
aberration indices (R2 = 0.23908) but a slightly stronger
relationship for Co (R2 = 0.64292). Across both groups,
Spearman’s correlation detected no overall association between Co and Cr
levels and each of the studied chromosomal aberrations. There remains
no clear indication which THA bearing couple is the most biocompatible,
especially in young active patients. While THA continues to be very
successful at alleviating pain and restoring function, the long-term
biological implications of the procedure still require further scrutiny. Cite this article:
A rigorous approach to developing, delivering and documenting
rehabilitation within randomised controlled trials of surgical interventions
is required to underpin the generation of reliable and usable evidence.
This article describes the key processes used to ensure provision
of good quality and comparable rehabilitation to all participants
of a multi-centre randomised controlled trial comparing surgery
with conservative treatment of proximal humeral fractures in adults. These processes included the development of a patient information
leaflet on self-care during sling immobilisation, the development
of a basic treatment physiotherapy protocol that received input
and endorsement by specialist physiotherapists providing patient
care, and establishing an expectation for the provision of home
exercises. Specially designed forms were also developed to facilitate
reliable reporting of the physiotherapy care that patients received.Objectives
Methods
The June 2014 Oncology Roundup360 looks at: Infection still a problem in endoprosthetic reconstruction; massive allografts not as successful as we perhaps think; curopsy for aneurysmal bone cysts?; lengthening prosthesis: days are numbered; new WHO classification in brief; proximal tumours and fluid levels: bad news; infection is predictable in orthopaedic oncology; psychosocial support key in oncological outcomes.
The interaction between the lumbosacral spine
and the pelvis is dynamically related to positional change, and
may be complicated by co-existing pathology. This review summarises
the current literature examining the effect of sagittal spinal deformity
on pelvic and acetabular orientation during total hip arthroplasty
(THA) and provides recommendations to aid in placement of the acetabular
component for patients with co-existing spinal pathology or long
spinal fusions. Pre-operatively, patients can be divided into four
categories based on the flexibility and sagittal balance of the
spine. Using this information as a guide, placement of the acetabular
component can be optimal based on the type and significance of co-existing
spinal deformity. Cite this article:
Degenerative problems of the hip in patients
with childhood and adult onset neuromuscular disorders can be challenging
to treat. Many orthopaedic surgeons are reluctant to recommend total
hip replacement (THR) for patients with underlying neuromuscular
disorders due to the perceived increased risks of dislocation, implant loosening,
and lack of information about the functional outcomes and potential
benefits of these procedures in these patients. Modular femoral
components and alternative bearings which facilitate the use of
large femoral heads, constrained acetabular components and perhaps
more importantly, a better understanding about the complications
and outcomes of THR in the patient with neuromuscular disorders,
make this option viable. This paper will review the current literature
and our experience with THR in the more frequently encountered neuromuscular
disorders. Cite this article:
Clinical studies of patients with bone sarcomas have been challenged
by insufficient numbers at individual centres to draw valid conclusions.
Our objective was to assess the feasibility of conducting a definitive
multi-centre randomised controlled trial (RCT) to determine whether
a five-day regimen of post-operative antibiotics, in comparison
to a
24-hour regimen, decreases surgical site infections in patients
undergoing endoprosthetic reconstruction for lower extremity primary
bone tumours. We performed a pilot international multi-centre RCT. We used
central randomisation to conceal treatment allocation and sham antibiotics
to blind participants, surgeons, and data collectors. We determined
feasibility by measuring patient enrolment, completeness of follow-up,
and protocol deviations for the antibiotic regimens. Objective
Methods