We reviewed the long-term radiological outcome,
complications and revision operations in 19 children with quadriplegic
cerebral palsy and hip dysplasia who underwent combined peri-iliac
osteotomy and femoral varus derotation osteotomy. They had a mean
age of 7.5 years (1.6 to 10.9) and comprised 22 hip dislocations
and subluxations. We also studied the outcome for the contralateral
hip. At a mean follow-up of 11.7 years (10 to 15.1) the Melbourne
cerebral palsy (CP) hip classification was grade 2 in 16 hips, grade
3 in five, and grade 5 in one. There were five complications seen
in four hips (21%, four patients), including one dislocation, one
subluxation, one coxa vara with adduction deformity, one subtrochanteric
fracture and one infection. A recurrent soft-tissue contracture occurred
in five hips and ten required revision surgery. In pre-adolescent children with quadriplegic cerebral palsy good
long-term outcomes can be achieved after reconstruction of the hip;
regular follow-up is required.
Cite this article:
Cementless femoral stems are currently preferred
for total hip replacement (THR) in the United States. Improvements
in stem design, instrumentation and surgical technique have made
this technology highly successful, reproducible, and applicable
to the vast majority of patients requiring a THR. However, there
are ongoing developments in some aspects of stem design that influence
clinical results, the incidence of complications and their inherent adaptability
in accommodating the needs of individual patients. Here we examine
some of these design features. Cite this article:
In an initial randomised controlled trial (RCT)
we segregated 180 patients to one of two knee positions following total
knee replacement (TKR): six hours of knee flexion using either a
jig or knee extension. Outcome measures included post-operative
blood loss, fall in haemoglobin, blood transfusion requirements,
knee range of movement, limb swelling and functional scores. A second
RCT consisted of 420 TKR patients randomised to one of three post-operative
knee positions: flexion for three or six hours post-operatively,
or knee extension. Positioning of the knee in flexion for six hours immediately
after surgery significantly reduced blood loss (p = 0.002). There
were no significant differences in post-operative range of movement,
swelling, pain or outcome scores between the various knee positions
in either study. Post-operative knee flexion may offer a simple
and cost-effective way to reduce blood loss and transfusion requirements
following TKR. We also report a cautionary note regarding the potential risks
of prolonged knee flexion for more than six hours observed during
clinical practice in the intervening period between the two trials,
with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy
at their three-month review. Cite this article:
We prospectively followed 171 patients who underwent
bilateral unicompartmental knee replacement (UKR) over a period
of two years. Of these, 124 (72.5%) underwent a simultaneous bilateral
procedure and 47 (27.5%) underwent a staged procedure. The mean
cumulative operating time and length of hospital stay were both
shorter in the simultaneous group, by 22.5 minutes (p <
0.001)
and three days (p <
0.001), respectively. The mean reduction
in haemoglobin level post-operatively was greater by 0.15 g/dl in
the simultaneous group (p = 0.023), but this did not translate into
a significant increase in the number of patients requiring blood
transfusion (p = 1.000). The mean hospital cost was lower by $8892
in the simultaneous group (p <
0.001). There was no significant
difference in the rate of complications between the groups, and
at two-year follow-up there was no difference in the outcomes between
the two groups. We conclude that simultaneous bilateral UKR can be recommended
as an appropriate treatment for patients with bilateral medial compartment
osteoarthritis of the knee. Cite this article:
To determine the morbidity and mortality outcomes of patients
presenting with a fractured neck of femur in an Australian context.
Peri-operative variables related to unfavourable outcomes were identified
to allow planning of intervention strategies for improving peri-operative
care. We performed a retrospective observational study of 185 consecutive
adult patients admitted to an Australian metropolitan teaching hospital
with fractured neck of femur between 2009 and 2010. The main outcome
measures were 30-day and one-year mortality rates, major complications
and factors influencing mortality. Objectives
Methods
The purpose of this article is to provide the
reader with a seven-step checklist that could help in minimising
the risk of PJI. The check list includes strategies that can be
implemented pre-operatively such as medical optimisation, and reduction
of the bioburden by effective skin preparation or actions taking
during surgery such as administration of timely and appropriate
antibiotics or blood conservation, and finally implementation of
post-operative protocols such as efforts to minimise wound drainage
and haematoma formation. Cite this article:
Early total hip replacement (THR) for acetabular
fractures offers accelerated rehabilitation, but a high risk of heterotopic
ossification (HO) has been reported. The purpose of this study was
to evaluate the incidence of HO, its associated risk factors and
functional impact. A total of 40 patients with acetabular fractures
treated with a THR weres retrospectively reviewed. The incidence
and severity of HO were evaluated using the modified Brooker classification,
and the functional outcome assessed. The overall incidence of HO
was 38%
(n = 15), with nine severe grade III cases. Patients who underwent
surgery early after injury had a fourfold increased chance of developing
HO. The mean blood loss and operating time were more than twice
that of those whose surgery was delayed (p = 0.002 and p <
0.001,
respectively). In those undergoing early THR, the incidence of grade
III HO was eight times higher than in those in whom THR was delayed
(p = 0.01). Only three of the seven patients with severe HO showed
good or excellent Harris hip scores compared with eight of nine
with class 0, I or II HO (p = 0.049). Associated musculoskeletal
injuries, high-energy trauma and head injuries were associated with
the development of grade III HO. The incidence of HO was significantly higher in patients with
a displaced acetabular fracture undergoing THR early compared with
those undergoing THR later and this had an adverse effect on the
functional outcome. Cite this article:
We compared the clinical, radiological and quality-of-life
outcomes between hybrid and total pedicle screw instrumentation
in patients undergoing surgery for neuromuscular scoliosis. Total pedicle screw instrumentation provided shorter operating
times, less blood loss and better correction of the major curve
compared with hybrid constructs in patients undergoing surgery for
neuromuscular scoliosis.
This prospective multicentre study was undertaken
to determine whether the timing of the post-operative administration
of bisphosphonate affects fracture healing and the rate of complication
following an intertrochanteric fracture. Between August 2008 and
December 2009, 90 patients with an intertrochanteric fracture who
underwent internal fixation were randomised to three groups according
to the timing of the commencement of risedronate treatment after
surgery: Group A (from one week after surgery), Group B (from one
month after surgery), and Group C (from three months after surgery).
The radiological time to fracture healing was assessed as the primary
endpoint, and the incidence of complications, including excessive
displacement or any complication requiring revision surgery, as
the secondary endpoint. The mean time to fracture healing post-operatively
in groups A, B and C was 10.7 weeks ( This study demonstrates that the timing of the post-operative
administration of bisphosphonates does not appear to affect the
rate of healing of an intertrochanteric fracture or the incidence
of complications.
The outcome of an anatomical shoulder replacement
depends on an intact rotator cuff. In 1981 Grammont designed a novel
large-head reverse shoulder replacement for patients with cuff deficiency.
Such has been the success of this replacement that it has led to
a rapid expansion of the indications. We performed a systematic
review of the literature to evaluate the functional outcome of each
indication for the reverse shoulder replacement. Secondary outcome
measures of range of movement, pain scores and complication rates
are also presented.
Obesity is a risk factor for complications following
many orthopaedic procedures. The purpose of this study was to investigate
whether obesity was an independent risk factor increasing the rate
of complications following periacetabular osteotomy (PAO) and to
determine whether radiographic correction after PAO was affected
by obesity. We retrospectively collected demographic, clinical and radiographic
data on 280 patients (231 women; 82.5% and 49 men; 17.5%) who were
followed for a mean of 48 months (12 to 60) after PAO. A total of
65 patients (23.2%) were obese (body mass index (BMI) >
30 kg/m2).
Univariate and multivariate analysis demonstrated that BMI was an independent
risk factor associated with the severity of the complications. The
average probability of a patient developing a major complication
was 22% (95% confidence interval (CI) 11.78 to 38.21) for an obese
patient compared with 3% (95% CI 1.39 to 6.58) for a non-obese patient
The odds of a patient developing a major complication were 11 times
higher (95% CI 4.71 to 17.60, p <
0.0001) for an obese compared
with a non-obese patient. Following PAO surgery, there was no difference in radiographic
correction between obese and non-obese patients. PAO procedures
in obese patients correct the deformity effectively but are associated
with an increased rate of complications. Cite this article:
Direct anterior approaches to the hip have gained
popularity as a minimally invasive method when performing primary
total hip replacement (THR). A retrospective review of a single
institution joint registry was performed in order to compare patient
outcomes after THR using the Anterior Supine Intermuscular (ASI)
approach Cite this article
Mobile-bearing unicompartmental knee replacements
(UKRs) with a flat tibial plateau have not performed well in the
lateral compartment, owing to a high dislocation rate. This led
to the development of the Domed Lateral Oxford UKR (Domed OUKR)
with a biconcave bearing. The aim of this study was to assess the
survival and clinical outcomes of the Domed OUKR in a large patient
cohort in the medium term. We prospectively evaluated 265 consecutive knees with isolated
disease of the lateral compartment and a mean age at surgery of
64 years (32 to 90). At a mean follow-up of four years ( The Domed Lateral OUKR gives good clinical outcomes, low re-operation
and revision rates and a low dislocation rate in patients with isolated
lateral compartmental disease, in the hands of the designer surgeons. Cite this article:
We carried out a systematic review of the literature
to evaluate the evidence regarding the clinical results of the Ilizarov
method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one
prospective study and 33 case-series) met our inclusion criteria.
Although several studies were unsatisfactory in terms of statistical
heterogeneity, our analysis appears to show that the Ilizarov method
of distraction osteogenesis significantly reduced the risk of deep
infection in infected osseous lesions (risk ratio 0.14 (95% confidence
interval (CI) 0.10 to 0.20), p <
0.001). However, there was a
rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular
complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of
2.9% (95% CI 1.4 to 4.4).The data was generally not statistically
heterogeneous. Where tibial defects were >
8 cm, the risk of re-fracture
increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary
amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the
need for careful patient selection. Cite this article:
Total hip replacement (THR) has been shown to
be a cost-effective procedure. However, it is not risk-free. Certain conditions,
such as diabetes mellitus, are thought to increase the risk of complications.
In this study we have evaluated the prevalence of diabetes mellitus
in patients undergoing THR and the associated risk of adverse operative
outcomes. A meta-analysis and systematic review were conducted according
to the guidelines of the meta-analysis of observational studies
in epidemiology. Inclusion criteria were observational studies reporting
the prevalence of diabetes in the study population, accompanied
by reports of at least one of the following outcomes: venous thromboembolic
events; acute coronary events; infections of the urinary tract,
lower respiratory tract or surgical site; or requirement for revision
arthroplasty. Altman and Bland’s methods were used to calculate differences
in relative risks. The prevalence of diabetes mellitus was found
to be 5.0% among patients undergoing THR, and was associated with
an increased risk of established surgical site infection (odds ratio
(OR) 2.04 (95% confidence interval (CI) 1.52 to 2.76)), urinary
infection (OR 1.43 (95% CI 1.33 to 1.55)) and lower respiratory
tract infections (OR 1.95 (95% CI 1.61 to 2.26)). Diabetes mellitus
is a relatively common comorbidity encountered in THR. Diabetic
patients have a higher rate of developing both surgical site and
non-surgical site infections following THR. Cite this article:
The December 2023 Oncology Roundup. 360. looks at: A single osteotomy technique for frozen autograft;
The indications for reverse shoulder arthroplasty
(RSA) continue to be expanded. Associated impairment of the deltoid
muscle has been considered a contraindication to its use, as function
of the RSA depends on the deltoid and impairment of the deltoid
may increase the risk of dislocation. The aim of this retrospective
study was to determine the functional outcome and risk of dislocation
following the use of an RSA in patients with impaired deltoid function.
Between 1999 and 2010, 49 patients (49 shoulders) with impairment
of the deltoid underwent RSA and were reviewed at a mean of 38 months
(12 to 142) post-operatively. There were nine post-operative complications (18%),
including two dislocations. The mean forward elevation improved
from 50° ( These results suggest that pre-operative deltoid impairment,
in certain circumstances, is not an absolute contraindication to
RSA. This form of treatment can yield reliable improvement in function
without excessive risk of post-operative dislocation. Cite this article:
The purpose of this study was to examine the
complications and outcomes of total hip replacement (THR) in super-obese
patients (body mass index (BMI) >
50 kg/m2) compared
with class I obese (BMI 30 to 34.9 kg/m2) and normal-weight
patients (BMI 18.5 to 24.9 kg/m2), as defined by the
World Health Organization. A total of 39 THRs were performed in 30 super-obese patients
with a mean age of 53 years (31 to 72), who were followed for a
mean of 4.2 years (2.0 to 11.7). This group was matched with two
cohorts of normal-weight and class I obese patients, each comprising
39 THRs in 39 patients. Statistical analysis was performed to determine differences
among these groups with respect to complications and satisfaction
based on the Western Ontario and McMaster Universities (WOMAC) osteoarthritis
index, the Harris hip score (HHS) and the Short-Form (SF)-12 questionnaire. Super-obese patients experienced significantly longer hospital
stays and higher rates of major complications and readmissions than
normal-weight and class I obese patients. Although super-obese patients
demonstrated reduced pre-operative and post-operative satisfaction
scores, there was no significant difference in improvement, or change in
the score, with respect to HHS or the WOMAC osteoarthritis index. Super-obese patients obtain similar satisfaction outcomes as
class I obese and normal-weight patients with respect to improvement
in their scores. However, they experience a significant increase
in length of hospital stay and major complication and readmission
rates. Cite this article:
We undertook a retrospective case-control study
to assess the clinical variables associated with infections in open fractures.
A total of 1492 open fractures were retrieved; these were Gustilo
and Anderson grade I in 663 (44.4%), grade II in 370 (24.8%), grade
III in 310 (20.8%) and unclassifiable in 149 (10.0%). The median
duration of prophylaxis was three days (interquartile range (IQR)
1 to 3), and the median number of surgical interventions was two
(1 to 9). We identified 54 infections (3.6%) occurring at a median
of ten days (IQR 5 to 20) after trauma. Pathogens intrinsically
resistant to the empirical antibiotic regimen used (enterococci, Infection in open fractures is related to the extent of tissue
damage but not to the duration of prophylactic antibiotic therapy.
Even for grade III fractures, a one-day course of prophylactic antibiotics
might be as effective as prolonged prophylaxis. Cite this article:
Aims. Proximal humeral fractures are the third most common fracture among the elderly.