The dismal outcome of tuberculosis of the spine in the pre-antibiotic era has improved significantly because of the use of potent antitubercular drugs, modern diagnostic aids and advances in surgical management. MRI allows the diagnosis of a tuberculous lesion, with a sensitivity of 100% and specificity of 88%, well before deformity develops. Neurological deficit and deformity are the worst complications of spinal tuberculosis. Patients treated conservatively show an increase in deformity of about 15°. In children, a kyphosis continues to increase with growth even after the lesion has healed. Tuberculosis of the spine is a medical disease which is not primarily treated surgically, but operation is required to prevent and treat the complications. Panvertebral lesions, therapeutically refractory disease, severe kyphosis, a developing neurological deficit, lack of improvement or deterioration are indications for surgery. Patients who present with a kyphosis of 60° or more, or one which is likely to progress, require anterior decompression, posterior shortening, posterior instrumented stabilisation and anterior and posterior bone grafting in the active stage of the disease. Late-onset paraplegia is best prevented rather than treated. The awareness and suspicion of an atypical presentation of spinal tuberculosis should be high in order to obtain a good outcome. Therapeutically refractory cases of tuberculosis of the spine are increasing in association with the presence of HIV and multidrug-resistant tuberculosis.
The increasing need for total hip replacement
(THR) in an ageing population will inevitably generate a larger number
of revision procedures. The difficulties encountered in dealing
with the bone deficient acetabulum are amongst the greatest challenges
in hip surgery. The failed acetabular component requires reconstruction
to restore the hip centre and improve joint biomechanics. Impaction
bone grafting is successful in achieving acetabular reconstruction
using both cemented and cementless techniques. Bone graft incorporation
restores bone stock whilst providing good component stability. We
provide a summary of the evidence and current literature regarding impaction
bone grafting using both cemented and cementless techniques in revision
THR. Cite this article:
A total of 92 patients with symptoms for over
six months due to subacromial impingement of the shoulder, who were
being treated with physiotherapy, were included in this study. While
continuing with physiotherapy they waited a further six months for
surgery. They were divided into three groups based on the following
four clinical and radiological criteria: temporary benefit following
steroid injection, pain in the mid-arc of abduction, a consistently positive
Hawkins test and radiological evidence of impingement. Group A fulfilled
all four criteria, group B three criteria and group C two criteria.
A total of nine patients improved while waiting for surgery and
were excluded, leaving 83 who underwent arthroscopic subacromial
decompression (SAD). The new Oxford shoulder score was recorded
pre-operatively and at three and 12 months post-operatively. A total of 51 patients (group A) had a significant improvement
in the mean shoulder score from 18 (13 to 22) pre-operatively to
38 (35 to 42) at three months (p <
0.001). The mean score in
this group was significantly better than in group B (21 patients)
and C (11 patients) at this time. At one year patients in all groups
showed improvement in scores, but patients in group A had a higher
mean score (p = 0.01). At one year patients in groups A and B did
better than those in group C (p = 0.01). Arthroscopic SAD is a beneficial intervention in selected patients.
The four criteria could help identify patients in whom it is likely
to be most effective.
The optimal method for the management of neglected traumatic bifacetal dislocation of the subaxial cervical spine has not been established. We treated four patients in whom the mean delay between injury and presentation was four months (1 to 5). There were two dislocations at the C5-6 level and one each at C4-5 and C3-4. The mean age of the patients was 48.2 years (27 to 60). Each patient presented with neck pain and restricted movement of the cervical spine. Three of the four had a myelopathy. We carried out a two-stage procedure under the same anaesthetic. First, a posterior soft-tissue release and partial facetectomy were undertaken. This allowed partial reduction of the dislocation which was then supplemented by interspinous wiring and corticocancellous graft. Next, through an anterior approach, discectomy, tricortical bone grafting and anterior cervical plating were carried out. All the patients achieved a nearly anatomical reduction and sagittal alignment. The mean follow-up was 2.6 years (1 to 4). The myelopathy settled completely in the three patients who had a pre-operative neurological deficit. There was no graft dislodgement or graft-related problems. Bony fusion occurred in all patients and a satisfactory reduction was maintained. The posteroanterior procedure for neglected traumatic bifacetal dislocation of the subaxial cervical spine is a good method of achieving sagittal alignment with less risk of iatrogenic neurological injury, a reduced operating time, decreased blood loss, and a shorter hospital stay compared with other procedures.
The August 2012 Research Roundup360 looks at: PRP and chondrogenic differentiation; basic fibroblast growth factor; whether glucosamine works; randomised trials; ossification of the ligamentum flavum; treadmill running; inhibiting BMP antagonists; and whether NSAIDs delay union after all.
Traumatic brachial plexus injury causes severe functional impairment
of the arm. Elbow flexion is often affected. Nerve surgery or tendon
transfers provide the only means to obtain improved elbow flexion.
Unfortunately, the functionality of the arm often remains insufficient.
Stem cell therapy could potentially improve muscle strength and
avoid muscle-tendon transfer. This pilot study assesses the safety
and regenerative potential of autologous bone marrow-derived mononuclear
cell injection in partially denervated biceps. Nine brachial plexus patients with insufficient elbow flexion
(i.e., partial denervation) received intramuscular escalating doses
of autologous bone marrow-derived mononuclear cells, combined with
tendon transfers. Effect parameters included biceps biopsies, motor
unit analysis on needle electromyography and computerised muscle tomography,
before and after cell therapy.Objectives
Methods
We have evaluated the clinical effectiveness
of a metal resurfacing inlay implant for osteochondral defects of
the medial talar dome after failed previous surgical treatment.
We prospectively studied 20 consecutive patients with a mean age
of 38 years (20 to 60), for a mean of three years (2 to 5) post-surgery.
There was statistically significant reduction of pain in each of
four situations (i.e., rest, walking, stair climbing and running;
p ≤ 0.01). The median American Orthopaedic Foot and Ankle Society
ankle-hindfoot score improved from 62 (interquartile range (IQR)
46 to 72) pre-operatively to 87 (IQR 75 to 95) at final follow-up
(p <
0.001). The Foot and Ankle Outcome Score improved on all
subscales (p ≤ 0.03). The mean Short-Form 36 physical component
scale improved from 36 (23 to 50) pre-operatively to 45 (29 to 55)
at final follow-up (p = 0.001); the mental component scale did not
change significantly. On radiographs, progressive degenerative changes
of the opposing tibial plafond were observed in two patients. One
patient required additional surgery for the osteochondral defect.
This study shows that a metal implant is a promising treatment for
osteochondral defects of the medial talar dome after failed previous
surgery. Cite this article:
We investigated the functional outcome in patients
who underwent reverse shoulder replacement (RSR) after removal of
a tumour of the proximal humerus. A total of 16 patients (ten women
and six men) underwent this procedure between 1998 and 2011 in our
hospital. Five patients died and one was lost to follow-up. Ten
patients were available for review at a mean follow-up of 46 months
(12 to 136). Eight patients had a primary and two patients a secondary
bone tumour. At final follow up the mean range of active movement was: abduction
78° (30° to 150°); flexion 98° (45° to 180°); external rotation
32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal
Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity
Salvage Score was 70% (30% to 91%). Two patients had a superficial
infection and one had a deep infection and underwent a two-stage
revision procedure. In two patients there was loosening of the RSR;
one dislocated twice. All patients had some degree of atrophy or
pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus
gives acceptable results. Cite this article:
The August 2012 Trauma Roundup360 looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China.
The October 2013 Wrist &
Hand Roundup360 looks at: Cost effectiveness of Dupuytren’s surgery; A 'new horizon' in distal radius imaging; Undisplaced means undisplaced; The mystery of the distal radial fracture continues; How thick is thick enough?: articular cartilage step off revisited; Is the midcarpal joint more important than we think?; Plates and Kirschner wires; Better early results with an IM nail?
Medium-term survivorship of the Oxford phase
3 unicompartmental knee replacement (UKR) has not yet been established
in an Asian population. We prospectively evaluated the outcome of
400 phase 3 Oxford UKRs in 320 Korean patients with a mean age at
the time of operation of 69 years (48 to 82). The mean follow-up
was 5.2 years (1 to 10). Clinical and radiological assessment was
carried out pre- and post-operatively. At five years, the mean Knee
Society knee and functional scores had increased significantly from
56.2 (30 to 91) pre-operatively to 87.2 (59 to 98) (p = 0.034) and
from 59.2 (30 to 93) to 88.3 (50 to 100) (p = 0.021), respectively.
The Oxford knee score increased from a mean of 25.8 (12 to 39) pre-operatively
to 39.8 (25 to 58) at five years (p = 0.038). The ten-year survival
rate was 94% (95% confidence interval 90.1 to 98.0). A total of
14 UKRs (3.5%) required revision. The most common reason for revision
was dislocation of the bearing in 12 (3%). Conversion to a total
knee replacement was required in two patients who developed osteoarthritis
of the lateral compartment. This is the largest published series of UKR in Korean patients.
It shows that the mid-term results after a minimally invasive Oxford
phase 3 UKR can yield satisfactory clinical and functional results
in this group of patients.
A combined anterior and posterior surgical approach
is generally recommended in the treatment of severe congenital kyphosis,
despite the fact that the anterior vascular supply of the spine
and viscera are at risk during exposure. The aim of this study was
to determine whether the surgical treatment of severe congenital thoracolumbar
kyphosis through a single posterior approach is feasible, safe and
effective. We reviewed the records of ten patients with a mean age of 11.1
years (5.4 to 14.1) who underwent surgery either by pedicle subtraction
osteotomy or by vertebral column resection with instrumented fusion
through a single posterior approach. The mean kyphotic deformity improved from 59.9° (45° to 110°)
pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0
months (29 to 85). Spinal cord monitoring was used in all patients
and there were no complications during surgery. These promising
results indicate the possible advantages of the described technique
over the established procedures. We believe that surgery should
be performed in case of documented progression and before structural
secondary curves develop. Our current strategy after documented
progression is to recommend surgery at the age of five years and
when 90% of the diameter of the spinal canal has already developed. Cite this article:
We report the clinical and radiological outcomes
of a series of contemporary cementless ceramic-on-ceramic total hip
replacements (THRs) at ten years in patients aged ≤ 55 years of
age. Pre- and post-operative activity levels are described. A total
of 120 consecutive ceramic cementless THRs were performed at a single
centre in 110 patients from 1997 to 1999. The mean age of the patients
at operation was 45 years (20 to 55). At ten years, four patients
had died and six were lost to follow-up, comprising ten hips. The
mean post-operative Harris hip score was 94.7 (55 to 100). Radiological
analysis was undertaken in 90 available THRs of the surviving 106
hips at final review: all had evidence of stable bony ingrowth,
with no cases of osteolysis. Wear was undetectable. There were four
revisions. The survival for both components with revision for any
cause as an endpoint was 96.5% (95% confidence interval 94.5 to
98.7). The mean modified University of California, Los Angeles activity
level rose from a mean of 6.4 (4 to 10) pre-operatively to 9.0 (6
to 10) at the ten-year post-operative period. Alumina ceramic-on-ceramic bearings in cementless primary THR
in this series have resulted in good clinical and radiological outcomes
with undetectable rates of wear and excellent function in the demanding
younger patient group at ten years. Cite this article:
We evaluated the safety and efficacy of total
knee replacement in patients receiving continuous warfarin therapy. We identified 24 consecutive patients receiving long-term warfarin
therapy who underwent total knee replacement between 2006 and 2008
and compared them with a group of age- and gender-matched patients
not on long-term anticoagulation. Primary observations were changes
in haemoglobin, transfusion rates and complications. Secondary observations
were fluctuations in the international normalised ratio (INR) and
post-operative range of movement. There was no significant difference between the two groups in
pre- or post-operative haemoglobin, incidence of transfusion or
incidence of post-operative complications. There were no surgical
delays due to a high INR level. The mean change in INR during the
peri-operative phase was minimal (mean 0.4; Current American College of Chest Physicians guidelines recommend
bridging therapy for high-risk patients receiving oral anticoagulation
and undergoing major orthopaedic procedures. We have shown that
a safe alternative is to continue the steady-state warfarin peri-operatively
in patients on long-term anticoagulation requiring total knee replacement.
We present the electromyographic (EMG) results
ten years after open decompression of the median nerve at the wrist
and compare them with the clinical and functional outcomes as judged
by Levine’s Questionnaire. This retrospective study evaluated 115
patients who had undergone carpal tunnel decompression at a mean
of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis
was found in 77 patients (67%), including those who were asymptomatic
at ten years. It is necessary to include both clinical and functional results
as well as electromyographic testing in the long-term evaluation
of patients who have undergone carpal tunnel decompression particularly
in those in whom revision surgery is being considered. In doubtful
cases or when there are differing outcomes, self-administered scales
such as Levine’s Questionnaire should prevail over EMG results when
deciding on the need for revision surgery.
We present a series of 35 patients (19 men and
16 women) with a mean age of 64 years (36.7 to 75.9), who underwent
total hip replacement using the ESKA dual-modular short stem with
metal on-polyethylene bearing surfaces. This implant has a modular
neck section in addition to the modular head. Of these patients,
three presented with increasing post-operative pain due to pseudotumour
formation that resulted from corrosion at the modular neck-stem
junction. These patients underwent further surgery and aseptic lymphocytic
vaculitis associated lesions were demonstrated on histological analysis. Retrieval analysis of two modular necks showed corrosion at the
neck-stem taper. Blood cobalt and chromium levels were measured
at a mean of nine months (3 to 28) following surgery. These were
compared with the levels in seven control patients (three men and
four women) with a mean age of 53.4 years (32.1 to 64.1), who had
an identical prosthesis and articulation but with a prosthesis that
had no modularity at neck-stem junction. The mean blood levels of
cobalt in the study group were raised at 50.75 nmol/l (5 to 145)
compared with 5.6 nmol/l (2 to 13) in control patients. Corrosion at neck-stem tapers has been identified as an important
source of metal ion release and pseudotumour formation requiring
revision surgery. Finite element modelling of the dual modular stem
demonstrated high stresses at the modular stem-neck junction. Dual
modular cobalt-chrome hip prostheses should be used with caution
due to these concerns.
We describe five adolescent patients aged between 13 and 16 years with bipartite ossification of the posteromedial aspect of the talus. All presented without a history of trauma. All the ankles had a similar radiological appearance. Clinically, some restriction of movement was noted in three ankles and two subtalar joints, In addition, pain was noted over the posteromedial aspect of the ankle in three patients. In each patient the bipartite fragment was excised through a posteromedial approach to the ankle. Complete resolution was achieved at six months in three patients, with the remaining two describing exercise-induced symptoms. In one of these this precluded participation in sport. Despite numerous anatomical variations within the tarsus, a case series of a bipartite talus has not previously been reported. This anatomical variation should be recognised to avoid misinterpretation as post-traumatic or other pathological processes. In the presence of recalcitrant symptoms excision is an option, but this is not universally successful in abolishing symptoms.
This multicentre prospective clinical trial aimed
to determine whether early administration of alendronate (ALN) delays
fracture healing after surgical treatment of fractures of the distal
radius. The study population comprised 80 patients (four men and
76 women) with a mean age of 70 years (52 to 86) with acute fragility
fractures of the distal radius requiring open reduction and internal
fixation with a volar locking plate and screws. Two groups of 40 patients
each were randomly allocated either to receive once weekly oral
ALN administration (35 mg) within a few days after surgery and continued
for six months, or oral ALN administration delayed until four months
after surgery. Postero-anterior and lateral radiographs of the affected
wrist were taken monthly for six months after surgery. No differences
between groups was observed with regard to gender (p = 1.0), age
(p = 0.916), fracture classification (p = 0.274) or bone mineral
density measured at the spine (p = 0.714). The radiographs were
assessed by three independent assessors. There were no significant
differences in the mean time to complete cortical bridging observed
between the ALN group (3.5 months ( Cite this article:
Metal artefact reduction (MAR) MRI is now widely
considered to be the standard for imaging metal-on-metal (MoM) hip
implants. The Medicines and Healthcare Products Regulatory Agency
(MHRA) has recommended cross-sectional imaging for all patients
with symptomatic MoM bearings. This paper describes the natural
history of MoM disease in a 28 mm MoM total hip replacement (THR)
using MAR MRI. Inclusion criteria were patients with MoM THRs who had
not been revised and had at least two serial MAR MRI scans. All
examinations were reported by an experienced observer and classified
as A (normal), B (infection) or C1–C3 (mild, moderate, severe MoM-related
abnormalities). Between 2002 and 2011 a total of 239 MRIs were performed
on 80 patients (two to four scans per THR); 63 initial MRIs (61%)
were normal. On subsequent MRIs, six initially normal scans (9.5%)
showed progression to a disease state; 15 (15%) of 103 THRs with
sequential scans demonstrated worsening disease on subsequent imaging. Most patients with a MoM THR who do not undergo early revision
have normal MRI scans. Late progression (from normal to abnormal,
or from mild to more severe MoM disease) is not common and takes
place over several years. Cite this article:
In a time of limited resources, the debate continues
over which types of hip prosthesis are clinically superior and more
cost-effective. Orthopaedic surgeons increasingly need robust economic
evidence to understand the full value of the operation, and to aid
decision making on the ‘package’ of procedures that are available
and to justify their practice beyond traditional clinical preference. In this paper we explore the current economic debate about the
merits of cemented and cementless total hip replacement, an issue
that continues to divide the orthopaedic community. Cite this article: