An experimental piglet model induces avascular necrosis (AVN)
and deformation of the femoral head but its secondary effects on
the developing acetabulum have not been studied. The aim of this
study was to assess the development of secondary acetabular deformation
following femoral head ischemia. Intracapsular circumferential ligation at the base of the femoral
neck and sectioning of the ligamentum teres were performed in three
week old piglets. MRI was then used for qualitative and quantitative
studies of the acetabula in operated and non-operated hips in eight
piglets from 48 hours to eight weeks post-surgery. Specimen photographs and
histological sections of the acetabula were done at the end of the
study. Objectives
Methods
This paper describes the presence of tenodesis effects in normal physiology and explores the uses of operative tenodesis in surgery of the upper limb.
Total knee replacement (TKR) is an operation
that can be performed with or without the use of a tourniquet. Meta-analyses
of the available Level-1 studies have demonstrated that the use
of a tourniquet leads to a significant reduction in blood loss.
The opponents for use of a tourniquet cite development of complications
such as skin bruising, neurovascular injury, and metabolic disturbance
as drawbacks. Although there may certainly be reason for concern
in arteriopathic patients, there is little evidence that routine
use of a tourniquet during TKR results in any of the above complications.
The use of a tourniquet, on the other hand, provides a bloodless
field that allows the surgeon to perform the procedure with expediency
and optimal visualisation. Blood conservation has gained great importance
in recent years due to increased understanding of the problems associated
with blood transfusion, such as increased surgical site infection
(due to immunomodulation effect), increased length of hospital stay
and increased cost. Based on the authors’ understanding of the available
evidence, the routine use of a tourniquet during TKR is justified
as good surgical practice. Cite this article:
The ability of mesenchymal stem cells (MSCs)
to differentiate Despite their increasing application in clinical trials, the
origin and role of MSCs in the development, repair and regeneration
of organs have remained unclear. Until recently, MSCs could only
be isolated in a process that requires culture in a laboratory;
these cells were being used for tissue engineering without understanding
their native location and function. MSCs isolated in this indirect
way have been used in clinical trials and remain the reference standard
cellular substrate for musculoskeletal engineering. The therapeutic
use of autologous MSCs is currently limited by the need for In this annotation we provide an update on the recent developments
in the understanding of the identity of MSCs within tissues and
outline how this may affect their use in orthopaedic surgery in
the future. Cite this article:
A 25-year-old male weightlifter felt increasing intractable low back pain during training but denied any acute injury. The physical examination, blood parameters, radiographs and MRI were unremarkable. He had been treated non-operatively by various means, with only temporary relief. The pressures in the lumbar paraspinal compartment were abnormally high and he was treated by surgical decompression. This gave rapid relief, he returned to training, and one year later the pain had not recurred.
Van Nes rotationplasty may be used for patients
with congenital proximal focal femoral deficiency (PFFD). The lower
limb is rotated to use the ankle and foot as a functional knee joint
within a prosthesis. A small series of cases was investigated to
determine the long-term outcome. At a mean of 21.5 years (11 to
45) after their rotationplasty, a total of 12 prosthetic patients
completed the Short-Form (SF)-36, Faces Pain Scale-Revised, Harris
hip score, Oswestry back pain score and Prosthetic Evaluation Questionnaires,
as did 12 age- and gender-matched normal control participants. A
physical examination and gait analysis, computerised dynamic posturography
(CDP), and timed ‘Up &
Go’ testing was also completed. Wilcoxon
Signed rank test was used to compare each PFFD patient with a matched
control participant with false discovery rate of 5%. There were no differences between the groups in overall health
and well-being on the SF-36. Significant differences were seen in
gait parameters in the PFFD group. Using CDP, the PFFD group had
reduced symmetry in stance, and reduced end point and maximum excursions. Patients who had undergone Van Nes rotationplasty had a high
level of function and quality of life at long-term follow-up, but
presented with significant differences in gait and posture compared
with the control group. Cite this article:
Adult presentation of neglected congenital muscular torticollis is rare. We report 12 patients with this condition who underwent a modified Ferkel’s release comprising a bipolar release of sternocleidomastoid with Z-lengthening. They had a mean age of 24 years (17 to 31) and were followed up for a minimum of two years. Post-operatively a cervical collar was applied for three weeks with intermittent supervised active assisted exercises for six weeks. Outcome was assessed using a modified Lee score and a Cheng and Tang score. The mean pre-operative rotational deficit was 8.25° (0° to 15°) and mean lateral flexion deficit was 20.42° (15° to 30°), which improved after treatment to a mean of 1.67° (0° to 5°) and 7.0° (4° to 14°) after treatment, respectively. According to the modified Lee scoring system, six patients had excellent results, two had good results and four had fair results, and using the Cheng and Tang score, eight patients had excellent results and four had good results. Surgical management of adult patients with neglected congenital muscular torticollis using a modified Ferkel’s bipolar release gives excellent results. The range of neck movement and head tilt improved in all 12 patients and cosmesis improved in 11, despite the long-standing nature of the deformity.
We reviewed the outcome of 69 uncemented, custom-made,
distal femoral endoprosthetic replacements performed in 69 patients
between 1994 and 2006. There were 31 women and 38 men with a mean
age at implantation of 16.5 years (5 to 37). All procedures were
performed for primary malignant bone tumours of the distal femur.
At a mean follow-up of 124.2 months (4 to 212), 53 patients were
alive, with one patient lost to follow-up. All nine implants (13.0%)
were revised due to aseptic loosening at a mean of 52 months (8
to 91); three implants (4.3%) were revised due to fracture of the
shaft of the prosthesis and three patients (4.3%) had a peri-prosthetic
fracture. Bone remodelling associated with periosteal cortical thinning
adjacent to the uncemented intramedullary stem was seen in 24 patients
but this did not predispose to failure. All aseptically loose implants
in this series were diagnosed to be loose within the first five
years. The results from this study suggest that custom-made uncemented
distal femur replacements have a higher rate of aseptic loosening
compared to published results for this design when used with cemented
fixation. Loosening of uncemented replacements occurs early indicating
that initial fixation of the implant is crucial. 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 use of short stems has become more popular
with the increased interest in less invasive approaches for total hip
arthroplasty. The curved broaches and stem can be inserted along
a curved track to avoid the abductor attachments. Short stems have
the potential of being more bone conserving by allowing for higher
neck retention, maintenance of the medial greater trochanter, and
preferential stress transfer to the proximal femur. An initial experience with 500 new short stems (Fitmore, Zimmer
Orthopedics) stems used for total hip arthroplasty is reported.
No stems have been revised for aseptic loosening.
There are several reports clarifying successful results following
open reduction using Ludloff’s medial approach for congenital (CDH)
or developmental dislocation of the hip (DDH). This study aimed
to reveal the long-term post-operative course until the period of
hip-joint maturity after the conventional surgical treatments. A long-term follow-up beyond the age of hip-joint maturity was
performed for 115 hips in 103 patients who underwent open reduction
using Ludloff’s medial approach in our hospital. The mean age at
surgery was 8.5 months (2 to 26) and the mean follow-up was 20.3
years (15 to 28). The radiological condition at full growth of the hip
joint was evaluated by Severin’s classification.Objectives
Methods
We describe the clinical outcome of a technique of surgical augmentation of chronic massive tears of the rotator cuff using a polyester ligament (Dacron) in 21 symptomatic patients (14 men, seven women) with a mean age of 66.5 years (55.0 to 85.0). All patients had MRI and arthroscopic evidence of chronic massive tears. The clinical outcome was assessed using the Constant and Murley and patient satisfaction scores at a mean follow-up of 36 months (30 to 46). The polyester ligament (500 mm × 10 mm) was passed into the joint via the portal of Neviaser, medial to the tear through healthy cuff. The two ends of the ligament holding the cuff were passed through tunnels made in the proximal humerus at the footprint of the insertion of the cuff. The ligament was tied with a triple knot over the humeral cortex. All the patients remained free from pain (p <
0.001) with improvement in function (p <
0.001) and range of movement (p <
0.001). The mean pre-operative and post-operative Constant scores were 46.7 (39.0 to 61.0) and 85.4 (52.0 to 96.0), respectively (p <
0.001). The mean patient satisfaction score was 90%. There were two failures, one due to a ruptured ligament after one year and the other due to deep-seated infection. The MR scan at the final follow-up confirmed intact and thickened bands in 15 of 17 patients. This technique of augmentation gives consistent relief from pain with improved shoulder movement in patients with symptomatic massive tears of the rotator cuff.
The December 2013 Spine Roundup360 looks at: Just how common is lumbar spinal stenosis?; How much will they bleed?; C5 palsy associated with stenosis; Atlanto-axial dislocations revisited; 3D predictors of progression in scoliosis; No difference in outcomes by surgical approach for fusion; Cervical balance changes after thoracolumbar surgery; and spinal surgeons first in space.
A comprehensive study of osteology remains a cornerstone of current orthopaedic and traumatological education. Osteology was already established as an important part of surgical education by the 16th century. In order to teach anatomy and osteology, the corpses of executed criminals were dissected by the
We report the case of an 82-year-old man who
underwent fasciectomy for a severe Dupuytren’s contracture, during which
an ossified lesion was encountered within the contracture and surrounding
the neurovascular bundle. The abnormal tissue was removed with difficulty
and heterotopic ossification was confirmed histologically. We believe this
is the first report of heterotopic ossification in Dupuytren’s disease.
We determined the frequency, rate and extent
of development of scoliosis (coronal plane deformity) in wheelchair-dependent
patients with Duchenne muscular dystrophy (DMD) who were not receiving
steroid treatment. We also assessed kyphosis and lordosis (sagittal
plane deformity). The extent of scoliosis was assessed on sitting anteroposterior
(AP) spinal radiographs in 88 consecutive non-ambulatory patients
with DMD. Radiographs were studied from the time the patients became
wheelchair-dependent until the time of spinal fusion, or the latest assessment
if surgery was not undertaken. Progression was estimated using a
longitudinal mixed-model regression analysis to handle repeated
measurements. Scoliosis ≥ 10° occurred in 85 of 88 patients (97%), ≥ 20° in
78 of 88 (89%) and ≥ 30° in 66 of 88 patients (75%). The fitted
longitudinal model revealed that time in a wheelchair was a highly
significant predictor of the magnitude of the curve, independent
of the age of the patient (p <
0.001). Scoliosis developed in
virtually all DMD patients not receiving steroids once they became
wheelchair-dependent, and the degree of deformity deteriorated over
time. In general, scoliosis increased at a constant rate, beginning
at the time of wheelchair-dependency (p <
0.001). In some there
was no scoliosis for as long as three years after dependency, but
scoliosis then developed and increased at a constant rate. Some
patients showed a rapid increase in the rate of progression of the
curve after a few years – the clinical phenomenon of a rapidly collapsing
curve over a few months. A sagittal plane kyphotic deformity was seen in 37 of 60 patients
(62%) with appropriate radiographs, with 23 (38%) showing lumbar
lordosis (16 (27%) abnormal and seven (11%) normal). This study provides a baseline to assess the effects of steroids
and other forms of treatment on the natural history of scoliosis
in patients with DMD, and an approach to assessing spinal deformity
in the coronal and sagittal planes in wheelchair-dependent patients
with other neuromuscular disorders. Cite this article:
Over a five-year period, adult patients with
marginal impaction of acetabular fractures were identified from
a registry of patients who underwent acetabular reconstruction in
two tertiary referral centres. Fractures were classified according
to the system of Judet and Letournel. A topographic classification
to describe the extent of articular impaction was used, dividing
the joint surface into superior, middle and inferior thirds. Demographic information,
hospitalisation and surgery-related complications, functional (EuroQol
5-D) and radiological outcome according to Matta’s criteria were
recorded and analysed. In all, 60 patients (57 men, three women)
with a mean age of 41 years (18 to 72) were available at a mean
follow-up of 48 months (24 to 206). The quality of the reduction
was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%).
The originally achieved anatomical reduction was lost in Univariate linear regression analysis of the functional outcome
showed that factors associated with worse pain were increasing age
and an inferior location of the impaction. Elevation of the articular
impaction leads to joint preservation with satisfactory overall
medium-term functional results, but secondary collapse is likely
to occur in some patients. Cite this article:
Young adults with hip pain secondary to femoroacetabular
impingement (FAI) are rapidly being recognised as an important cohort
of orthopaedic patients. Interest in FAI has intensified over the
last decade since its recognition as a precursor to arthritis of
the hip and the number of publications related to the topic has
increased exponentially in the last decade. Although not all patients
with abnormal hip morphology develop osteoarthritis (OA), those
with FAI-related joint damage rapidly develop premature OA. There
are no explicit diagnostic criteria or definitive indications for
surgical intervention in FAI. Surgery for symptomatic FAI appears
to be most effective in younger individuals who have not yet developed
irreversible OA. The difficulty in predicting prognosis in FAI means
that avoiding unnecessary surgery in asymptomatic individuals, while
undertaking intervention in those that are likely to develop premature
OA poses a considerable dilemma. FAI treatment in the past has focused
on open procedures that carry a potential risk of complications. Recent developments in hip arthroscopy have facilitated a minimally
invasive approach to the management of FAI with few complications
in expert hands. Acetabular labral preservation and repair appears
to provide superior results when compared with debridement alone.
Arthroscopic correction of structural abnormalities is increasingly becoming
the standard treatment for FAI, however there is a paucity of high-level
evidence comparing open and arthroscopic techniques in patients
with similar FAI morphology and degree of associated articular cartilage damage.
Further research is needed to develop an understanding of the natural
course of FAI, the definitive indications for surgery and the long-term
outcomes. Cite this article:
Total hip replacement (THR) is a very common
procedure undertaken in up to 285 000 Americans each year. Patient
satisfaction with THR is very high, with improvements in general
health, quality of life, and function while at the same time very
cost effective. Although the majority of patients have a high degree
of satisfaction with their THR, 27% experience some discomfort,
and up to 6% experience severe chronic pain. Although it can be
difficult to diagnose the cause of the pain in these patients, this
clinical issue should be approached systematically and thoroughly.
A detailed history and clinical examination can often provide the
correct diagnosis and guide the appropriate selection of investigations, which
will then serve to confirm the clinical diagnosis made. Cite this article:
The December 2013 Oncology Roundup360 looks at: Peri-articular resection fraught with complications; Navigated margins; Skeletal tumours and thromboembolism; Conditional survival in Ewing’s sarcoma; Reverse shoulders and tumour; For how long should we follow up sarcoma patients?; and already metastasised?