The December 2014 Wrist &
Hand Roundup360 looks at: ultrasound for carpal tunnel diagnosis; where we are at with management of undisplaced scaphoid fractures; ARPE for thumb metacarpals?; extravasation injuries in the hand and wrist; research and practice in hand surgery; and physio ineffective in hand osteoarthritis
We report the kinematic and early clinical results
of a patient- and observer-blinded randomised controlled trial in which
CT scans were used to compare potential impingement-free range of
movement (ROM) and acetabular component cover between patients treated
with either the navigated ‘femur-first’ total hip arthroplasty (THA) method
(n = 66; male/female 29/37, mean age 62.5 years; 50 to 74) or conventional
THA (n = 69; male/female 35/34, mean age 62.9 years; 50 to 75).
The Hip Osteoarthritis Outcome Score, the Harris hip score, the
Euro-Qol-5D and the Mancuso THA patient expectations score were
assessed at six weeks, six months and one year after surgery. A
total of 48 of the patients (84%) in the navigated ‘femur-first’
group and 43 (65%) in the conventional group reached all the desirable
potential ROM boundaries without prosthetic impingement for activities
of daily living (ADL) in flexion, extension, abduction, adduction
and rotation (p = 0.016). Acetabular component cover and surface
contact with the host bone were >
87% in both groups. There was
a significant difference between the navigated and the conventional
groups’ Harris hip scores six weeks after surgery (p = 0.010). There
were no significant differences with respect to any clinical outcome
at six months and one year of follow-up. The navigated ‘femur-first’
technique improves the potential ROM for ADL without prosthetic
impingement, although there was no observed clinical difference
between the two treatment groups. Cite this article:
This study identifies early risk factors for symptomatic nonunion
of displaced midshaft fractures of the clavicle that aid identification
of an at risk group who may benefit from surgery. We performed a retrospective study of 88 patients aged between
16 and 60 years that were managed non-operatively. Aims
Methods
The aims of this study were to report functional
outcomes of salvage procedures for patients with cerebral palsy (CP)
who have chronic dislocation of the hip using validated scoring
systems, and to compare the results of three surgical techniques. We reviewed 37 patients retrospectively. The mean age at the
time of surgery was 12.2 years (8 to 22) and the mean follow-up
was 56 months (24 to 114). Patients were divided into three groups:
14 who underwent proximal femoral resection arthroplasty (PFRA group
1), ten who underwent subtrochanteric valgus osteotomy (SVO group 2),
and 13 who underwent subtrochanteric valgus osteotomy with resection
of the femoral head (SVO with FHR group 3). All patients were evaluated
using the Caregiver Priorities and Child Health Index of Life with
Disabilities (CPCHILD) and the Pediatric Quality of Life Inventory
(PedsQL). Significant improvements occurred in most CPCHILD and PedsQL
subsection scores following surgery in all patients, without significant
differences between the groups. There were 12 post-operative complications.
Less severe complications were seen in group 1 than in groups 2
and 3. Salvage surgery appears to provide pain relief in patients with
CP who have painful chronic dislocation of the hip. The three salvage
procedures produced similar results, however, we recommend the use
of PFRA as the complications are less severe. Take home message: Salvage surgery can be of benefit to patients
with CP with chronic painful hip dislocation, but should be limited
to selected patients considering complications. Cite this article:
We evaluated clinical and radiographic outcomes of total shoulder
arthroplasty (TSA) using the second-generation Trabecular Metal
(TM) Glenoid component. The first generation component was withdrawn
in 2005 after a series of failures were reported. Between 2009 and
2012, 40 consecutive patients with unilateral TSA using the second-generation
component were enrolled in this clinical study. The mean age of
the patients was 63.8 years (40 to 75) and the mean follow-up was
38 months (24 to 42). Patients were evaluated using the Constant score (CS), the American
Shoulder and Elbow Surgeons (ASES) score and routine radiographs.Aims
Methods
In this case study, we describe the clinical
presentation and treatment of 36 patients with periosteal chondrosarcoma
collected over a 59-year period by the archive of the Netherlands
Committee on Bone Tumours. The demographics, clinical presentation,
radiological features, treatment and follow-up are presented with
the size, location, the histological grading of the tumour and the
survival. We found a slight predominance of men (61%), and a predilection
for the distal femur (33%) and proximal humerus (33%). The metaphysis
was the most common site (47%) and the most common presentation
was with pain (44%). Half the tumours were classified histologically
as grade 1. Pulmonary metastases were reported in one patient after
an intra-lesional resection. A second patient died from local recurrence
and possible pulmonary and skin metastases after an incomplete resection. It is clearly important to make the diagnosis appropriately because
an incomplete resection may result in local recurrence and metastatic
spread. Staging for metastatic disease is recommended in grade II
or III lesions. These patients should be managed with a contrast-enhanced MRI
of the tumour and histological confirmation by biopsy, followed
by Cite this article:
Injury to the anterior cruciate ligament (ACL)
is one of the most devastating and frequent injuries of the knee. Surgical
reconstruction is the current standard of care for treatment of
ACL injuries in active patients. The widespread adoption of ACL
reconstruction over primary repair was based on early perception
of the limited healing capacity of the ACL. Although the majority
of ACL reconstruction surgeries successfully restore gross joint stability,
post-traumatic osteoarthritis is commonplace following these injuries,
even with ACL reconstruction. The development of new techniques
to limit the long-term clinical sequelae associated with ACL reconstruction
has been the main focus of research over the past decades. The improved
knowledge of healing, along with recent advances in tissue engineering
and regenerative medicine, has resulted in the discovery of novel
biologically augmented ACL-repair techniques that have satisfactory
outcomes in preclinical studies. This instructional review provides
a summary of the latest advances made in ACL repair. Cite this article:
This study aimed to determine the long-term functional,
clinical and radiological outcomes in patients with Schatzker IV
to VI fractures of the tibial plateau treated with an Ilizarov frame.
Clinical, functional and radiological assessment was carried out
at a minimum of one year post-operatively. A cohort of 105 patients
(62 men, 43 women) with a mean age of 49 years (15 to 87) and a
mean follow-up of 7.8 years (1 to 19) were reviewed. There were
18 type IV, 10 type V and 77 type VI fractures. All fractures united
with a mean time to union of 20.1 weeks (10.6 to 42.3). No patient
developed a deep infection. The median range of movement (ROM) of
the knee was 110o and the median Iowa score was 85. Our study demonstrates good long-term functional outcome with
no deep infection; spanning the knee had no detrimental effect on
the ROM or functional outcome. High-energy fractures of the tibial plateau may be treated effectively
with a fine wire Ilizarov fixator. Cite this article:
Analysis of the morphology of the distal femur, and by extension
of the femoral components in total knee arthroplasty (TKA), has
largely been related to the aspect ratio, which represents the width
of the femur. Little is known about variations in trapezoidicity
(i.e. whether the femur is more rectangular or more trapezoidal).
This study aimed to quantify additional morphological characteristics
of the distal femur and identify anatomical features associated
with higher risks of over- or under-sizing of components in TKA. We analysed the shape of 114 arthritic knees at the time of primary
TKA using the pre-operative CT scans. The aspect ratio and trapezoidicity
ratio were quantified, and the post-operative prosthetic overhang
was calculated. We compared the morphological characteristics with
those of 12 TKA models.Aims
Methods
Revision of a cemented hemiarthroplasty of the
hip may be a hazardous procedure with high rates of intra-operative complications.
Removing well-fixed cement is time consuming and risks damaging
already weak bone or perforating the femoral shaft. The cement-in-cement
method avoids removal of intact cement and has shown good results
when used for revision total hip arthroplasty (THA). The use of
this technique for the revision of a hemiarthroplasty to THA has
not been previously reported. A total of 28 consecutive hemiarthroplasties (in 28 patients)
were revised to a THA using an Exeter stem and the cement-in-cement
technique. There were four men and 24 women; their mean age was
80 years (35 to 93). Clinical and radiographic data, as well as
operative notes, were collected prospectively and no patient was
lost to follow-up. Four patients died within two years of surgery. The mean follow
up of the remainder was 70 months (25 to 124). Intra-operatively
there was one proximal perforation, one crack of the
femoral calcar and one acetabular fracture. No femoral components
have required subsequent revision for aseptic loosening or are radiologically loose. Four patients with late complications (14%) have since undergone
surgery (two for a peri-prosthetic fracture, and one each for deep
infection and recurrent dislocation) resulting in an overall major
rate of complication of 35.7%. The cement-in-cement technique provides reliable femoral fixation
in this elderly population and may reduce operating time and rates
of complication. Cite this article:
Treatment of an infected total elbow replacement
(TER) is often successful in eradicating or suppressing the infection.
However, the extensor mechanism may be compromised by both the infection
and the surgery. The goal of this study was to assess triceps function
in patients treated for deep infection complicating a TER. Between
1976 and 2007 a total of 217 TERs in 207 patients were treated for
infection of a TER at our institution. Superficial infections and
those that underwent resection arthroplasty were excluded, leaving
93 TERs. Triceps function was assessed by examination and a questionnaire.
Outcome was measured using the Mayo Elbow Performance Score (MEPS). Triceps weakness was identified in 51 TERs (49 patients, 55%).
At a mean follow-up of five years (0.8 to 34), the extensor mechanism
was intact in 13 patients, with the remaining 38 having bone or
soft-tissue loss. The mean MEPS was 70 points (5 to 100), with a
mean functional score of 18 (0 to 25) of a possible 25 points. Infection following TER can often be eradicated; however, triceps
weakness occurs in more than half of the patients and may represent
a major functional problem. Cite this article:
The October 2015 Foot &
Ankle Roundup360 looks at: TightRope in Weber C fractures; A second look at the TightRope; Incisional VAC comes of age?; Platelet-derived growth factor and ankle fusions; Achilles tendon rehab in the longer term following surgery; Telemedicine for diabetic foot ulcer
The patient with a painful arthritic knee awaiting
total knee arthroplasty (TKA) requires a multidisciplinary approach.
Optimal control of acute post-operative pain and the prevention
of chronic persistent pain remains a challenge. The aim of this
paper is to evaluate whether stratification of patients can help
identify those who are at particular risk for severe acute or chronic
pain. Intense acute post-operative pain, which is itself a risk factor
for chronic pain, is more common in younger, obese female patients
and those suffering from central pain sensitisation. Pre-operative
pain, in the knee or elsewhere in the body, predisposes to central
sensitisation. Pain due to osteoarthritis of the knee may also trigger
neuropathic pain and may be associated with chronic medication like
opioids, leading to a state of nociceptive sensitisation called
‘opioid-induced hyperalgesia’. Finally, genetic and personality
related risk factors may also put patients at a higher risk for
the development of chronic pain. Those identified as at risk for chronic pain would benefit from
specific peri-operative management including reduction in opioid
intake pre-operatively, the peri-operative use of antihyperalgesic
drugs such as ketamine and gabapentinoids, and a close post-operative
follow-up in a dedicated chronic pain clinic. Cite this article:
We are currently facing an epidemic of periprosthetic
fractures around the hip. They may occur either during surgery or
post-operatively. Although the acetabulum may be involved, the femur
is most commonly affected. We are being presented with new, difficult
fracture patterns around cemented and cementless implants, and we
face the challenge of an elderly population who may have grossly
deficient bone and may struggle to rehabilitate after such injuries.
The correct surgical management of these fractures is challenging.
This article will review the current choices of implants and techniques
available to deal with periprosthetic fractures of the femur. Cite this article:
The February 2015 Hip &
Pelvis Roundup360 looks at: Hip arthroplasty in Down syndrome; Bulk femoral autograft successful in acetabular reconstruction; Arthroplasty follow-up: is the internet the solution?; Total hip arthroplasty following acetabular fracture; Salvage arthroplasty following failed hip internal fixation; Bone banking sensible financially and clinically; Allogenic blood transfusion in arthroplasty.
We reviewed 34 consecutive patients (18 female-16 male) with
isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis
who underwent in situ posterolateral arthodesis between the L5 transverse
processes and the sacral ala with the use of iliac crest autograft.
Ten patients had an associated scoliosis which required surgical correction
at a later stage only in two patients with idiopathic curves unrelated
to the spondylolisthesis. No patient underwent spinal decompression or instrumentation
placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative
blood loss 200 ml (150 to 340). There was one wound infection treated
with antibiotics but no other complication. Radiological assessment
included standing posteroanterior and lateral, Ferguson and lateral flexion/extension
views, as well as CT scans. Aims
Methods
Flexor digitorum longus transfer and medial displacement
calcaneal osteotomy is a well-recognised form of treatment for stage
II posterior tibial tendon dysfunction. Although excellent short-
and medium-term results have been reported, the long-term outcome
is unknown. We reviewed the clinical outcome of 31 patients with
a symptomatic flexible flat-foot deformity who underwent this procedure
between 1994 and 1996. There were 21 women and ten men with a mean
age of 54.3 years (42 to 70). The mean follow-up was 15.2 years
(11.4 to 16.5). All scores improved significantly (p <
0.001).
The mean American Orthopedic Foot and Ankle Society (AOFAS) score improved
from 48.4 pre-operatively to 90.3 (54 to 100) at the final follow-up.
The mean pain component improved from 12.3 to 35.2 (20 to 40). The
mean function score improved from 35.2 to 45.6 (30 to 50). The mean
visual analogue score for pain improved from 7.3 to 1.3 (0 to 6).
The mean Short Form-36 physical component score was 40.6 ( Cite this article:
Systemic antibiotics reduce infection in open
fractures. Local delivery of antibiotics can provide higher doses
to wounds without toxic systemic effects. This study investigated
the effect on infection of combining systemic with local antibiotics
via polymethylmethacrylate (PMMA) beads or gel delivery. An established Combined local and systemic antibiotics were superior to systemic
antibiotics alone at reducing the quantity of bacteria recoverable
from each group (p = 0.002 for gel; p = 0.032 for beads). There
was no difference in the bacterial counts between bead and gel delivery
(p = 0.62). These results suggest that local antibiotics augment the antimicrobial
effect of systemic antibiotics. Although no significant difference
was found between vehicles, gel delivery offers technical advantages
with its biodegradable nature, ability to conform to wound shape
and to deliver increased doses. Further study is required to see
if the gel delivery system has a clinical role. Cite this article: