The June 2012 Research Roundup360 looks at: platelet-rich plasma; ageing, bone and mesenchymal stem cells; cytokines and the herniated intervertebral disc; ulcerative colitis, Crohn’s disease and anti-inflammatories; the effect of NSAIDs on bone healing; osteoporosis of the fractured hip; herbal medicine and recovery after acute muscle injury; and ultrasound and the time to fracture union.
We reviewed 78 femoral and tibial nonunions treated between January 1992 and December 2003. Of these, we classified 41 in 40 patients as complex cases because of infection (22), bone loss (6) or failed previous surgery (13). The complex cases were all treated with Ilizarov frames. At a mean time of 14.1 months (4 to 38), 39 had healed successfully. Using the Association for the Study and Application of the Methods of Ilizarov scoring system we obtained 17 excellent, 14 good, four fair and six poor bone results. The functional results were excellent in 14 patients, good in 14, fair in two and poor in two. A total of six patients were lost to follow-up and two had amputations so were not evaluated for final functional assessment. All but two patients were very satisfied with the results. The average cost of treatment to the treating hospital was approximately £30 000 per patient. We suggest that early referral to a tertiary centre could reduce the morbidity and prolonged time off work for these patients. The results justify the expense, but the National Health Service needs to make financial provision for the reconstruction of this type of complex nonunion.
The April 2012 Shoulder &
Elbow Roundup360 looks at katakori in Japan, frozen shoulder, if shoulder impingement actually exists, shoulder arthroscopy and suprascapular nerve blocks, why shoulder replacements fail, the infected elbow replacement, the four-part fracture, the acromion index, and arm transplantation
We used demineralised bone matrix (DBM) to augment re-attachment of tendon to a metal prosthesis in an A significant increase of 23.5% was observed in functional weight-bearing at six weeks in the DBM-augmented group compared with non-augmented controls (p = 0.004). By 12 weeks augmentation with DBM resulted in regeneration of a more direct-type enthesis, with regions of fibrocartilage, mineralised fibrocartilage and bone. In the controls the interface was predominantly indirect, with the tendon attached to the bone graft-hydroxyapatite base plate by perforating collagen fibres.
Dislocation of the shoulder may occur during
seizures in epileptics and other patients who have convulsions. Following
the initial injury, recurrent instability is common owing to a tendency
to develop large bony abnormalities of the humeral head and glenoid
and a susceptibility to further seizures. Assessment is difficult
and diagnosis may be missed, resulting in chronic locked dislocations
with protracted morbidity. Many patients have medical comorbidities,
and successful treatment requires a multidisciplinary approach addressing
the underlying seizure disorder in addition to the shoulder pathology.
The use of bony augmentation procedures may have improved the outcomes
after surgical intervention, but currently there is no evidence-based
consensus to guide treatment. This review outlines the epidemiology
and pathoanatomy of seizure-related instability, summarising the
currently-favoured options for treatment, and their results.
The open blast fracture of the pelvis is considered
to be the most severe injury within the spectrum of battlefield trauma.
We report our experience of 29 consecutive patients who had sustained
this injury in Afghanistan between 2008 and 2010. Their median new
injury severity score (NISS) was 41 (8 to 75), and mean blood requirement
in the first 24 hours was 60.3 units (0 to 224). In addition to
their orthopaedic injury, six had an associated vascular injury, seven
had a bowel injury, 11 had a genital injury and seven had a bladder
injury. In all, eight fractures were managed definitively with external
fixation and seven required internal fixation. Of those patients
who underwent internal fixation, four required removal of metalwork
for infection. Faecal diversion was performed in nine cases. The
median length of hospital stay following emergency repatriation
to the United Kingdom was 70.5 days (5 to 357) and the mean total
operating time was 29.6 hours (5 to 187). At a mean follow-up of
20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk
and 26 (89.7%) had clinical and radiological evidence of stability
of the pelvic ring. As a result of the increase in terrorism, injuries that were
previously confined exclusively to warfare can now occur anywhere,
with civilian surgeons who are involved in trauma care potentially
required to manage similar injuries. Our study demonstrates that
the management of this injury pattern demands huge resources and significant
multidisciplinary input. Given the nature of the soft-tissue injury,
we would advocate external fixation as the preferred management
of these fractures. With the advent of emerging wound and faecal
management techniques, we do not believe that faecal diversion is
necessary in all cases.
The Bologna–Oxford (BOX) total ankle replacement
(TAR) was developed with the aim of achieving satisfactory pain-free
movement of the ankle. To date, only one single multicentre study
has reported its clinical results. The aim of this study was to
conduct an independent review of its mid-term results. We retrospectively reviewed a total of 60 prospectively followed
patients in whom 62 BOX TARs had been implanted between 2004 and
2008. We used the American Orthopedic Foot and Ankle Society (AOFAS)
score to assess the clinical results. Standardised radiographs taken
at the time of final follow-up were analysed by two observers. The
overall survival was 91.9% at a mean follow-up of 42.5 months (24
to 71). The mean AOFAS score had improved from 35.1 points (
An international faculty of orthopaedic surgeons
presented their work on the current challenges in hip surgery at
the London Hip Meeting which was attended by over
400 delegates. The topics covered included femoroacetabular impingement, thromboembolic
phenomena associated with hip surgery, bearing surfaces (including metal-on-metal
articulations), outcomes of hip replacement surgery and revision
hip replacement. We present a concise report of the current opinions
on hip surgery from this meeting with appropriate references to
the current literature.
Up to 20% of patients are not satisfied with the outcome following total knee replacement (TKR). This study investigated the pre- and post-operative predictors of dissatisfaction in a large cohort of patients undergoing TKR. We assessed 1217 consecutive patients between 2006 and 2008 both before operation and six months after, using the Short-form (SF)-12 health questionnaire and the Oxford Knee Score. Detailed information concerning comorbidity was also gathered. Satisfaction was measured at one year when 18.6% (226 of 1217) of patients were unsure or dissatisfied with their replacement and 81.4% (911 of 1217) were satisfied or very satisfied. Multivariate regression analysis was performed to identify independent predictors of dissatisfaction. Significant (p <
0.001) predictors at one year included the pre-operative SF-12 mental component score, depression and pain in other joints, the six-month SF-12 score and poorer improvement in the pain element of the Oxford Knee Score. Patient expectations were highly correlated with satisfaction. Satisfaction following TKR is multifactorial. Managing the expectations and mental health of the patients may reduce dissatisfaction. However, the most significant predictor of dissatisfaction is a painful total knee replacement.
Between June 2005 and March 2008, 14 patients with a Campanacci grade-3 giant-cell tumour of the distal radius were treated by en bloc resection and reconstruction by ulnar translocation with arthrodesis of the wrist. The mean length of radius resected was 7.9 cm (5.5 to 15). All the patients were followed to bony union and 12 were available at a mean follow-up of 26 months (10 to 49). The mean time to union was four months (3 to 7) at the ulnocarpal junction and five months (3 to 8) at the ulnoradial junction. All except one patient had an excellent range of pronation and supination. The remaining patient developed a radio-ulnar synostosis. The mean Musculoskeletal Tumor Society score was 26 (87%, range 20 to 28). Three patients had a soft-tissue recurrence, but with no bony involvement. They underwent a further excision and are currently well and free from disease. Ulnar translocation provides a local vascularised bone graft to reconstruct the defect left after excision of the distal radius for giant cell tumour. It avoids the need for a microvascular procedure while retaining rotation of the forearm and good function of the hand.
We compared 55 consecutive total hip replacements performed on 53 morbidly obese patients with osteoarthritis with a matched group of 55 total hip replacements in 53 non-obese patients. The groups were matched for age, gender, prosthesis type, laterality and preoperative Harris Hip Score. They were followed prospectively for five years and the outcomes were assessed using the Harris Hip Score, the Short-form 36 score and radiological findings. Survival at five years using revision surgery as an endpoint, was 90.9% (95% confidence interval 82.9 to 98.9) for the morbidly obese and 100% for the non-obese patients. The Harris Hip and the Short-form 36 scores were significantly better in the non-obese group (p <
0.001). The morbidly obese patients had a higher rate of complications (22% In light of these inferior results, morbidly obese patients should be advised to lose weight before undergoing a total hip replacement, and counselled regarding the complications. Despite these poorer results, however, the patients have improved function and quality of life.
The management of injury to the distal tibiofibular syndesmosis remains controversial in the treatment of ankle fractures. Operative fixation usually involves the insertion of a metallic diastasis screw. There are a variety of options for the position and characterisation of the screw, the type of cortical fixation, and whether the screw should be removed prior to weight-bearing. This paper reviews the relevant anatomy, the clinical and radiological diagnosis and the mechanism of trauma and alternative methods of treatment for injuries to the syndesmosis.
We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group.
Following arthroplasty of the knee, the patient’s
perception of improvement in symptoms is fundamental to the assessment
of outcome. Better clinical outcome may offset the inferior survival
observed for some types of implant. By examining linked National
Joint Registry (NJR) and patient-reported outcome measures (PROMs)
data, we aimed to compare PROMs collected at a minimum of six months
post-operatively for total (TKR: n = 23 393) and unicondylar knee
replacements (UKR: n = 505). Improvements in knee-specific (Oxford
knee score, OKS) and generic (EuroQol, EQ-5D) scores were compared
and adjusted for case-mix differences using multiple regression.
Whereas the improvements in the OKS and EQ-5D were significantly
greater for TKR than for UKR, once adjustments were made for case-mix
differences and pre-operative score, the improvements in the two
scores were not significantly different. The adjusted mean differences
in the improvement of OKS and EQ-5D were 0.0 (95% confidence interval (CI)
-0.9 to 0.9; p = 0.96) and 0.009 (95% CI -0.034 to 0.015; p = 0.37),
respectively. We found no difference in the improvement of either knee-specific
or general health outcomes between TKR and UKR in a large cohort
of registry patients. With concerns about significantly higher revision
rates for UKR observed in worldwide registries, we question the
widespread use of an arthroplasty that does not confer a significant
benefit in clinical outcome.
Fractures of the proximal humerus can lead to malalignment of the humeral head, necrosis and post-traumatic osteoarthritis. In such cases surface replacement might be a promising option. A total of 28 shoulders with glenohumeral arthritis subsequent to a fracture underwent surface replacement arthroplasty of the humeral head in patients with a mean age of 60 years (35 to 83). On the basis of the inclination of the impacted head, post-traumatic arthritis was divided into three types: type 1, an impacted fracture of the head in an anatomical position (seven cases); type 2, a valgus impacted fracture (13 cases); type 3, a varus impacted fracture (eight cases). The outcome was measured by means of the Constant score. According to the Boileau classification of the sequelae of fractures of the proximal humerus, all 28 patients had a final result of intra-capsular category 1. The mean Constant score for the 28 shoulders increased from 23.2 points (2 to 45) pre-operatively to 55.1 points (20 to 89) at a mean of 31 months (24 to 66) post-operatively. Valgus impacted fractures had significantly better results (p <
0.039). Surface replacement arthroplasty can provide good results for patients with post-traumatic osteoarthritis of the shoulder. Their use avoids post-operative complications of the humeral shaft, such as peri-prosthetic fractures. Further surgery can be undertaken more easily as the bone stock is preserved.
The purpose of this study was to evaluate the
long-term functional and radiological outcomes of arthroscopic removal
of unstable osteochondral lesions with subchondral drilling in the
lateral femoral condyle. We reviewed the outcome of 23 patients
(28 knees) with stage III or IV osteochondritis dissecans lesions
of the lateral femoral condyle at a mean follow-up of 14 years (10
to 19). The functional clinical outcomes were assessed using the Lysholm
score, which improved from a mean of 38.1 ( We found radiological evidence of degenerative changes in the
third or fourth decade of life at a mean of 14 years after arthroscopic
excision of the loose body and subchondral drilling for an unstable
osteochondral lesion of the lateral femoral condyle. Clinical and
functional results were more satisfactory.
The ideal bearing surface for young patients
undergoing total hip replacement (THR) remains controversial. We report
the five-year results of a randomised controlled trial comparing
the clinical and radiological outcomes of 102 THRs in 91 patients
who were <
65 years of age. These patients were randomised to
receive a cobalt–chrome on ultra-high-molecular-weight polyethylene,
cobalt–chrome on highly cross-linked polyethylene, or a ceramic-on-ceramic
bearing. In all, 97 hip replacements in 87 patients were available
for review at five years. Two hips had been revised, one for infection
and one for peri-prosthetic fracture. At the final follow-up there were no significant differences
between the groups for the mean Western Ontario and McMaster Universities
osteoarthritis index (pain, p = 0.543; function, p = 0.10; stiffness,
p = 0.99), Short Form-12 (physical component, p = 0.878; mental
component, p = 0.818) or Harris hip scores (p = 0.22). Radiological
outcomes revealed no significant wear in the ceramic group. Comparison of standard and highly cross-linked polyethylene,
however, revealed an almost threefold difference in the mean annual
linear wear rates (0.151 mm/year
Open reduction and internal fixation of high-energy pilon fractures are often associated with serious complications. Various methods have been used to treat these injuries, with variable results. A total of 17 consecutive patients with pilon fractures of AO/OTA type 43-B3 (n = 1), type C2 (n = 12) and type C3 (n = 4) were treated by indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov fixator. The calcaneal ring was removed at a mean of 3.7 weeks (3 to 6). A total of 16 patients were available for follow-up at a mean of 29 months (23 to 43). The mean time to healing was 15.8 weeks (13 to 23). Nine patients had pin-track infections but none had deep infection or osteomyelitis. Four patients (25%) had malunion. Fair, good or excellent ankle scores were found in 14 patients. External fixation with a ring fixator achieves stable reduction of the fractured fragments without additional trauma to soft tissues. With minimum complications and good healing results, the Ilizarov apparatus is particularly useful for high-energy pilon fractures.
Hip arthroscopy is particularly attractive in
children as it confers advantages over arthrotomy or open surgery,
such as shorter recovery time and earlier return to activity. Developments
in surgical technique and arthroscopic instrumentation have enabled
extension of arthroscopy of the hip to this age group. Potential
challenges in paediatric and adolescent hip arthroscopy include
variability in size, normal developmental change from childhood to
adolescence, and conditions specific to children and adolescents
and their various consequences. Treatable disorders include the
sequelae of traumatic and sports-related hip joint injuries, Legg–Calve–Perthes’
disease and slipped capital femoral epiphysis, and the arthritic
and septic hip. Intra-articular abnormalities are rarely isolated and
are often associated with underlying morphological changes. This review presents the current concepts of hip arthroscopy
in the paediatric and adolescent patient, covering clinical assessment
and investigation, indications and results of the experience to
date, as well as technical challenges and future directions.