We report the incidence of and risk factors for complications after scoliosis surgery in patients with Duchenne muscular dystrophy (DMD) and compare them with those of other neuromuscular conditions.

We identified 110 (64 males, 46 females) consecutive patients with a neuromuscular disorder who underwent correction of the scoliosis at a mean age of 14 years (7 to 19) and had a minimum two-year follow-up. We recorded demographic and peri-operative data, including complications and re-operations.

There were 60 patients with cerebral palsy (54.5%) and 26 with DMD (23.6%). The overall complication rate was 22% (24 patients), the most common of which were deep wound infection (9, 8.1%), gastrointestinal complications (5, 4.5%) and hepatotoxicity (4, 3.6%). The complication rate was higher in patients with DMD (10/26, 38.5%) than in those with other neuromuscular conditions (14/84, 16.7% (p = 0.019). All hepatotoxicity occurred in patients with DMD (p = 0.003), who also had an increased rate of deep wound infection (19% vs 5%) (p = 0.033). In the DMD group, no peri-operative factors were significantly associated with the rate of overall complications or deep wound infection. Increased intra-operative blood loss was associated with hepatotoxicity (p = 0.036).

In our series, correction of a neuromuscular scoliosis had an acceptable rate of complications: patients with DMD had an increased overall rate compared with those with other neuromuscular conditions. These included deep wound infection and hepatotoxicity. Hepatotoxicity was unique to DMD patients, and we recommend peri-operative vigilance after correction of a scoliosis in this group.

Cite this article: Bone Joint J 2014; 96-B:943–9.

Objectives

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.

At our institution surgical correction of symptomatic flat foot deformities in children has been guided by a paradigm in which radiographs and pedobarography are used in the assessment of outcome following treatment. Retrospective review of children with symptomatic flat feet who had undergone surgical correction was performed to assess the outcome and establish the relationship between the static alignment and the dynamic loading of the foot.

A total of 17 children (21 feet) were assessed before and after correction of soft-tissue contractures and lateral column lengthening, using standardised radiological and pedobarographic techniques for which normative data were available.

We found significantly improved static segmental alignment of the foot, significantly improved mediolateral dimension foot loading, and worsened fore-aft foot loading, following surgical treatment. Only four significant associations were found between radiological measures of static segmental alignment and dynamic loading of the foot.

Weakness of the plantar flexors of the ankle was a common post-operative finding. Surgeons should be judicious in the magnitude of lengthening of the plantar flexors that is undertaken and use techniques that minimise subsequent weakening of this muscle group.

Cite this article: Bone Joint J 2013;95-B:706–13.

We performed a CT-based computer simulation study to determine how the relationship between any inbuilt posterior slope in the proximal tibial osteotomy and cutting jig rotational orientation errors affect tibial component alignment in total knee replacement. Four different posterior slopes (3°, 5°, 7° and 10°), each with a rotational error of 5°, 10°, 15°, 20°, 25° or 30°, were simulated. Tibial cutting block malalignment of 20° of external rotation can produce varus malalignment of 2.4° and 3.5° with a 7° and a 10° sloped cutting jig, respectively. Care must be taken in orientating the cutting jig in the sagittal plane when making a posterior sloped proximal tibial osteotomy in total knee replacement.

Cite this article: Bone Joint J 2013;95-B:1201–3.

The October 2013 Shoulder & Elbow Roundup³⁶⁰ looks at: Deltoid impairment not necessarily a contra-indication for shoulder arthroplasty; The tricky radiograph; Not so asymptomatic cuff tears; Total shoulder arthroplasty: kinder on the glenoid; Barbotage for calcific tendonitis; What happens to the arthritic glenoid?; Two screws a screw too few?; Sloppy hinge best for elbow arthroplasty.

We explored the outcome of staged bilateral total knee replacement (TKR) for symmetrical degenerative joint disease and deformity in terms of patient expectations, functional outcome and satisfaction. From 2009 to 2011, 70 consecutive patients (41 female) with a mean age of 71.7 years (43 to 89) underwent 140 staged bilateral TKRs at our institution, with a mean time between operations of 7.8 months (2 to 25). Patients were assessed pre-operatively and at six and 12 months post-operatively using the Short Form-12, Oxford knee score (OKS), expectation questionnaire and satisfaction score. The pre-operative OKS was significantly worse before the first TKR (TKR1), but displayed significantly greater improvement than that observed after the second TKR (TKR2). Expectation level increased from TKR1 to TKR2 in 17% and decreased in 20%. Expectations of pain relief and stair-climbing were less before TKR2; in contrast, expectations of sporting and social activities were greater. Decreased expectations of TKR2 were significantly associated with younger age and high expectations before TKR1. Patient satisfaction was high for both TKR1 (93%) and TKR2 (87%) but did not correlate significantly within individuals. We concluded that satisfaction with one TKR does not necessarily translate to satisfaction following the second.

Cite this article: Bone Joint J 2014;96-B:752–8.

A total of 20 patients with a depressed fracture of the lateral tibial plateau (Schatzker II or III) who would undergo open reduction and internal fixation were randomised to have the metaphyseal void in the bone filled with either porous titanium granules or autograft bone. Radiographs were undertaken within one week, after six weeks, three months, six months, and after 12 months.

The primary outcome measure was recurrent depression of the joint surface: a secondary outcome was the duration of surgery.

The risk of recurrent depression of the joint surface was lower (p < 0.001) and the operating time less (p < 0.002) when titanium granules were used.

The indication is that it is therefore beneficial to use porous titanium granules than autograft bone to fill the void created by reducing a depressed fracture of the lateral tibial plateau. There is no donor site morbidity, the operating time is shorter and the risk of recurrent depression of the articular surface is less.

Cite this article: Bone Joint J 2015; 97-B:836–41

Successful management of late presenting hip dislocation in childhood is judged by the outcome not just at skeletal maturity but well beyond into adulthood and late middle age. This review considers different methods of treatment and looks critically at the handful of studies reporting long-term follow-up after successful reduction.

Cite this article: Bone Joint J 2015;97-B:729–33.

We evaluated the accuracy with which a custom-made acetabular component could be positioned at revision arthroplasty of the hip in patients with a Paprosky type 3 acetabular defect.

A total of 16 patients with a Paprosky type 3 defect underwent revision surgery using a custom-made trabecular titanium implant. There were four men and 12 women with a median age of 67 years (48 to 79). The planned inclination (INCL), anteversion (AV), rotation and centre of rotation (COR) of the implant were compared with the post-operative position using CT scans.

A total of seven implants were malpositioned in one or more parameters: one with respect to INCL, three with respect to AV, four with respect to rotation and five with respect to the COR.

To the best of our knowledge, this is the first study in which CT data acquired for the pre-operative planning of a custom-made revision acetabular implant have been compared with CT data on the post-operative position. The results are encouraging.

Cite this article: Bone Joint J 2015; 97-B:780–5.

Pre-operative planning for total hip replacement (THR) is challenging in hips with severe acetabular deformities, including those with a hypoplastic acetabulum or severe defects and in the presence of arthrodesis or ankylosis. We evaluated whether a Rapid Prototype (RP) model, which is a life-sized reproduction based on three-dimensional CT scans, can determine the feasibility of THR and provide information about the size and position of the acetabular component in severe acetabular deformities. THR was planned using an RP model in 21 complex hips in five men (five hips) and 16 women (16 hips) with a mean age of 47.7 years (24 to 70) at operation. An acetabular component was implanted successfully and THR completed in all hips. The acetabular component used was within 2 mm of the predicted size in 17 hips (80.9%). All of the acetabular components and femoral stems had radiological evidence of bone ingrowth and stability at the final follow-up, without any detectable wear or peri-prosthetic osteolysis. The RP model allowed a simulated procedure pre-operatively and was helpful in determining the feasibility of THR pre-operatively, and to decide on implant type, size and position in complex THRs.

Cite this article: Bone Joint J 2013;95-B:1458–63.

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: Bone Joint J 2015; 97-B:890–8.

The aim of this study was to investigate the relationship between the geometry of the proximal femur and the incidence of intra-operative fracture during uncemented total hip arthroplasty (THA).

We studied the pre-operative CT scans of 100 patients undergoing THA with an uncemented femoral component. We measured the anteroposterior and mediolateral dimensions at the level of division of the femoral neck to calculate the aspect ratio of the femur. Wide variations in the shape of the femur were observed, from round, to very narrow elliptic. The femurs of women were narrower than those of men (p < 0.0001) and small femurs were also narrower than large ones. Patients with an intra-operative fracture of the calcar had smaller and narrower femurs than those without a fracture (p < 0.05) and the implanted Corail stems were smaller in those with a fracture (mean size 9 vs 12, p < 0.0001).

The variability of the shape of the femoral neck at the level of division contributes to the understanding of the causation of intra-operative fractures in uncemented THA.

Cite this article: Bone Joint J 2015;97-B:741–8.

Down’s syndrome is associated with a number of musculoskeletal abnormalities, some of which predispose patients to early symptomatic arthritis of the hip. The purpose of the present study was to review the general and hip-specific factors potentially compromising total hip replacement (THR) in patients with Down’s syndrome, as well as to summarise both the surgical techniques that may anticipate the potential adverse impact of these factors and the clinical results reported to date. A search of the literature was performed, and the findings further informed by the authors’ clinical experience, as well as that of the hip replacement in Down Syndrome study group. The general factors identified include a high incidence of ligamentous laxity, as well as associated muscle hypotonia and gait abnormalities. Hip-specific factors include: a high incidence of hip dysplasia, as well as a number of other acetabular, femoral and combined femoroacetabular anatomical variations. Four studies encompassing 42 hips, which reported the clinical outcomes of THR in patients with Down’s syndrome, were identified. All patients were successfully treated with standard acetabular and femoral components. The use of supplementary acetabular screw fixation to enhance component stability was frequently reported. The use of constrained liners to treat intra-operative instability occurred in eight hips. Survival rates of between 81% and 100% at a mean follow-up of 105 months (6 to 292) are encouraging. Overall, while THR in patients with Down’s syndrome does present some unique challenges, the overall clinical results are good, providing these patients with reliable pain relief and good function.

Cite this article: Bone Joint J 2013;95-B, Supple A:41–5.

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.

The term developmental dysplasia of the hip (DDH) describes a spectrum of disorders that results in abnormal development of the hip joint. If not treated successfully in childhood, these patients may go on to develop hip symptoms and/or secondary osteoarthritis in adulthood. In this review we describe the altered anatomy encountered in adults with DDH along with the management options, and the challenges associated with hip arthroscopy, osteotomies and arthroplasty for the treatment of DDH in young adults.

Cite this article: Bone Joint J 2013;95-B:732–7.

The December 2013 Hip & Pelvis Roundup³⁶⁰ looks at: Enhanced recovery works; Acetabular placement; Exercise better than rest in osteoarthritis patients; if Birmingham hip resurfacing is immune from pseudotumour; HIV and arthroplasty; Labral tears revisited; Prophylactic surgery for FAI; and Ceramics and impaction grafting

Minimally invasive total knee replacement (MIS-TKR) has been reported to have better early recovery than conventional TKR. Quadriceps-sparing (QS) TKR is the least invasive MIS procedure, but it is technically demanding with higher reported rates of complications and outliers. This study was designed to compare the early clinical and radiological outcomes of TKR performed by an experienced surgeon using the QS approach with or without navigational assistance (NA), or using a mini-medial parapatellar (MP) approach. In all, 100 patients completed a minimum two-year follow-up: 30 in the NA-QS group, 35 in the QS group, and 35 in the MP group. There were no significant differences in clinical outcome in terms of ability to perform a straight-leg raise at 24 hours (p = 0.700), knee score (p = 0.952), functional score (p = 0.229) and range of movement (p = 0.732) among the groups. The number of outliers for all three radiological parameters of mechanical axis, frontal femoral component alignment and frontal tibial component alignment was significantly lower in the NA-QS group than in the QS group (p = 0.008), but no outlier was found in the MP group.

In conclusion, even after the surgeon completed a substantial number of cases before the commencement of this study, the supplementary intra-operative use of computer-assisted navigation with QS-TKR still gave inferior radiological results and longer operating time, with a similar outcome at two years when compared with a MP approach.

Cite this article: Bone Joint J 2013;95-B:906–10.

The August 2014 Trauma Roundup³⁶⁰ looks at: On-table CT for calcaneal fractures; timing of femoral fracture surgery and outcomes; salvage arthroplasty for failed internal fixation of the femoral neck; screw insertion in osteoporotic bone; fibular intramedullary nailing on the ascendant; posterior wall acetabular fractures not all that innocent; bugs, plating and resistance and improving outcomes in olecranon tension band wiring.

In 2012 we reviewed a consecutive series of 92 uncemented THRs performed between 1986 and 1991 at our institution using the CLS Spotorno stem, in order to assess clinical outcome and radiographic data at a minimum of 21 years. The series comprised 92 patients with a mean age at surgery of 59.6 years (39 to 77) (M:F 43;49).

At the time of this review, seven (7.6%) patients had died and two (2.2%) were lost to follow-up. The 23-year Kaplan–Meier survival rates were 91.5% (95% confidence intervals (CI) 85.4% to 97.6%; 55 hips at risk) and 80.3% (95% CI, 71.8% to 88.7%; 48 hips at risk) respectively, with revision of the femoral stem or of any component as endpoints. At the time of this review, 76 patients without stem revision were assessed clinically and radiologically (mean follow-up 24.0 years (21.5 to 26.5)). For the 76 unrevised hips the mean Harris hip score was 87.1 (65 to 97). Femoral osteolysis was detected in five hips (6.6%) only in Gruen zone 7. Undersized stems were at higher risk of revision owing to aseptic loosening (p = 0.0003). Patients implanted with the stem in a varus position were at higher risk of femoral cortical hypertrophy and thigh pain (p = 0.0006 and p = 0.0007, respectively).

In our study, survival, clinical outcome and radiographic data remained excellent in the third decade after implantation. Nonetheless, undersized stems were at higher risk of revision owing to aseptic loosening.

Cite this article: Bone Joint J 2014;96-B:455–61.