Antiplatelet agents are widely prescribed for the primary and secondary prevention of cardiovascular events. A common clinical problem facing orthopaedic and trauma surgeons is how to manage patients receiving these agents who require surgery, either electively or following trauma. The dilemma is to balance the risk of increased blood loss if the antiplatelet agents are continued peri-operatively against the risk of coronary artery/stent thrombosis and/or other vascular event if the drugs are stopped. The traditional approach of stopping these medications up to two weeks before surgery appears to pose significant danger to patients and may require review. This paper covers the important aspects regarding the two most commonly prescribed antiplatelet agents, aspirin and clopidogrel.
The optimal timing of percutaneous vertebroplasty
as treatment for painful osteoporotic vertebral compression fractures
(OVCFs) is still unclear. With the position of vertebroplasty having
been challenged by recent placebo-controlled studies, appropriate
timing gains importance. We investigated the relationship between the onset of symptoms
– the time from fracture – and the efficacy of vertebroplasty in
115 patients with 216 painful subacute or chronic OVCFs (mean time
from fracture 6.0 months ( It was found that there was an immediate and sustainable improvement
in the level of back pain and HRQoL after vertebroplasty, which
was independent of the time from fracture. Greater time from fracture
was associated with neither worse pre-operative conditions nor increased
vertebral deformity, nor with the presence of an intravertebral cleft. We conclude that vertebroplasty can be safely undertaken at an
appropriate moment between two and 12 months following the onset
of symptoms of an OVCF.
The April 2013 Hip &
Pelvis Roundup360 looks at: hip cartilage and magnets; labral repair or resection; who benefits from injection; rotational osteotomy for osteonecrosis; whether ceramic implants risk fracture; dual articulation; and hydroxyapatite.
The April 2013 Research Roundup360 looks at: when the ‘residency cake’ is done; steroids, stem cells and tendons; what exactly is osteoarthritis; platelet-rich plasma; CRPS; d-Dimer for DVT; reducing bacterial adhesion; and fin or limb?
Most surgeons favour removing forearm plates
in children. There is, however, no long-term data regarding the complications
of retaining a plate. We present a prospective case series of 82
paediatric patients who underwent plating of their forearm fracture
over an eight-year period with a minimum follow-up of two years.
The study institution does not routinely remove forearm plates.
A total of 116 plates were used: 79 one-third tubular plates and 37 dynamic
compression plates (DCP). There were 12 complications: six plates
(7.3%) were removed for pain or stiffness and there were six (7.3%)
implant-related fractures. Overall, survival of the plates was 85%
at 10 years. Cox regression analysis identified radial plates (odds
ratio (OR) 4.4, p = 0.03) and DCP fixation (OR 3.2, p = 0.02) to
be independent risk factors of an implant-related fracture. In contrast
ulnar plates were more likely to cause pain or irritation necessitating
removal (OR 5.6, p = 0.04). The complications associated with retaining a plate are different,
but do not occur more frequently than the complications following
removal of a plate in children.
We investigated the fracture-free survival of long bones stabilised by a telescopic intramedullary rod (TIMR) in patients with osteogenesis imperfecta with respect to the remodelling status of fracture or osteotomy sites and TIMR regions, in order to identify risk factors for fracture. A total of 44 femora and 28 tibiae in 25 patients with a mean age of 5.0 years (1.9 to 10.5) at presentation were studied. There were six patients with Sillence type I, five with type III, 13 with type IV and one with type V osteogenesis imperfecta. All received bisphosphonate treatment at the same stage during the mean follow-up of 7.3 years (0.5 to 18.1). The fracture-free survival was estimated at 6.2 years (95% confidence interval 5.1 to 7.3) by Kaplan-Meier analysis. More than half the fracture or osteotomy sites remained in a less-remodelled state at the latest follow-up or time of fracture. Of the 33 fractures, 29 (87.9%) occurred in long bones containing a less-remodelled site, and these fractures were located at this site. The relative fracture risk at the rod tip was significantly greater than in any other TIMR region (p <
0.001), and this was higher in bone segments having a less-remodelled site. This study shows a persistent fracture risk in TIMR-stabilised long bones, especially at less-remodelled fracture or osteotomy sites and at the rod tip.
Autologous retransfusion and no-drainage are
both blood-saving measures in total hip replacement (THR). A new combined
intra- and post-operative autotransfusion filter system has been
developed especially for primary THR, and we conducted a randomised
controlled blinded study comparing this with no-drainage. A total of 204 THR patients were randomised to autologous blood
transfusion (ABT)
(n = 102) or no-drainage (n = 102). In the ABT group, a mean of
488 ml ( The use of a new intra- and post-operative autologous blood transfusion
filter system results in less total blood loss and a smaller maximum
decrease in haemoglobin levels than no-drainage following primary
THR. Cite this article:
Ancient Egypt was a highly developed agrarian society with a massive civil engineering capability. Trauma and skeletal disease were common and vestiges of the evidence for that survive, largely in the form of hieratic images and papyri dedicated to the practice of medicine. The earliest treatise on trauma is the
Fractures of the odontoid in children with an open basilar synchondrosis differ from those which occur in older children and adults. We have reviewed the morphology of these fractures and present a classification system for them. There were four distinct patterns of fracture (types IA to IC and type II) which were distinguished by the site of the fracture, the degree of displacement and the presence or absence of atlantoaxial dislocation. Children with a closed synchondrosis were classified using the system devised by Anderson and D’Alonzo. Those with an open synchondrosis had a comparatively lower incidence of traumatic brain injury, a higher rate of missed diagnosis and a shorter mean stay in hospital. Certain subtypes (type IA and type II) are likely to be missed on plain radiographs and therefore more advanced imaging is recommended. We suggest staged treatment with initial stabilisation in a Halo body jacket and early fusion for those with unstable injuries, severe displacement or neurological involvement.
The purpose of this study was to establish whether
exploration and neurolysis is an effective method of treating neuropathic
pain in patients with a sciatic nerve palsy after total hip replacement
(THR). A total of 56 patients who had undergone this surgery at
our hospital between September 1999 and September 2010 were retrospectively identified.
There were 42 women and 14 men with a mean age at exploration of
61.2 years (28 to 80). The sciatic nerve palsy had been sustained
by 46 of the patients during a primary THR, five during a revision
THR and five patients during hip resurfacing. The mean pre-operative
visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean
post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement
of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were
significantly different (p <
0.001). Based on the findings of
our study, we recommend this form of surgery over conservative management
in patients with neuropathic pain associated with a sciatic nerve
palsy after THR. Cite this article:
Loss of proprioception following an anterior
cruciate ligament (ACL) injury has been well documented. We evaluated
proprioception in both the injured and the uninjured limb in 25 patients
with ACL injury and in 25 healthy controls, as assessed by joint
position sense (JPS), the threshold for the detection of passive
movement (TDPM) and postural sway during single-limb stance on a
force plate. There were significant proprioceptive deficits in both ACL-deficient
and uninjured knees compared with control knees, as assessed by
the angle reproduction test (on JPS) and postural sway on single
limb stance. The degree of loss of proprioception in the ACL-deficient
knee and the unaffected contralateral knee joint in the same patient
was similar. The TDPM in the injured knee was significantly higher
than that of controls at 30° and 70° of flexion. The TDPM of the
contralateral knee joint was not significantly different from that
in controls. Based on these findings, the effect of proprioceptive training
of the contralateral uninjured knee should be explored. Cite this article:
We compared the complications and outcome of tibial lengthening using the Ilizarov method with and without the use of a supplementary intramedullary nail. In a retrospective case-matched series assembled from 176 patients with tibial lengthening, we matched 52 patients (26 pairs, group A with nail and group B without) according to the following criteria in order of importance: 1) difference in amount of lengthening (± 2 cm); 2) percentage difference in lengthening (± 5%); 3) difference in patient’s age (± seven years); 4) aetiology of the shortening, and 5) level of difficulty in obtaining the correction. The outcome was evaluated using the external fixator index, the healing index and an outcome score according to the criteria of Paley. It was found that some complications were specific to group A or B respectively, but others were common to both groups. The outcome was generally better in lengthenings with a nail, although there was a higher incidence of rectifiable equinus deformity in these patients.
Given the growing prevalence of obesity around
the world and its association with osteoarthritis of the knee, orthopaedic
surgeons need to be familiar with the management of the obese patient
with degenerative knee pain. The precise mechanism by which obesity
leads to osteoarthritis remains unknown, but is likely to be due
to a combination of mechanical, humoral and genetic factors. Weight loss has clear medical benefits for the obese patient
and seems to be a logical way of relieving joint pain associated
with degenerative arthritis. There are a variety of ways in which
this may be done including diet and exercise, and treatment with
drugs and bariatric surgery. Whether substantial weight loss can
delay or even reverse the symptoms associated with osteoarthritis
remains to be seen. Surgery for osteoarthritis in the obese patient can be technically
more challenging and carries a risk of additional complications.
Substantial weight loss before undertaking total knee replacement
is advisable. More prospective studies that evaluate the effect
of significant weight loss on the evolution of symptomatic osteoarthritis
of the knee are needed so that orthopaedic surgeons can treat this
patient group appropriately.
Arteriovenous fistula formation after a closed
extremity fracture is rare. We present the case of an 11-year-old
boy who developed an arteriovenous fistula between the anterior
tibial artery and popliteal vein after closed fractures of the proximal
tibia and fibula. The fractures were treated by closed reduction
and casting. A fistula was diagnosed 12 weeks after the injury.
It was treated by embolisation with coils. Subsequent angiography
and ultrasonography confirmed patency of the popliteal vein and
anterior and posterior tibial and peroneal arteries, with no residual shunting
through the fistula. The fractures healed uneventfully and he returned
to full unrestricted activities 21 weeks after his injury.
Stem cells are a key component of regenerative medicine strategies. Particular areas of musculoskeletal application include cartilage and bone regeneration in arthritis and trauma. There are several types of stem cell and this article will focus on the adult derived cells. The review includes current issues and future developments.
The introduction of a trabecular tantalum rod
has been proposed for the management of early-stage osteonecrosis of
the femoral head but serves as a single-point of support of the
necrotic lesion. We describe a technique using two or three 4.2
mm (or later 4.7 mm) tantalum pegs for the prevention of collapse
of the necrotic lesion. We prospectively studied 21 patients (26
hips) with non-traumatic osteonecrosis of the femoral head treated
in this manner. Of these, 21 patients (24 hips) were available for
radiological and clinical evaluation at a mean follow-up of 46 months
(18 to 67). Radiological assessment showed that only eight hips
deteriorated according to the Association Research Circulation Osseous
classification, and four hips according to the Classification of
the Japanese Investigation Committee of Health and Welfare. Functional
improvement was obtained with an improvement in the mean Harris
hip score from 65.2 (33.67 to 95) to 88.1 (51.72 to 100), the mean
Merle D’Aubigné-Postel score from 13 (6 to 18) to 16 (11 to 18),
a mean visual analogue score for pain from 5.2 (0 to 9.5) to 2.6
(0 to 7), and the mean Short-Form 36 score from 80.4 (56.8 to 107.1)
to 92.4 (67.5 to 115.7). Of these 24 hips followed for a minimum
of 18 months, three were considered as failures at the final follow-up,
having required total hip replacement. One of the hips without full
follow-up was also considered to be a failure. In more than two-thirds
of the surviving hips a satisfactory clinical outcome was achieved
with promising radiological findings. The estimated mean implant
survival was 60 months (95% confidence interval 53.7 to 66.3).
In late developmental dysplasia of the hip in childhood, the deformed dysplastic acetabulum is malaligned and has lost its shape due to pressure from the subluxed femoral head. The outer part of the acetabulum involves the upper part of the original acetabulum, thereby giving a bipartite appearance. A clear edge separates the outer from inner part which represents the lower part of the original acetabulum and has no direct contact with the femoral head. Combined pelvic osteotomy (CPO) using a Lance acetabuloplasty with either a Salter or a Pemberton procedure restores the original shape and realigns the acetabulum. A total of 20 children (22 hips), with a mean age of 46 months (28 to 94) at primary operation underwent CPO with follow-up for between 12 and 132 months. In each case concentric stable reduction with good acetabular cover was achieved and maintained throughout the period of follow-up.
The sternoclavicular joint (SCJ) is a pivotal
articulation in the linked system of the upper limb girdle, providing
load-bearing in compression while resisting displacement in tension
or distraction at the manubrium sterni. The SCJ and acromioclavicular
joint (ACJ) both have a small surface area of contact protected
by an intra-articular fibrocartilaginous disc and are supported
by strong extrinsic and intrinsic capsular ligaments. The function
of load-sharing in the upper limb by bulky periscapular and thoracobrachial
muscles is extremely important to the longevity of both joints.
Ligamentous and capsular laxity changes with age, exposing both
joints to greater strain, which may explain the rising incidence
of arthritis in both with age. The incidence of arthritis in the
SCJ is less than that in the ACJ, suggesting that the extrinsic
ligaments of the SCJ provide greater stability than the coracoclavicular
ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish
from medial clavicular physeal or metaphyseal fracture-separation:
cross-sectional imaging is often required. The distinction is important
because the treatment options and outcomes of treatment are dissimilar,
whereas the treatment and outcomes of ACJ separation and fracture
of the lateral clavicle can be similar. Proper recognition and treatment
of traumatic instability is vital as these injuries may be life-threatening.
Instability of the SCJ does not always require surgical intervention.
An accurate diagnosis is required before surgery can be considered,
and we recommend the use of the Stanmore instability triangle. Most
poor outcomes result from a failure to recognise the underlying
pathology. There is a natural reluctance for orthopaedic surgeons to operate
in this area owing to unfamiliarity with, and the close proximity
of, the related vascular structures, but the interposed sternohyoid
and sternothyroid muscles are rarely injured and provide a clear
boundary to the medial retroclavicular space, as well as an anatomical
barrier to unsafe intervention. This review presents current concepts of instability of the SCJ,
describes the relevant surgical anatomy, provides a framework for
diagnosis and management, including physiotherapy, and discusses
the technical challenges of operative intervention. Cite this article:
We compared the intracompartmental pressures
(ICPs) of open and closed tibial fractures with the same injury pattern
in a rabbit model. In all, 20 six-month-old New Zealand White male
rabbits were used. They were randomised into two equal groups of
ten rabbits; an open fracture group (group 1) and a closed fracture
group (group 2). Each anaesthetised rabbit was subjected to a standardised
fracture of the proximal half of the right tibia using a custom-made
device. In order to create a grade II open fracture in group 1,
a 10 mm segment of fascia and periosteum was excised. The ICP in
the anterior compartment was monitored at six-hourly intervals for
48 hours. Although there was a statistically significant difference
in ICP values within each group (both p <
0.001), there was no
significant difference between the groups for all measurements (all
p ≥ 0.089). In addition, in both groups there was a statistically
significant increase in ICP within the first 24 hours, whereas there
was a statistically significant decrease within the second 24 hours
(p <
0.001 for both groups). We conclude that open tibial fractures
should be monitored for the development of acute compartment syndrome
to the same extent as closed fractures. Cite this paper: