The October 2014 Knee Roundup360 looks at: microfracture equivalent to OATS; examination better than MRI in predicting hamstrings re-injury; a second view on return to play with hamstrings injuries; dislocation risks in the Oxford Unicompartmental Knee; what about the tibia?; getting on top of lateral facet pain post TKR; readmission in TKR; patient-specific instrumentation; treating infrapatellar saphenous neuralgia; and arthroscopy in the middle-aged.
The aim of this study was to evaluate the functional
and oncological outcome of extracorporeally irradiated autografts
used to reconstruct the pelvis after a P1/2 internal hemipelvectomy. The study included 18 patients with a primary malignant bone
tumour of the pelvis. There were 13 males and five females with
a mean age of 24.8 years (8 to 62). Of these, seven had an osteogenic
sarcoma, six a Ewing’s sarcoma, and five a chondrosarcoma. At a
mean follow-up of 51.6 months (4 to 185), nine patients had died
with metastatic disease while nine were free from disease. Local
recurrence occurred in three patients all of whom eventually died of
their disease. Deep infection occurred in three patients and required
removal of their graft in two while the third underwent a hindquarter
amputation for extensive flap necrosis. The mean Musculoskeletal Tumor Society functional score of the
16 patients who could be followed-up for at least 12 months was
77% (50 to 90). Those 15 patients who completed the Toronto Extremity
Salvage Score questionnaire had a mean score of 71% (53 to 85). Extracorporeal irradiation and re-implantation of bone is a valid
method of reconstruction after an internal hemipelvectomy. It has
an acceptable morbidity and a functional outcome that compares favourably
with other available reconstructive techniques. Cite this article:
There is conflicting evidence about the merits
of mobile bearings in total knee replacement, partly because most randomised
controlled trials (RCTs) have not been adequately powered. We report
the results of a multicentre RCT of mobile There was no significant difference between the groups pre-operatively:
mean OKS was 17.18 ( In this appropriately powered RCT, over the first five years
after total knee replacement functional outcomes, re-operation rates
and healthcare costs appear to be the same irrespective of whether
a mobile or fixed bearing is used. 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?
In order to achieve satisfactory reduction of
complex distal humeral fractures, adequate exposure of the fracture fragments
and the joint surface is required. Several surgical exposures have
been described for distal humeral fractures. We report our experience
using the anconeus pedicle olecranon flip osteotomy approach. This
involves detachment of the triceps along with a sliver of olecranon,
which retains the anconeus pedicle. We report the use of this approach
in ten patients (six male, four female) with a mean age of 38.4
years (28 to 51). The mean follow-up was 15 months (12 to 18) with
no loss to follow-up. Elbow function was graded using the Mayo Score.
The results were excellent in four patients, good in five and fair
in one patient. The mean time to both fracture and osteotomy union
was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We
found this approach gave reliably good exposure for these difficult
fractures enabling anatomical reduction and bicondylar plating without
complications. Cite this article:
Abnormal wear of cobalt-containing metal-on-metal
joints is associated with inflammatory pseudotumours. Cobalt ions
activate human toll-like receptor 4 (TLR4), which normally responds
to bacterial lipopolysaccharide (LPS) in sepsis. Activation of TLR4
by LPS increases the expression of chemokines IL-8 and CXCL10, which
recruit leukocytes and activated T-cells, respectively. This study
was designed to determine whether cobalt induces a similar inflammatory
response to LPS by promoting the expression of IL-8 and CXCL10.
A human monocytic cell line, derived from acute monocytic leukaemia,
was treated with cobalt ions and expression of IL-8 and CXCL10 measured at
mRNA and protein levels. Cobalt-treated macrophages showed a 60-fold
increase in IL-8 mRNA, and an eightfold increase in production of
the mature chemokine (both p <
0.001); expression of the CXCL10
gene and protein was also significantly increased by cobalt (both
p <
0.001). Experiments were also performed in the presence of
CLI-095, a TLR4-specific antagonist which abrogated the cobalt-mediated
increase in IL-8 and CXCL10 expression. These findings suggest that cobalt ions induce inflammation similar
to that observed during sepsis by the simultaneous activation of
two TLR4-mediated signalling pathways. These pathways result in
increased production of IL-8 and CXCL10, and may be implicated in
pseudotumour formation following metal-on-metal replacement. Cite this article:
The aim of this study was to compare a third-generation
cementing procedure for glenoid components with a new technique
for cement pressurisation. In 20 pairs of scapulae, 20 keeled and
20 pegged glenoid components were implanted using either a third-generation
cementing technique (group 1) or a new pressuriser (group 2). Cement penetration
was measured by three-dimensional (3D) analysis of micro-CT scans.
The mean 3D depth of penetration of the cement was significantly
greater in group 2 (p <
0.001). The mean thickness of the cement
mantle for keeled glenoids was 2.50 mm (2.0 to 3.3) in group 1 and
5.18 mm (4.4 to 6.1) in group 2, and for pegged glenoids it was 1.72 mm
(0.9 to 2.3) in group 1 and 5.63 mm (3.6 to 6.4) in group 2. A cement
mantle <
2 mm was detected less frequently in group 2 (p <
0.001). Using the cement pressuriser the proportion of cement mantles
<
2 mm was significantly reduced compared with the third-generation
cementing technique.
We report the use of porous metal acetabular
revision shells in the treatment of contained bone loss. The outcomes of
53 patients with
We studied the bone mineral density (BMD) and
the bone mineral content (BMC) of the proximal tibia in patients with
a well-functioning uncemented Oxford medial compartment arthroplasty
using the Lunar iDXA bone densitometer. Our hypothesis was that
there would be decreased BMD and BMC adjacent to the tibial base
plate and increased BMD and BMC at the tip of the keel. There were 79 consecutive patients (33 men, 46 women) with a
mean age of 65 years (44 to 84) with a minimum two-year follow-up
(mean 2.6 years (2.0 to 5.0)) after unilateral arthroplasty, who
were scanned using a validated standard protocol where seven regions
of interest (ROI) were examined and compared with the contralateral
normal knee. All had well-functioning knees with a mean Oxford knee
score of 43 (14 to 48) and mean Knee Society function score of 90
(20 to 100), showing a correlation with the increasing scores and
higher BMC and BMD values in ROI 2 in the non-implanted knee relative
to the implanted knee (p = 0.013 and p = 0.015, respectively). The absolute and percentage changes in BMD and BMC were decreased
in all ROIs in the implanted knee compared with the non-implanted
knee, but this did not reach statistical significance. Bone loss
was markedly less than reported losses with total knee replacement. There was no significant association with side, although there
was a tendency for the BMC to decrease with age in men. The BMC
was less in the implanted side relative to the non-implanted side
in men compared with women in ROI 2 (p = 0.027), ROI 3 (p = 0.049)
and ROI 4 (p = 0.029). The uncemented Oxford medial compartment arthroplasty appears
to allow relative preservation of the BMC and BMD of the proximal
tibia, suggesting that the implant acts more physiologically than
total knee replacement. Peri-prosthetic bone loss is an important
factor in assessing long-term implant stability and survival, and
the results of this study are encouraging for the long-term outcome
of this arthroplasty. Cite this article:
Two types of fracture, early and late, have been
reported following limb lengthening in patients with achondroplasia (ACH)
and hypochondroplasia (HCH). We reviewed 25 patients with these conditions who underwent 72
segmental limb lengthening procedures involving the femur and/or
tibia, between 2003 and 2011. Gender, age at surgery, lengthened
segment, body mass index, the shape of the callus, the amount and
percentage of lengthening and the healing index were evaluated to determine
predictive factors for the occurrence of early (within three weeks
after removal of the fixation pins) and late fracture (>
three weeks
after removal of the pins). The Mann‑Whitney U test and Pearson’s
chi-squared test for univariate analysis and stepwise regression
model for multivariate analysis were used to identify the predictive factor
for each fracture. Only one patient (two tibiae) was excluded from
the analysis due to excessively slow formation of the regenerate,
which required supplementary measures. A total of 24 patients with
70 limbs were included in the study. There were 11 early fractures in eight patients. The shape of
the callus (lateral or central callus) was the only statistical
variable related to the occurrence of early fracture in univariate
and multivariate analyses. Late fracture was observed in six limbs
and the mean time between removal of the fixation pins and fracture
was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing
index, and lateral or central callus were related to the occurrence
of a late fracture in univariate analysis. A multivariate analysis
demonstrated that the shape of the callus was the strongest predictor
for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91
to 128). Lateral or central callus had a significantly larger risk
of fracture than fusiform, cylindrical, or concave callus. Radiological monitoring of the shape of the callus during distraction
is important to prevent early and late fracture of lengthened limbs
in patients with ACH or HCH. In patients with thin callus formation,
some measures to stimulate bone formation should be considered as
early as possible. Cite this article:
The August 2014 Shoulder &
Elbow Roundup360 looks at: Myofibroblasts perhaps not implicated in post-traumatic elbow stiffness; olecranon tip biomechanically sound for coranoid reconstruction; obesity and elbow replacement don’t mix; single column plating successful for extra-articular distal humeral fractures; satisfaction not predictable in frozen shoulder; tenodesis and repair both acceptable in Grade II SLAP tears; glenoid bone grafting is effective and glenohumeral articular lesions best seen with an arthroscope.
We carried out a prospective investigation into
the radiological outcomes of uncemented Oxford medial compartment
unicondylar replacement in 220 consecutive patients (231 knees)
performed in a single centre with a minimum two-year follow-up.
The functional outcomes using the mean Oxford knee score and the
mean high-activity arthroplasty score were significantly improved
over the pre-operative scores (p <
0.001). There were 196 patients
with a two-year radiological examination performed under fluoroscopic
guidance, aiming to provide images acceptable for analysis of the
bone–implant interface. Of the six tibial zones examined on each
knee on the anteroposterior radiograph, only three had a partial
radiolucent line. All were in the medial aspect of the tibial base plate
(zone 1) and all measured <
1 mm. All of these patients were
asymptomatic. There were no radiolucent lines seen around the femoral
component or on the lateral view. There was one revision for loosening
at one year due to initial inadequate seating of the tibial component.
These results confirm that the early uncemented Oxford medial unicompartmental
compartmental knee replacements were reliable and the incidence
of radiolucent lines was significantly decreased compared with the
reported results of cemented versions of this implant. These independent
results confirm those of the designing centre.
Giant cell tumour is the most common aggressive
benign tumour of the musculoskeletal system and has a high rate of
local recurrence. When it occurs in proximity to the hip, reconstruction
of the joint is a challenge. Options for reconstruction after wide
resection include the use of a megaprosthesis or an allograft-prosthesis
composite. We performed a clinical and radiological study to evaluate
the functional results of a proximal femoral allograft-prosthesis
composite in the treatment of proximal femoral giant cell tumour
after wide resection. This was an observational study, between 2006
and 2012, of 18 patients with a mean age of 32 years (28 to 42)
and a mean follow-up of 54 months (18 to 79). We achieved excellent
outcomes using Harris Hip Score in 13 patients and a good outcome
in five. All allografts united. There were no complications such
as infection, failure, fracture or resorption of the graft, or recurrent
tumour. Resection and reconstruction of giant cell tumours with
proximal femoral allograft–prosthesis composite is a better option
than using a prosthesis considering preservation of bone stock and excellent
restoration of function. A good result requires demanding bone banking techniques, effective
measures to prevent infection and stability at the allograft-host
junction. Cite this article:
Following the recall of modular neck hip stems
in July 2012, research into femoral modularity will intensify over
the next few years. This review aims to provide surgeons with an
up-to-date summary of the clinically relevant evidence. The development
of femoral modularity, and a classification system, is described.
The theoretical rationale for modularity is summarised and the clinical
outcomes are explored. The review also examines the clinically relevant problems
reported following the use of femoral stems with a modular neck. Joint replacement registries in the United Kingdom and Australia
have provided data on the failure rates of modular devices but cannot
identify the mechanism of failure. This information is needed to
determine whether modular neck femoral stems will be used in the
future, and how we should monitor patients who already have them implanted. Cite this article:
We compared the rate of revision for instability
after total hip replacement (THR) when lipped and non-lipped acetabular
liners were used. We hypothesised that the use of a lipped liner
in a modular uncemented acetabular component reduces the risk of
revision for instability after primary THR. Using data from the
New Zealand Joint Registry, we found that the use of a lipped liner
was associated with a significantly decreased rate of revision for instability
and for all other indications. Adjusting for the size of the femoral
head, the surgical approach and the age and gender of the patient,
this difference remained strongly significant (p <
0.001). We conclude that evidence from the New Zealand registry suggests
that the use of lipped liners with modular uncemented acetabular
components is associated with a decreased rate of revision for instability
after primary THR. Cite this article:
Hip implant retrieval analysis is the most important
source of insight into the performance of new materials and designs
of hip arthroplasties. Even the most rigorous
This systematic review of the literature summarises
the clinical experience with ceramic-on-ceramic hip bearings over
the past 40 years and discusses the concerns that exist in relation
to the bearing combination. Loosening, fracture, liner chipping
on insertion, liner canting and dissociation, edge-loading and squeaking
have all been reported, and the relationship between these issues
and implant design and surgical technique is investigated. New design
concepts are introduced and analysed with respect to previous clinical
experience.
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.
Radiostereometric analysis (RSA) can detect early
micromovement in unstable implant designs which are likely subsequently
to have a high failure rate. In 2010, the Articular Surface Replacement
(ASR) was withdrawn because of a high failure rate. In 19 ASR femoral
components, the mean micromovement over the first two years after implantation
was 0.107 mm ( We conclude that the ASR femoral component achieves initial stability
and that early migration is not the mode of failure for this resurfacing
arthroplasty.
There is little in the literature on the level
of participation in sports which patients undertake after total
hip replacement (THR). Our aims in this study were to determine
first, the level of sporting activity, second, the predictive factors
for returning to sporting activity, and third, the correlation between
participation in sports and satisfaction after THR. We retrospectively
identified 815 patients who had undergone THR between 1995 and 2005. All
were asked to complete a self-administered questionnaire regarding
their sporting activity. A total of 571 patients (71%) met the inclusion
criteria and completed the evaluation. At a mean follow-up of 9.8
years ( In conclusion, we found that most patients participate in sporting
activity after THR, regardless of the advice of their surgeon, and
that there is a correlation between the level of participation and
pre-operative function, motivation, duration of symptoms and post-operative
satisfaction. Cite this article: