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
Isolated patellofemoral arthritis is a common
condition and there are varying opinions on the most effective treatments.
Non-operative and operative treatments have failed to demonstrate
effective long-term treatment for those in an advanced stage of
the condition. Newer designs and increased technology in patellofemoral replacement
(PFR) have produced more consistent outcomes. This has led to a
renewed enthusiasm for this procedure. Newer PFR prostheses have
addressed the patellar maltracking issues plaguing some of the older designs.
Short-term results with contemporary prostheses and new technology
are described here. Cite this article:
This cohort study investigated the influence
of psychological factors, including perception of illness, anxiety
and depression on recovery and functional outcome after total knee
replacement surgery. A total of 100 patients (55 male; 45 female) with a mean age
of 71 (42 to 92) who underwent a primary total knee replacement
for osteoarthritis were recruited into this study. In all 97 participants
completed the six week and 87 the one year follow-up questionnaires. Pre-operatively patients completed the revised Illness Perception
Questionnaire, Hospital Anxiety and Depression Scale and Recovery
Locus of Control Scale. Function was assessed pre-operatively, at
six weeks and one year using Oxford Knee Score (OKS) and the goniometer-measured
range of movement (ROM). The results showed that pre-operative function had the biggest
impact on post-operative outcome for ROM and OKS. In addition questionnaire
variables and depression had an impact on the OKS at six weeks.
Depression and anxiety were also associated with a higher (worse)
knee score at one year but did not influence the ROM at either six weeks
or one year. Recovery from total knee replacement can be difficult to predict.
This study has identified psychological factors that play an important
role in recovery from surgery and functional outcome. These should
be taken into account when considering patients for total knee replacement. Cite this article:
Pelvic discontinuity represents a rare but challenging
problem for orthopaedic surgeons. It is most commonly encountered
during revision total hip replacement, but can also result from
an iatrogentic acetabular fracture during hip replacement. The general
principles in management of pelvic discontinuity include restoration
of the continuity between the ilium and the ischium, typically with
some form of plating. Bone grafting is frequently required to restore
pelvic bone stock. The acetabular component is then impacted, typically
using an uncemented, trabecular metal component. Fixation with multiple
supplemental screws is performed. For larger defects, a so-called
‘cup–cage’ reconstruction, or a custom triflange implant may be
required. Pre-operative CT scanning can greatly assist in planning
and evaluating the remaining bone stock available for bony ingrowth.
Generally, good results have been reported for constructs that restore
stability to the pelvis and allow some form of biologic ingrowth. 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:
The augmentation of fixation with bone cement
is increasingly being used in the treatment of severe osteoporotic fractures.
We investigated the influence of bone quality on the mechanics of
augmentation of plate fixation in a distal femoral fracture model
(AO 33 A3 type). Eight osteoporotic and eight non-osteoporotic femoral
models were randomly assigned to either an augmented or a non-augmented
group. Fixation was performed using a locking compression plate.
In the augmented group additionally 1 ml of bone cement was injected
into the screw hole before insertion of the screw. Biomechanical
testing was performed in axial sinusoidal loading. Augmentation significantly
reduced the cut-out distance in the osteoporotic models by about
67% (non-augmented mean 0.30 mm ( Cite this article:
Lately, concerns have arisen following the use of large metal-on-metal bearings in hip replacements owing to reports of catastrophic soft-tissue reactions resulting in implant failure and associated complications. This review examines the literature and contemporary presentations on current clinical dilemmas in metal-on-metal hip replacement.
The aim of this prospective randomised study
was to compare the clinical and radiological results of a cemented
all-polyethylene Ultima acetabular component with those of a cementless
porous-coated acetabular component (PFC) following total hip replacement
(THR). A total of 287 patients received either a polyethylene acetabular
component (group A) or a cobalt–chromium porous-coated component
(group B) with an identical cemented femoral component and 28 mm
cobalt-chromium head, thus making it the largest study of its type.
Patients were evaluated radiologically and clinically using the
Harris hip score (HHS). Group A comprised 183 patients (73 male,
110 female) with a mean age of
71.3 years (55 to 89). Group B comprised 104 patients (48 male,
56 female) with a mean age of 69.8 years (56 to 89). A total of
16 patients (13 in Group A, three in Group B) did not have post-operative
data for analysis. The mean follow-up in group A was 7.52 years
(0.4 to 15.0) and in Group B 7.87 years (0.5 to 14.0). At final follow-up the mean HHS was similar between groups A
and B (74.5 (25 to 100) and 78.0 (37 to 100), respectively; p =
0.068). The total number of revisions for any cause was 28, 17 of
which were in group A and 11 in group B. The ten-year survivorship
was 86.8% (95% confidence interval (CI) 78.4 to 92.1) and 89.2%
(95% CI 78.3 to 94.8) for groups A and B, respectively (log-rank
p-value = 0.938). A total of 20 cemented and two cementless acetabular
components had evidence of acetabular radiolucencies or acetabular
component migration at last follow-up (p = 0.001). These results indicate that patients with a cemented all-polyethylene
and cementless porous-coated polyethylene lined acetabular component
have similar long-term clinical outcomes.
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:
The aim of this study was to perform a cost–utility
analysis of total hip (THR) and knee replacement (TKR). Arthritis is
a disabling condition that leads to long-term deterioration in quality
of life. Total joint replacement, despite being one of the greatest
advances in medicine of the modern era, has recently come under
scrutiny. The National Health Service (NHS) has competing demands,
and resource allocation is challenging in times of economic restraint. Patients
who underwent THR (n = 348) or TKR (n = 323) between January and
July 2010 in one Scottish region were entered into a prospective
arthroplasty database. A health–utility score was derived from the
EuroQol (EQ-5D) score pre-operatively and at one year, and was combined
with individual life expectancy to derive the quality-adjusted life years
(QALYs) gained. Two-way analysis of variance was used to compare
QALYs gained between procedures, while controlling for baseline
differences. The number of QALYs gained was higher after THR than
after TKR (6.5 Cite this article:
We investigated the functional outcome in patients
who underwent reverse shoulder replacement (RSR) after removal of
a tumour of the proximal humerus. A total of 16 patients (ten women
and six men) underwent this procedure between 1998 and 2011 in our
hospital. Five patients died and one was lost to follow-up. Ten
patients were available for review at a mean follow-up of 46 months
(12 to 136). Eight patients had a primary and two patients a secondary
bone tumour. At final follow up the mean range of active movement was: abduction
78° (30° to 150°); flexion 98° (45° to 180°); external rotation
32° (10° to 60°); internal rotation 51° (10° to 80°). The mean Musculoskeletal
Tumor Society score was 77% (60% to 90%) and the mean Toronto Extremity
Salvage Score was 70% (30% to 91%). Two patients had a superficial
infection and one had a deep infection and underwent a two-stage
revision procedure. In two patients there was loosening of the RSR;
one dislocated twice. All patients had some degree of atrophy or
pseudo-atrophy of the deltoid muscle. Use of a RSR in patients with a tumour of the proximal humerus
gives acceptable results. Cite this article:
Autologous chondrocyte implantation (ACI) and
mosaicplasty are methods of treating symptomatic articular cartilage
defects in the knee. This study represents the first long-term randomised
comparison of the two techniques in 100 patients at a minimum follow-up
of ten years. The mean age of the patients at the time of surgery was
31.3 years (16 to 49); the mean duration of symptoms pre-operatively
was 7.2 years (9 months to 20 years). The lesions were large with
the mean size for the ACI group being 440.9 mm2 (100
to 1050) and the mosaicplasty group being 399.6 mm2 (100
to 2000). Patients had a mean of 1.5 previous operations (0 to 4)
to the articular cartilage defect. Patients were assessed using
the modified Cincinnati knee score and the Stanmore-Bentley Functional Rating
system. The number of patients whose repair had failed at ten years
was ten of 58 (17%) in the ACI group and 23 of 42 (55%) in the mosaicplasty
group (p <
0.001). The functional outcome of those patients with a surviving graft
was significantly better in patients who underwent ACI compared
with mosaicplasty (p = 0.02).
We present the clinical results and survivorship
of consecutive 100 Birmingham Hip Resurfacings in 90 patients at
a minimum follow-up of ten years. All procedures were carried out
by an independent surgeon who commenced a prospective study in 1998.
Patients were assessed clinically using the Western Ontario and
McMaster Universities osteoarthritis index, Short-Form 36, Harris
hip score and University of California, Los Angeles activity score. Radiological
analysis was performed by an independent observer and blood metal
ion levels concentrations were measured at ten years post-operatively
in 62 patients. The median acetabular component inclination was
46.2° (34° to 59°) and anteversion 11.0° (0° to 30°). The median
chromium concentration in the unilateral group was 1.74 (0.41 to
15.23) and for the bilateral group was 2.98 (1.57 to 18.01). The
equivalent values for cobalt were 1.67 (0.54 to 20.4) and 1.88 (1.38
to 19.32). In total there were eight failures giving an overall survival
at ten years of 92% (95% confidence interval (CI) 86.7 to 97.3).
BHR in male patients had an improved survivorship of 94.6% (95%
CI 89.4 to 100) compared with females at 84.6% (95% CI 70.7 to 98.5),
but this did not reach statistical significance (p = 0.119). Four
of the nine BHRs with a bearing diameter of 42 mm failed. The overall results were consistent with data produced from other
centres in that the clinical outcome of large male patients was
extremely encouraging, whereas the survival of the smaller joints
was less satisfactory.
The October 2012 Shoulder &
Elbow Roundup360 looks at: fast-absorbing suture anchors for use in shoulder labral tears; double-row rotator cuff repair; degenerate massive rotator cuff tears addressed with partial repair; open and arthroscopic stabilisation of Bankart lesions; predicting the risk of revision humeral head replacement; arthroscopic treatment for frozen shoulder; and long-term follow-up of the Bristow-Latarjet procedure.
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.
The October 2012 Hip &
Pelvis Roundup360 looks at: diagnosing the infected hip replacement; whether tranexamic acid has a low complication rate; the relationship between poor cementing technique and early failure of resurfacing; debridement and retention for the infected replacement; triple-tapered stems and bone mineral density; how early discharge can be bad for your sleep; an updated QFracture algorithm to predict the risk of an osteoporotic fracture; and local infiltration analgesia and total hip replacement.
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.
The October 2013 Hip &
Pelvis Roundup360 looks at: Young and impinging; Clothes, weather and femoral heads?; Go long, go cemented; Surgical repair of the abductors?; Aspirin for DVT prophylaxis?; Ceramic-on-polyethylene: a low-wear solution?; ALVAL and ASR™: the story continues….; Salvaging Legg-Calve-Perthes’ disease
The strain on clinic and surgeon resources resulting
from a rise in demand for total knee replacement (TKR) requires reconsideration
of when and how often patients need to be seen for follow-up. Surgeons
will otherwise require increased paramedical staff or need to limit
the number of TKRs they undertake. We reviewed the outcome data
of 16 414 primary TKRs undertaken at our centre to determine the
time to re-operation for any reason and for specific failure mechanisms.
Peak risk years for failure were determined by comparing the conditional
probability of failure, the number of failures divided by the total
number of TKRs cases, for each year. The median times to failure
for the most common failure mechanisms were 4.9 years (interquartile
range (IQR) 1.7 to 10.7) for femoral and tibial loosening, 1.9 years
(IQR 0.8 to 3.9) for infection, 3.1 years (IQR 1.6 to 5.5) for tibial
collapse and 5.6 years (IQR 3.4 to 9.3) for instability. The median
time to failure for all revisions was 3.3 years (IQR 1.2 to 8.5),
with an overall revision rate of 1.7% (n = 282). Results from our
patient population suggest that patients be seen for follow-up at
six months, one year, three years, eight years, 12 years, and every
five years thereafter. Patients with higher pain in the early post-operative
period or high body mass index (≥ 41 kg/m2) should be
monitored more closely. Cite this article:
As part of the national initiative to reduce
waiting times for joint replacement surgery in Wales, the Cardiff
and Vale NHS Trust referred 224 patients to the NHS Treatment Centre
in Weston-Super-Mare for total knee replacement (TKR). A total of
258 Kinemax TKRs were performed between November 2004 and August
2006. Of these, a total of 199 patients (232 TKRs, 90%) have been
followed up for five years. This cohort was compared with 258 consecutive
TKRs in 250 patients, performed at Cardiff and Vale Orthopaedic
Centre (CAVOC) over a similar time period. The five year cumulative
survival rate was 80.6% (95% confidence interval (CI) 74.0 to 86.0)
in the Weston-Super-Mare cohort and 95.0% (95% CI 90.2 to 98.2)
in the CAVOC cohort with revision for any reason as the endpoint.
The relative risk for revision at Weston-Super-Mare compared with
CAVOC was 3.88 (p <
0.001). For implants surviving five years,
the mean Oxford knee scores (OKS) and mean EuroQol (EQ-5D) scores
were similar (OKS: Weston-Super-Mare 29 (2 to 47) The results show a higher revision rate for patients operated
at Weston-Super-Mare Treatment Centre, with a reduction in functional
outcome and quality of life after revision. This further confirms
that patients moved from one area to another for joint replacement
surgery fare poorly.