The aim of this study was to define the incidence
of venous thromboembolism (VTE) and risk factors for the development
of deep-vein thrombosis (DVT) after the resection of a musculoskeletal
tumour. A total of 94 patients who underwent resection of a musculoskeletal
tumour between January 2003 and December 2005 were prospectively
studied. There were 42 men and 52 women with a mean age of 54.4
years (18 to 86). All patients wore intermittent pneumatic compression
devices and graduated compression stockings. Ultrasound examination
of the lower limbs was conducted to screen for DVT between the fifth
and ninth post-operative days. DVT was detected in 21 patients (22%). Of these, two were symptomatic
(2%). One patient (1%) had a fatal pulmonary embolism. Patients
aged ≥ 70 years had an increased risk of DVT (p = 0.004). The overall incidence of DVT (both symptomatic and asymptomatic)
after resection of a musculoskeletal tumour with mechanical prophylaxis
was high. It seems that both mechanical and anticoagulant prophylaxis
is needed to prevent VTE in patients who have undergone the resection
of a musculoskeletal tumour. Cite this article:
The lack of a consensus for core health outcomes
that should be reported in clinical research has hampered study design
and evidence synthesis. We report a United Kingdom consensus for
a core outcome set (COS) for clinical trials of patients with a
hip fracture. We adopted a modified nominal group technique to derive consensus
on 1) which outcome domains should be measured, and 2) methods of
assessment. Participants reflected a diversity of perspectives and
experience. They received an evidence synthesis and postal questionnaire
in advance of the consensus meeting, and ranked the importance of
candidate domains and the relevance and suitability of short-listed
measures. During the meeting, pre-meeting source data and questionnaire
responses were summarised, followed by facilitated discussion and
a final plenary session. A COS was determined using a closed voting
system: a 70% consensus was required. Consensus supported a five-domain COS: mortality, pain, activities
of daily living, mobility, and health-related quality of life (HRQL).
Single-item measures of mortality and mobility (indoor/outdoor walking
status) and a generic multi-item measure of HRQL - the EuroQoL EQ-5D
- were recommended. These measures should be included as a minimum
in all hip fracture trials. Other outcome measures should be added
depending on the particular interventions being studied. Cite this article:
A clinical investigation into a new bone void filler is giving
first data on systemic and local exposure to the anti-infective
substance after implantation. A total of 20 patients with post-traumatic/post-operative bone
infections were enrolled in this open-label, prospective study.
After radical surgical debridement, the bone cavity was filled with
this material. The 21-day hospitalisation phase included determination
of gentamicin concentrations in plasma, urine and wound exudate, assessment
of wound healing, infection parameters, implant resorption, laboratory
parameters, and adverse event monitoring. The follow-up period was
six months. Objective
Method
Acetabular retractors have been implicated in damage to the femoral
and obturator nerves during total hip replacement. The aim of this
study was to determine the anatomical relationship between retractor
placement and these nerves. A posterior approach to the hip was carried out in six fresh
cadaveric half pelves. Large Hohmann acetabular retractors were
placed anteriorly, over the acetabular lip, and inferiorly, and
their relationship to the femoral and obturator nerves was examined.Objectives
Methods
In this paper, we consider wound healing after
total knee arthroplasty.
Although the importance of lateral femoral wall
integrity is increasingly being recognised in the treatment of intertrochanteric
fracture, little attention has been put on the development of a
secondary post-operative fracture of the lateral wall. Patients
with post-operative fractures of the lateral wall were reported
to have high rates of re-operation and complication. To date, no
predictors of post-operative lateral wall fracture have been reported.
In this study, we investigated the reliability of lateral wall thickness
as a predictor of lateral wall fracture after dynamic hip screw
(DHS) implantation. A total of 208 patients with AO/OTA 31-A1 and -A2 classified
intertrochanteric fractures who received internal fixation with
a DHS between January 2003 and May 2012 were reviewed. There were
103 men and 150 women with a mean age at operation of
78 years (33 to 94). The mean follow-up was 23 months (6 to 83).
The right side was affected in 97 patients and the left side in
111. Clinical information including age, gender, side, fracture
classification, tip–apex distance, follow-up time, lateral wall
thickness and outcome were recorded and used in the statistical
analysis. Fracture classification and lateral wall thickness significantly
contributed to post-operative lateral wall fracture (both p <
0.001). The lateral wall thickness threshold value for risk of developing
a secondary lateral wall fracture was found to be 20.5 mm. To our knowledge, this is the first study to investigate the
risk factors of post-operative lateral wall fracture in intertrochanteric
fracture. We found that lateral wall thickness was a reliable predictor
of post-operative lateral wall fracture and conclude that intertrochanteric
fractures with a lateral wall thickness <
20.5 mm should not
be treated with DHS alone. Cite this article:
The August 2013 Trauma Roundup360 looks at: reverse oblique fractures do better with a cephalomedullary device; locking screws confer no advantage in tibial plateau fractures; it’s all about the radius of curvature; radius of curvature revisited; radial head replacement in complex elbow reconstruction; stem cells in early fracture haematoma; heterotrophic ossification in forearms; and Boston in perspective.
Neurogenic heterotopic ossification (NHO) is
a disorder of aberrant bone formation affecting one in five patients sustaining
a spinal cord injury or traumatic brain injury. Ectopic bone forms
around joints in characteristic patterns, causing pain and limiting
movement especially around the hip and elbow. Clinical sequelae
of neurogenic heterotopic ossification include urinary tract infection,
pressure injuries, pneumonia and poor hygiene, making early diagnosis
and treatment clinically compelling. However, diagnosis remains
difficult with more investigation needed. Our pathophysiological
understanding stems from mechanisms of basic bone formation enhanced
by evidence of systemic influences from circulating humor factors
and perhaps neurological ones. This increasing understanding guides
our implementation of current prophylaxis and treatment including
the use of non-steroidal anti-inflammatory drugs, bisphosphonates,
radiation therapy and surgery and, importantly, should direct future, more
effective ones.
Conventional methods of treating ankle fractures
in the elderly are associated with high rates of complication. We describe
the results of treating these injuries in 48 frail elderly patients
with a long calcaneotalotibial nail. The mean age of the group was 82 years (61 to 96) and 41 (85%)
were women. All were frail, with multiple medical comorbidities
and their mean American Society of Anaesthesiologists score was
3 (3 to 4). None could walk independently before their operation.
All the fractures were displaced and unstable; the majority (94%,
45 of 48) were low-energy injuries and 40% (19 of 48) were open. The overall mortality at six months was 35%. Of the surviving
patients, 90% returned to their pre-injury level of function. The
mean pre- and post-operative Olerud and Molander questionnaire scores
were 62 and 57 respectively. Complications included superficial
infection (4%, two of 48); deep infection (2%, one of 48); a broken
or loose distal locking screw (6%, three of 48); valgus malunion
(4%, two of 48); and one below-knee amputation following an unsuccessful
vascular operation. There were no cases of nonunion, nail breakage
or peri-prosthetic fracture. A calcaneotalotibial nail is an excellent device for treating
an unstable fracture of the ankle in the frail elderly patient.
It allows the patient to mobilise immediately and minimises the
risk of bone or wound problems. A long nail which crosses the isthmus
of the tibia avoids the risk of peri-prosthetic fracture associated
with shorter devices. Cite this article:
Metal-on-metal hip resurfacing (MOMHR) is available as an alternative
option for younger, more active patients. There are failure modes
that are unique to MOMHR, which include loosening of the femoral
head and fractures of the femoral neck. Previous studies have speculated
that changes in the vascularity of the femoral head may contribute
to these failure modes. This study compares the survivorship between
the standard posterior approach (SPA) and modified posterior approach
(MPA) in MOMHR. A retrospective clinical outcomes study was performed examining
351 hips (279 male, 72 female) replaced with Birmingham Hip Resurfacing
(BHR, Smith and Nephew, Memphis, Tennessee) in 313 patients with
a pre-operative diagnosis of osteoarthritis. The mean follow-up
period for the SPA group was 2.8 years (0.1 to 6.1) and for the
MPA, 2.2 years (0.03 to 5.2); this difference in follow-up period
was statistically significant (p <
0.01). Survival analysis was
completed using the Kaplan–Meier method. Objectives
Methods
We prospectively followed 191 consecutive collarless
polished tapered (CPT) femoral stems, implanted in 175 patients
who had a mean age at operation of 64.5 years (21 to 85). At a mean
follow-up of 15.9 years (14 to 17.5), 86 patients (95 hips) were
still alive. The fate of all original stems is known. The 16-year
survivorship with re-operation for any reason was 80.7% (95% confidence
interval 72 to 89.4). There was no loss to follow-up, with clinical
data available on all 95 hips and radiological assessment performed
on 90 hips (95%). At latest follow-up, the mean Harris hip score
was 78 (28 to 100) and the mean Oxford hip score was 36 (15 to 48).
Stems subsided within the cement mantle, with a mean subsidence
of 2.1 mm (0.4 to 19.2). Among the original cohort, only one stem
(0.5%) has been revised due to aseptic loosening. In total seven
stems were revised for any cause, of which four revisions were required
for infection following revision of the acetabular component. A
total of 21 patients (11%) required some sort of revision procedure;
all except three of these resulted from failure of the acetabular
component. Cemented acetabular components had a significantly lower
revision burden (three hips, 2.7%) than Harris Galante uncemented
components (17 hips, 21.8%) (p <
0.001). The CPT stem continues to provide excellent radiological and
clinical outcomes at 15 years following implantation. Its results
are consistent with other polished tapered stem designs.
We retrospectively reviewed the records of 1150
computer-assisted total knee replacements and analysed the clinical
and radiological outcomes of 45 knees that had arthritis with a
pre-operative recurvatum deformity. The mean pre-operative hyperextension
deformity of 11° (6° to 15°), as measured by navigation at the start
of the operation, improved to a mean flexion deformity of 3.1° (0°
to 7°) post-operatively. A total of 41 knees (91%) were managed
using inserts ≤ 12.5 mm thick, and none had mediolateral laxity
>
2 mm from a mechanical axis of 0° at the end of the surgery. At
a mean follow-up of 26.4 months (13 to 48) there was significant
improvement in the mean Knee Society, Oxford knee and Western Ontario
and McMaster Universities Osteoarthritis Index scores compared with
the pre-operative values. The mean knee flexion improved from 105°
(80° to 125°) pre-operatively to 131° (120° to 145°), and none of
the limbs had recurrent recurvatum. These early results show that total knee replacement using computer
navigation and an algorithmic approach for arthritic knees with
a recurvatum deformity can give excellent radiological and functional
outcomes without recurrent deformity.
The June 2012 Oncology Roundup360 looks at: avoiding pelvic hemipelvectomy; proximal femoral metastasis; extendible prostheses; rotationplasty; soft-tissue sarcomas; osteosarcoma of the pelvis; recurrent chondrosarcoma ; MRI and the differentiation between benign and malignant lesions; and malignant fibrous histiocytoma.
We evaluated the oncological and functional outcome
of 18 patients, whose malignant bone tumours were excised with the
assistance of navigation, and who were followed up for more than
three years. There were 11 men and seven women, with a mean age
of 31.8 years (10 to 57). There were ten operations on the pelvic
ring and eight joint-preserving limb salvage procedures. The resection
margins were free of tumour in all specimens. The tumours, which
were stage IIB in all patients, included osteosarcoma, high-grade
chondrosarcoma, Ewing’s sarcoma, malignant fibrous histiocytoma
of bone, and adamantinoma. The overall three-year survival rate
of the 18 patients was 88.9% (95% confidence interval (CI) 75.4
to 100). The three-year survival rate of the patients with pelvic malignancy
was 80.0% (95% CI 55.3 to 100), and of the patients with metaphyseal
malignancy was 100%. The event-free survival was 66.7% (95% CI 44.9
to 88.5). Local recurrence occurred in two patients, both of whom
had a pelvic malignancy. The mean Musculoskeletal Tumor Society
functional score was 26.9 points at a mean follow-up of 48.2 months
(22 to 79). We suggest that navigation can be helpful during surgery for
musculoskeletal tumours; it can maximise the accuracy of resection
and minimise the unnecessary sacrifice of normal tissue by providing
precise intra-operative three-dimensional radiological information.
We compared a new fixation system, the Targon
Femoral Neck (TFN) hip screw, with the current standard treatment of
cannulated screw fixation. This was a single-centre, participant-blinded,
randomised controlled trial. Patients aged 65 years and over with
either a displaced or undisplaced intracapsular fracture of the
hip were eligible. The primary outcome was the risk of revision
surgery within one year of fixation. A total of 174 participants were included in the trial. The absolute
reduction in risk of revision was of 4.7% (95% CI 14.2 to 22.5)
in favour of the TFN hip screw (chi-squared test, p = 0.741), which
was less than the pre-specified level of minimum clinically important
difference. There were no significant differences in any of the
secondary outcome measures. We found no evidence of a clinical difference in the risk of
revision surgery between the TFN hip screw and cannulated screw
fixation for patients with an intracapsular fracture of the hip. Cite this article:
Ensuring correct rotation of the femoral component
is a challenging aspect of patellofemoral replacement surgery. Rotation
equal to the epicondylar axis or marginally more external rotation
is acceptable. Internal rotation is associated with poor outcomes.
This paper comprises two studies evaluating the use of the medial
malleolus as a landmark to guide rotation. We used 100 lower-leg anteroposterior radiographs to evaluate
the reliability of the medial malleolus as a landmark. Assessment
was made of the angle between the tibial shaft and a line from the
intramedullary rod entry site to the medial malleolus. The femoral
cut was made in ten cadaver knees using the inferior tip of the
medial malleolus as a landmark for rotation. Rotation of the cut
relative to the anatomical epicondylar axis was assessed using CT.
The study of radiographs found the position of the medial malleolus
relative to the tibial axis is consistent. Using the inferior tip
of the medial malleolus in the cadaver study produced a mean external
rotation of 1.6° (0.1° to 3.7°) from the anatomical epicondylar
axis. Using the inferior tip of the medial malleolus to guide the
femoral cutting jig avoids internal rotation and introduces an acceptable
amount of external rotation of the femoral component.
Bicruciate-stabilised total knee replacement (TKR) aims to restore normal kinematics by replicating the function of both cruciate ligaments. We performed a prospective, randomised controlled trial in which bicruciate- and posterior-stabilised TKRs were implanted in 13 and 15 osteo-arthritic knees, respectively. The mean age of the bicruciate-stabilised group was 63.9 years ( At near full extension during step-up, the bicruciate-stabilised TKR produced a higher mean PTA than the posterior-stabilised TKR, indicating that the bicruciate design at least partially restored the kinematic role of the anterior cruciate ligament. The bicruciate-stabilised TKR largely restored the pre-operative kinematics, whereas the posterior-stabilised TKR resulted in a consistently lower PTA at all activities. The PTA in the pre-operative knees was higher than in the control group during the step-up and at near full knee extension. Overall, both groups generated a more normal PTA than that seen in previous studies in high knee flexion. This suggested that both designs of TKR were more effective at replicating the kinematic role of the posterior cruciate ligament than those used in previous studies.
Medial patellofemoral ligament (MPFL) reconstruction
is used to treat patellar instability and recurrent patellar dislocation.
Anatomical studies have found the MPFL to be a double-bundle structure.
We carried out a meta-analysis of studies reporting outcomes of
patellofemoral reconstruction using hamstring tendon autograft in
a double-bundle configuration and patellar fixation via mediolateral
patellar tunnels. A literature search was undertaken with no language restriction
in various databases from their year of inception to July 2012.
The primary outcome examined was the post-operative Kujala score.
We identified 320 MPFL reconstructions in nine relevant articles.
The combined mean post-operative Kujala score was 92.02 (standard
error ( Cite this article:
We investigated the characteristics of patients
who achieved Japanese-style deep flexion (seiza-sitting) after total knee
replacement (TKR) and measured three-dimensional positioning and
the contact positions of the femoral and tibial components. Seiza-sitting
was achieved after surgery by 23 patients (29 knees) of a series
of 463 TKRs in 341 patients. Pre-operatively most of these patients
were capable of seiza-sitting, had a lower body mass index and a favourable
attitude towards the Japanese lifestyle (27 of 29 knees). According
to two-/three-dimensional image registration analysis in the seiza-sitting
position, flexion, varus and internal rotation angles of the tibial
component relative to the femoral component had means of 148° ( Cite this article:
The aim of this study was to determine the accuracy
of registration and the precision of the resection volume in navigated
hip arthroscopy for cam-type femoroacetabular impingement, using
imageless and image-based registration. A virtual cam lesion was
defined in 12 paired cadaver hips and randomly assigned to either
imageless or image-based (three-dimensional (3D) fluoroscopy) navigated
arthroscopic head–neck osteochondroplasty. The accuracy of patient–image
registration for both protocols was evaluated and post-operative
imaging was performed to evaluate the accuracy of the surgical resection.
We found that the estimated accuracy of imageless registration in the
arthroscopic setting was poor, with a mean error of 5.6 mm (standard
deviation ( In conclusion, given the limited femoral surface that can be
reached and digitised during arthroscopy of the hip, imageless registration
is inaccurate and does not allow for reliable surgical navigation.
However, image-based registration does acceptably allow for guided
femoral osteochondroplasty in the arthroscopic management of femoroacetabular
impingement.