Incomplete avulsion of the proximal hamstrings
can be a severely debilitating injury that causes weakness, pain
while sitting and inability to run. The results of the surgical treatment
of 23 consecutive patients with such injuries at least two years
after surgery are described. The surgery consisted of the repair
of the hamstrings directly onto the ischial tuberosity. At review,
using a visual analogue scale (VAS, 0 to 100), pain while sitting improved
from a mean of 40 (0 to 100) to 64 (0 to 100) (p = 0.024), weakness
from a mean of 39 (0 to 90) to 76 (7 to 100) (p = 0.0001) and the
ability to run from a mean of 24 (0 to 88) to 64 (0 to 95) (p =
0.0001). According to a VAS, satisfaction was rated at a mean of
81 (0 to 100) and 20 patients (87%) would have the same procedure
again. Hamstring strength measured pre- and post-operatively had
improved significantly from a mean of 64% (0% to 95%) to 88% (50%
to 114%) compared with the normal side. Most of these patients with symptomatic incomplete hamstring
avulsions unresponsive to conservative treatment had an improved
outcome after surgical repair.
Fracture of a ceramic component in total hip
replacement is a rare but potentially catastrophic complication.
The incidence is likely to increase as the use of ceramics becomes
more widespread. We describe such a case, which illustrates how
inadequate initial management will lead to further morbidity and
require additional surgery. We present the case as a warning that
fracture of a ceramic component should be revised to another ceramic-on-ceramic
articulation in order to minimise the risk of further catastrophic
wear.
Corticosteroids are prescribed for the treatment of many medical conditions and their adverse effects on bone, including steroid-associated osteoporosis and osteonecrosis, are well documented. Core decompression is performed to treat osteonecrosis, but the results are variable. As steroids may affect bone turnover, this study was designed to investigate bone healing within a bone tunnel after core decompression in an experimental model of steroid-associated osteonecrosis. A total of five 28-week-old New Zealand rabbits were used to establish a model of steroid-induced osteonecrosis and another five rabbits served as controls. Two weeks after the induction of osteonecrosis, core decompression was performed by creating a bone tunnel 3 mm in diameter in both distal femora of each rabbit in both the experimental osteonecrosis and control groups. An In the osteonecrosis group all measurements of bone healing and maturation were lower compared with the control group. Impaired osteogenesis and remodelling within the bone tunnel was demonstrated in the steroid-induced osteonecrosis, accompanied by inferior mechanical properties of the bone. We have confirmed impaired bone healing in a model of bone defects in rabbits with pulsed administration of corticosteroids. This finding may be important in the development of strategies for treatment to improve the prognosis of fracture healing or the repair of bone defects in patients receiving steroid treatment.
We reviewed 183 patients who had undergone reconstruction of the anterior cruciate ligament. The incidence of meniscal tears and degenerative change was assessed and related to the timing from injury to surgery. Degenerative change was scored using the French Society of Arthroscopy system. The patients were divided into an early (surgery within 12 months of injury) and a late group (surgery more than 12 months from injury). The late group was also subdivided into four groups of 12-month periods ranging from one year to more than four years after injury. There was a significantly higher incidence of meniscal tears in patients undergoing reconstruction after 12 months compared with those in the early group (71.2%
The June 2012 Research Roundup360 looks at: platelet-rich plasma; ageing, bone and mesenchymal stem cells; cytokines and the herniated intervertebral disc; ulcerative colitis, Crohn’s disease and anti-inflammatories; the effect of NSAIDs on bone healing; osteoporosis of the fractured hip; herbal medicine and recovery after acute muscle injury; and ultrasound and the time to fracture union.
Painful neuromas may follow traumatic nerve injury. We carried out a double-blind controlled trial in which patients with a painful neuroma of the lower limb (n = 20) were randomly assigned to treatment by resection of the neuroma and translocation of the proximal nerve stump into either muscle tissue or an adjacent subcutaneous vein. Translocation into a vein led to reduced intensity of pain as assessed by visual analogue scale (5.8 (sd 2.7) vs 3.8 (sd 2.4); p <
0.01), and improved sensory, affective and evaluative dimensions of pain as assessed by the McGill pain score (33 (sd 18) vs 14 (sd 12); p <
0.01). This was associated with an increased level of activity (p <
0.01) and improved function (p <
0.01). Transposition of the nerve stump into an adjacent vein should be preferred to relocation into muscle.
Giant cell tumours (GCT) of the synovium and
tendon sheath can be classified into two forms: localised (giant
cell tumour of the tendon sheath, or nodular tenosynovitis) and
diffuse (diffuse-type giant cell tumour or pigmented villonodular
synovitis). The former principally affects the small joints. It
presents as a solitary slow-growing tumour with a characteristic
appearance on MRI and is treated by surgical excision. There is
a significant risk of multiple recurrences with aggressive diffuse
disease. A multidisciplinary approach with dedicated MRI, histological assessment
and planned surgery with either adjuvant radiotherapy or systemic
targeted therapy is required to improve outcomes in recurrent and
refractory diffuse-type GCT. Although arthroscopic synovectomy through several portals has
been advocated as an alternative to arthrotomy, there is a significant
risk of inadequate excision and recurrence, particularly in the
posterior compartment of the knee. For local disease partial arthroscopic
synovectomy may be sufficient, at the risk of recurrence. For both
local and diffuse intra-articular disease open surgery is advised
for recurrent disease. Marginal excision with focal disease will
suffice, not dissimilar to the treatment of GCT of tendon sheath.
For recurrent and extra-articular soft-tissue disease adjuvant therapy,
including intra-articular radioactive colloid or moderate-dose external
beam radiotherapy, should be considered.
The current indications for functional restoration
of extension of the knee following quadriceps resection or loss require
reappraisal. The contribution of pedicled and free functional muscle
transfer is likely to be over-emphasised in many studies, with good
functional outcomes predominantly reported only in the context of
cases with residual quadriceps function. In cases with total quadriceps
resection or loss, all forms of reconstruction perform poorly. Furthermore,
in smaller resections with loss of two or fewer components of the
quadriceps, minimal impairment of function occurs in the absence
of functional reconstruction, suggesting that functional restoration
may not be warranted. Thus there is a paradox in the current approach
to quadriceps reconstruction, in that small resections are likely
to be over-treated and large resections remain under-treated. This review suggests a shift is required in the approach and
rationale for reconstructing functional extension of the knee after
quadriceps resection or loss. A classification based on current
evidence is suggested that emphasises more clearly the indications
and rationale for functional transfers.
The purpose of this prospective study was to
evaluate the long-term clinical and radiological outcomes of revision of
the femoral component of a total hip replacement using impaction
bone grafting. Femoral revision with an impacted allograft was performed
on 29 patients (31 hips). In all, 21 hips (68%) had grade III or
IV femoral defects according to the Endo-Klinik classification.
A total of 11 patients (12 hips) died before the ten-year follow-up
period. Of the remaining patients, 18 patients (19 hips) were followed
for 10 to 15 years; three further patients died during this time.
None of the 31 stems underwent further revision of their stem. However,
four stems showed extensive subsidence (>
15 mm). One of these patients
had a femoral fracture that required fixation. Three other patients
had a femoral fracture, two of which required fixation and the other
was treated conservatively. Patients with a femoral fracture and/or
severe subsidence had significantly more grade IV defects (six of
seven hips; p = 0.004). One patient needed a closed reduction for
dislocation. Impaction allografting in revision hip surgery gives good long-term
results for femora with grades I, II and III Endo-Klinik-classified
defects. Extensive subsidence and femoral fractures were seen mainly
in patients with grade IV damaged femora.
This is a retrospective case review of 237 patients with displaced fractures of the acetabulum presenting over a ten-year period, with a minimum follow-up of two years, who were studied to test the hypothesis that the time to surgery was predictive of radiological and functional outcome and varied with the pattern of fracture. Patients were divided into two groups based on the fracture pattern: elementary or associated. The time to surgery was analysed as both a continuous and a categorical variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables. For elementary fractures, an increase in the time to surgery of one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day. When time was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated). The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum. The organisation of regional trauma services must be capable of satisfying these time-dependent requirements to achieve optimal patient outcomes.
Dislocation of the shoulder may occur during
seizures in epileptics and other patients who have convulsions. Following
the initial injury, recurrent instability is common owing to a tendency
to develop large bony abnormalities of the humeral head and glenoid
and a susceptibility to further seizures. Assessment is difficult
and diagnosis may be missed, resulting in chronic locked dislocations
with protracted morbidity. Many patients have medical comorbidities,
and successful treatment requires a multidisciplinary approach addressing
the underlying seizure disorder in addition to the shoulder pathology.
The use of bony augmentation procedures may have improved the outcomes
after surgical intervention, but currently there is no evidence-based
consensus to guide treatment. This review outlines the epidemiology
and pathoanatomy of seizure-related instability, summarising the
currently-favoured options for treatment, and their results.
The open blast fracture of the pelvis is considered
to be the most severe injury within the spectrum of battlefield trauma.
We report our experience of 29 consecutive patients who had sustained
this injury in Afghanistan between 2008 and 2010. Their median new
injury severity score (NISS) was 41 (8 to 75), and mean blood requirement
in the first 24 hours was 60.3 units (0 to 224). In addition to
their orthopaedic injury, six had an associated vascular injury, seven
had a bowel injury, 11 had a genital injury and seven had a bladder
injury. In all, eight fractures were managed definitively with external
fixation and seven required internal fixation. Of those patients
who underwent internal fixation, four required removal of metalwork
for infection. Faecal diversion was performed in nine cases. The
median length of hospital stay following emergency repatriation
to the United Kingdom was 70.5 days (5 to 357) and the mean total
operating time was 29.6 hours (5 to 187). At a mean follow-up of
20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk
and 26 (89.7%) had clinical and radiological evidence of stability
of the pelvic ring. As a result of the increase in terrorism, injuries that were
previously confined exclusively to warfare can now occur anywhere,
with civilian surgeons who are involved in trauma care potentially
required to manage similar injuries. Our study demonstrates that
the management of this injury pattern demands huge resources and significant
multidisciplinary input. Given the nature of the soft-tissue injury,
we would advocate external fixation as the preferred management
of these fractures. With the advent of emerging wound and faecal
management techniques, we do not believe that faecal diversion is
necessary in all cases.
It is probable that both genetic and environmental
factors play some part in the aetiology of most cases of degenerative
hip disease. Geneticists have identified some single gene disorders
of the hip, but have had difficulty in identifying the genetics
of many of the common causes of degenerative hip disease. The heterogeneity
of the phenotypes studied is part of the problem. A detailed classification
of phenotypes is proposed. This study is based on careful documentation
of 2003 consecutive total hip replacements performed by a single
surgeon between 1972 and 2000. The concept that developmental problems
may initiate degenerative hip disease is supported. The influences
of gender, age and body mass index are outlined. Biomechanical explanations
for some of the radiological appearances encountered are suggested.
The body weight lever, which is larger than the abductor lever, causes
the abductor power to be more important than body weight. The possibility
that a deficiency in joint lubrication is a cause of degenerative
hip disease is discussed. Identifying the phenotypes may help geneticists
to identify genes responsible for degenerative hip disease, and
eventually lead to a definitive classification.
Matrix-induced autologous chondrocyte implantation
(MACI) is an established technique used to treat osteochondral lesions
in the knee. For larger osteochondral lesions (>
5 cm2)
deeper than approximately 8 mm we have combined the use of two MACI
membranes with impaction grafting of the subchondral bone. We report
our results of 14 patients who underwent the ‘bilayer collagen membrane’
technique (BCMT) with a mean follow-up of 5.2 years (2 to 8). There
were 12 men and two women with a mean age of 23.6 years (16 to 40).
The mean size of the defect was 7.2 cm2 (5.2 to 12 cm2)
and were located on the medial (ten) or lateral (four) femoral condyles.
The mean modified Cincinnati knee score improved from 45.1 (22 to
70) pre-operatively to 82.8 (34 to 98) at the most recent review
(p <
0.05). The visual analogue pain score improved from 7.3
(4 to 10) to 1.7 (0 to 6) (p <
0.05). Twelve patients were considered
to have a good or excellent clinical outcome. One graft failed at
six years. The BCMT resulted in excellent functional results and durable
repair of large and deep osteochondral lesions without a high incidence
of graft-related complications.
The Bologna–Oxford (BOX) total ankle replacement
(TAR) was developed with the aim of achieving satisfactory pain-free
movement of the ankle. To date, only one single multicentre study
has reported its clinical results. The aim of this study was to
conduct an independent review of its mid-term results. We retrospectively reviewed a total of 60 prospectively followed
patients in whom 62 BOX TARs had been implanted between 2004 and
2008. We used the American Orthopedic Foot and Ankle Society (AOFAS)
score to assess the clinical results. Standardised radiographs taken
at the time of final follow-up were analysed by two observers. The
overall survival was 91.9% at a mean follow-up of 42.5 months (24
to 71). The mean AOFAS score had improved from 35.1 points (
In the majority of patients with slipped upper
femoral epiphysis only one hip is involved at primary diagnosis. However,
the contralateral hip often becomes involved over time. There are
no reliable factors predicting a contralateral slip. Whether or
not the contralateral hip should undergo prophylactic fixation is
a matter of controversy. We present a number of essential points
that have to be considered both when choosing to fix the contralateral
hip prophylactically as well as when refraining from surgery and
instead following the patients with repeat radiographs.
We analysed the outcome of patients with primary
non-metastatic diaphyseal sarcomas who had Extracorporeal irradiation is an oncologically safe and inexpensive
technique for limb salvage in diaphyseal sarcomas and has good functional
results.
More than a million hip replacements are carried out each year worldwide, and the number of other artificial joints inserted is also rising, so that infections associated with arthroplasties have become more common. However, there is a paucity of literature on infections due to haematogenous seeding following dental procedures. We reviewed the published literature to establish the current knowledge on this problem and to determine the evidence for routine antibiotic prophylaxis prior to a dental procedure. We found that antimicrobial prophylaxis before dental interventions in patients with artificial joints lacks evidence-based information and thus cannot be universally recommended.
This retrospective cohort study was conducted to investigate whether operative treatment of patients with a pertrochanteric femoral fracture outside working hours is associated with an increased risk of complications and higher mortality. During the study period 165 patients were operated on outside working hours and 123 were operated on during working hours (08.00 to 17.00). There was no difference in the rate of early complications (outside working hours 33% versus working hours 33%, p = 0.91) or total complications during follow-up (outside working hours 40% versus working hours 41%, p = 0.91). Both in-hospital mortality (outside working hours 12% versus working hours 11%, p = 0.97) and mortality after one year (outside working hours 29% versus working hours 27%, p = 0.67) were comparable. Adjustment for possible confounders by multivariate logistic regression analysis revealed no increased risk of complications when patients were operated on outside working hours. On the basis of these data, there is no medical reason to postpone operative reduction and fixation in patients with a proximal femoral fracture until working hours.