Supracondylar humeral fractures are common in
children, but there are no classification systems or radiological parameters
that predict the likelihood of having to perform an open reduction.
In a retrospective case–control study we evaluated the use of the
medial spike angle and fracture tip–skin distance to predict the
mode of reduction (closed or open) and the operating time in fractures
with posterolateral displacement. A total of 21 patients (4.35%) with
a small medial spike angle (<
45°) were identified from a total
of 494 patients, and 42 patients with a medial spike angle of >
45° were randomly selected as controls. The medial spike group had
significantly smaller fracture tip–skin distances (p <
0.001),
longer operating times (p = 0.004) and more complications (p = 0.033)
than the control group. There was no significant difference in the
mode of reduction and a composite outcome measure. After adjustments
for age and gender, only fracture tip–skin distance remained significantly
associated with the operating time (β = -0.724, p = 0.042) and composite
outcome (OR 0.863 (95% confidence interval 0.746 to 0.998); p = 0.048). Paediatric orthopaedic surgeons should have a lower threshold
for open reduction when treating patients with a small medial spike
angle and a small fracture tip–skin distance. Cite this article:
In a randomised trial involving 598 patients
with 600 trochanteric fractures of the hip, the fractures were treated with
either a sliding hip screw (n = 300) or a Targon PF intramedullary
nail (n = 300). The mean age of the patients was 82 years (26 to
104). All surviving patients were reviewed at one year with functional
outcome assessed by a research nurse blinded to the treatment used.
The intramedullary nail was found to have a slightly increased mean
operative time (46 minutes ( In summary, both implants produced comparable results but there
was a tendency to better return of mobility for those treated with
the intramedullary nail.
A total of 445 consecutive primary total knee
replacements (TKRs) were followed up prospectively at six and 18 months
and three, six and nine years. Patients were divided into two groups:
non-obese (body mass index (BMI) <
30 kg/m2) and obese
(BMI ≥ 30 kg/m2). The obese group was subdivided into
mildly obese (BMI 30 to 35 kg/m2) and highly obese (BMI ≥ 35
kg/m2) in order to determine the effects of increasing
obesity on outcome. The clinical data analysed included the Knee
Society score, peri-operative complications and implant survival.
There was no difference in the overall complication rates or implant
survival between the two groups. Obesity appears to have a small but significant adverse effect
on clinical outcome, with highly obese patients showing lower function
scores than non-obese patients. However, significant improvements
in outcome are sustained in all groups nine years after TKR. Given
the substantial, sustainable relief of symptoms after TKR and the low
peri-operative complication and revision rates in these two groups,
we have found no reason to limit access to TKR in obese patients.
The August 2013 Foot &
Ankle Roundup360 looks at: mobility, ankles and fractures; hindfoot nailing: not such a bad option after all?; little treatment benefit for blood injection in tendonitis; fixed bearing ankles successful in the short term; hindfoot motion following STAR ankle replacement; minimally invasive calcaneal fracture fixation?; pes planus in adolescents; and subluxing peroneals and groove deepening
Peri-prosthetic osteolysis and subsequent aseptic
loosening is the most common reason for revising total hip replacements.
Wear particles originating from the prosthetic components interact
with multiple cell types in the peri-prosthetic region resulting
in an inflammatory process that ultimately leads to peri-prosthetic
bone loss. These cells include macrophages, osteoclasts, osteoblasts
and fibroblasts. The majority of research in peri-prosthetic osteolysis
has concentrated on the role played by osteoclasts and macrophages.
The purpose of this review is to assess the role of the osteoblast
in peri-prosthetic osteolysis. In peri-prosthetic osteolysis, wear particles may affect osteoblasts
and contribute to the osteolytic process by two mechanisms. First,
particles and metallic ions have been shown to inhibit the osteoblast
in terms of its ability to secrete mineralised bone matrix, by reducing
calcium deposition, alkaline phosphatase activity and its ability
to proliferate. Secondly, particles and metallic ions have been
shown to stimulate osteoblasts to produce pro inflammatory mediators Cite this article:
We investigated the clinical outcome of internal
fixation for pathological fracture of the femur after primary excision of
a soft-tissue sarcoma that had been treated with adjuvant radiotherapy. A review of our database identified 22 radiation-induced fractures
of the femur in 22 patients (seven men, 15 women). We noted the
mechanism of injury, fracture pattern and any complications after
internal fixation, including nonunion, hardware failure, secondary
fracture or deep infection. The mean age of the patients at primary excision of the tumour
was 58.3 years (39 to 86). The mean time from primary excision to
fracture was 73.2 months (2 to 195). The mean follow-up after fracture
fixation was 65.9 months (12 to 205). Complications occurred in
19 patients (86%). Nonunion developed in 18 patients (82%), of whom
11 had a radiological nonunion at 12 months, five a nonunion and
hardware failure and two an infected nonunion. One patient developed
a second radiation-associated fracture of the femur after internal
fixation and union of the initial fracture. A total of 13 patients
(59%) underwent 24 revision operations. Internal fixation of a pathological fracture of the femur after
radiotherapy for a soft-tissue sarcoma has an extremely high rate
of complication and requires specialist attention. Cite this article:
An ongoing prospective study to investigate failing metal-on-metal
hip prostheses was commenced at our centre in 2008. We report on
the results of the analysis of the first consecutive 126 failed
mated total hip prostheses from a single manufacturer. Analysis was carried out using highly accurate coordinate measuring
to calculate volumetric and linear rates of the articular bearing
surfaces and also the surfaces of the taper junctions. The relationship
between taper wear rates and a number of variables, including bearing
diameter and orientation of the acetabular component, was investigated.Objectives
Methods
We measured the orientation of the acetabular and femoral components in 45 patients (33 men, 12 women) with a mean age of 53.4 years (30 to 74) who had undergone revision of metal-on-metal hip resurfacings. Three-dimensional CT was used to measure the inclination and version of the acetabular component, femoral version and the horizontal femoral offset, and the linear wear of the removed acetabular components was measured using a roundness machine. We found that acetabular version and combined version of the acetabular and femoral components were weakly positively correlated with the rate of wear. The acetabular inclination angle was strongly positively correlated with the rate of wear. Femoral version was weakly negatively correlated with the rate of wear. Application of a threshold of >
5 μm/year for the rate of wear in order to separate the revisions into low or high wearing groups showed that more high wearing components were implanted outside Lewinnek’s safe zone, but that this was mainly due to the inclination of the acetabular component, which was the only parameter that significantly differed between the groups. We were unable to show that excess version of the acetabular component alone or combined with femoral version was associated with an increase in the rate of wear based on our assessment of version using CT.
The significance of weight in the indications
for unicompartmental knee replacement (UKR) is unclear. Our hypothesis was
that weight does not affect the long-term rate of survival of UKRs. We undertook a retrospective study of 212 UKRs at a mean follow-up
of 12 years (7 to 22). The patients were distributed according to
body mass index (BMI; <
The ten-year rates of survival were similar in the two weight
subgroups (≥ 82 kg: 93.5% (95% confidence interval (CI) 66.5 to
96.3); <
82 kg: 92.5% (95% CI 82.5 to 94.1)) and also in the
two BMI subgroups (≥ 30 kg/m2: 92% (95% CI 82.5 to 95.3);
<
30 kg/m2: 94% (95% CI 78.4 to 95.9)). Multimodal
regression analysis revealed that weight plays a part in reducing
the risk of revision with a relative risk of 0.387, although this
did not reach statistical significance (p = 0.662). The results
relating weight and BMI to the clinical outcome were not statistically
significant. Thus, this study confirms that weight does not influence
the long-term rate of survival of UKR. 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.
The August 2012 Hip &
Pelvis Roundup360 looks at: whether cemented hip replacement might be bad for your health; highly cross-linked polyethylene; iHOT-33 - a new hip outcome measure; hamstring injuries; total hip replacement; stemmed metal-on-metal THR; bipolar hemiarthroplasty, neuromuscular disease and dislocation; the high risk of secondary hemiarthroplasty; and whether we have to repair the labrum after all?
There is little information about the management
of peri-prosthetic fracture of the humerus after total shoulder replacement
(TSR). This is a retrospective review of 22 patients who underwent
a revision of their original shoulder replacement for peri-prosthetic
fracture of the humerus with bone loss and/or loose components.
There were 20 women and two men with a mean age of 75 years (61
to 90) and a mean follow-up 42 months (12 to 91): 16 of these had
undergone a previous revision TSR. Of the 22 patients, 12 were treated
with a long-stemmed humeral component that bypassed the fracture.
All their fractures united after a mean of 27 weeks (13 to 94).
Eight patients underwent resection of the proximal humerus with
endoprosthetic replacement to the level of the fracture. Two patients
were managed with a clam-shell prosthesis that retained the original
components. The mean Oxford shoulder score (OSS) of the original
TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean
OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival
using re-intervention for any reason as the endpoint was 91% (95%
confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at
one and five years, respectively. There were two revisions for dislocation of the humeral head,
one open reduction for modular humeral component dissociation, one
internal fixation for nonunion, one trimming of a prominent screw
and one re-cementation for aseptic loosening complicated by infection,
ultimately requiring excision arthroplasty. Two patients sustained
nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated
with bone loss and/or loose components is a salvage procedure that
can provide a stable platform for elbow and hand function. Good
rates of union can be achieved using a stem that bypasses the fracture.
There is a high rate of complications and function is not as good as
with the original replacement.
We prospectively assessed the efficacy of a ceramic-on-metal
(CoM) hip bearing with uncemented acetabular and femoral components
in which cobalt–chrome acetabular liners and alumina ceramic heads
were used. The cohort comprised 94 total hip replacements (THRs) in 83 patients
(38 women and 45 men) with a mean age of 58 years (42 to 70). Minimum
follow-up was two years. All patients had pre- and post-operative
assessment using the Western Ontario and McMaster Universities osteoarthritis
index (WOMAC), Oxford hip score and Short-Form 12 scores. All showed
a statistically significant improvement from three months post-operatively
onwards (all p <
0.001). After two years whole blood metal ion levels were measured and
chromosomal analysis was performed. The levels of all metal ions
were elevated except vanadium. Levels of chromium, cobalt, molybdenum
and titanium were significantly higher in patients who underwent
bilateral THR compared with those undergoing unilateral THR (p <
0.001).
Chromosomal analysis demonstrated both structural and aneuploidy
mutations. There were significantly more breaks and losses than
in the normal population (p <
0.001). There was no significant
difference in chromosomal aberration between those undergoing unilateral
and bilateral procedures (all analyses p ≥ 0.62). The use of a CoM THR is effective clinically in the short-term,
with no concerns, but the significance of high metal ion levels
and chromosomal aberrations in the long-term remains unclear. Cite this article:
Heterotopic ossification (HO) is perhaps the
single most significant obstacle to independence, functional mobility, and
return to duty for combat-injured veterans of Operation Enduring
Freedom and Operation Iraqi Freedom. Recent research into the cause(s)
of HO has been driven by a markedly higher prevalence seen in these
wounded warriors than encountered in previous wars or following
civilian trauma. To that end, research in both civilian and military
laboratories continues to shed light onto the complex mechanisms
behind HO formation, including systemic and wound specific factors,
cell lineage, and neurogenic inflammation. Of particular interest,
non-invasive
Despite many claims of good wear properties following
total knee replacement (TKR) with an oxidised zirconium (OxZr) femoral
component, there are conflicting clinical results. We hypothesised
that there would be no difference in either the mid-term clinical
and radiological outcomes or the characteristics of the polyethylene
wear particles (weight, size and shape) in patients using an OxZr
or cobalt-chrome (CoCr) femoral component. In all 331 patients underwent
bilateral TKR, receiving an OxZr femoral component in one knee and
a CoCr femoral component in the other. The mean follow-up was 7.5
years (6 to 8). Following aspiration, polyethylene wear particles
were analysed using thermogravimetric methods and scanning electron
microscopy. At the most recent follow-up, the mean Knee Society
score, Western Ontario and McMaster Universities Osteoarthritis
Index score, range of movement and satisfaction score were not significantly
different in the two groups. The mean weight, size, aspect ratio
and roundness of the aspirated wear particles were similar for each
femoral component. Survivorship of the femoral, tibial and patellar
components was 100% in both groups. In the absence of evidence of an advantage in the medium term
we cannot justify the additional expense of an OxZr femoral component.
Scapulothoracic fusion (STF) for painful winging
of the scapula in neuromuscular disorders can provide effective pain
relief and functional improvement, but there is little information
comparing outcomes between patients with dystrophic and non-dystrophic
conditions. We performed a retrospective review of 42 STFs in 34
patients with dystrophic and non-dystrophic conditions using a multifilament
trans-scapular, subcostal cable technique supported by a dorsal
one-third semi-tubular plate. There were 16 males and 18 females
with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0
years (2.0 to 10.6). The mean Oxford shoulder score improved from
20 (4 to 39) to 31 (4 to 48). Patients with non-dystrophic conditions
had lower overall functional scores but achieved greater improvements
following STF. The mean active forward elevation increased from
59° (20° to 90°) to 97° (30° to 150°), and abduction from 51° (10°
to 90°) to 83° (30° to 130°) with a greater range of movement achieved
in the dystrophic group. Revision fusion for nonunion was undertaken
in five patients at a mean time of 17 months (7 to 31) and two required
revision for fracture. There were three pneumothoraces, two rib
fractures, three pleural effusions and six nonunions. The main risk
factors for nonunion were smoking, age and previous shoulder girdle surgery. STF is a salvage procedure that can provide good patient satisfaction
in 82% of patients with both dystrophic and non-dystrophic pathologies,
but there was a relatively high failure rate (26%) when poor outcomes
were analysed. Overall function was better in patients with dystrophic
conditions which correlated with better range of movement; however,
patients with non-dystrophic conditions achieved greater functional
improvement.
Local corticosteroid infiltration is a common practice of treatment
for lateral epicondylitis. In recent studies no statistically significant
or clinically relevant results in favour of corticosteroid injections
were found. The injection of autologous blood has been reported
to be effective for both intermediate and long-term outcomes. It
is hypothesised that blood contains growth factors, which induce
the healing cascade. A total of 60 patients were included in this prospective randomised
study: 30 patients received 2 ml autologous blood drawn from contralateral
upper limb vein + 1 ml 0.5% bupivacaine, and 30 patients received
2 ml local corticosteroid + 1 ml 0.5% bupivacaine at the lateral
epicondyle. Outcome was measured using a pain score and Nirschl
staging of lateral epicondylitis. Follow-up was continued for total
of six months, with assessment at one week, four weeks, 12 weeks
and six months.Objectives
Methods
Some surgeons are reluctant to perform a reverse
total shoulder arthroplasty (RTSA) on both shoulders because of concerns
regarding difficulty with activities of daily living post-operatively
as a result of limited rotation of the shoulders. Nevertheless,
we hypothesised that outcomes and patient satisfaction following
bilateral RTSA would be comparable to those following unilateral
RTSA. A single-surgeon RTSA registry was reviewed for patients who underwent
bilateral staged RTSA with a minimum follow-up of two years. A unilateral
RTSA matched control was selected for each shoulder in those patients
undergoing bilateral procedures. The Constant–Murley score (CMS), American
Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Values
(SSV), visual analogue scale (VAS) for pain, range of movement and
strength were measured pre- and post-operatively. The mean CMS,
ASES, SSV, VAS scores, strength and active forward elevation were
significantly improved
(all p <
0.01) following each operation in those undergoing bilateral
procedures. The mean active external rotation (p = 0.63 and p =
0.19) and internal rotation (p = 0.77 and p = 0.24) were not significantly
improved. The improvement in the mean ASES score after the first
RTSA was greater than the improvement in its control group (p =
0.0039). The improvement in the mean CMS, ASES scores and active
forward elevation was significantly less after the second RTSA than
in its control group (p = 0.0244, p = 0.0183, and p = 0.0280, respectively).
Pain relief and function significantly improved after each RTSA
in those undergoing a bilateral procedure. Bilateral RTSA is thus a reasonable form of treatment for patients
with severe bilateral rotator cuff deficiency, although inferior
results may be seen after the second procedure compared with the
first. Cite this article:
The goals of this study were: 1) to determine if high-fat diet
(HFD) feeding in female mice would negatively impact biomechanical
and histologic consequences on the Achilles tendon and quadriceps
muscle; and 2) to investigate whether exercise and branched-chain
amino acid (BCAA) supplementation would affect these parameters
or attenuate any negative consequences resulting from HFD consumption. We examined the effects of 16 weeks of 60% HFD feeding, voluntary
exercise (free choice wheel running) and BCAA administration in
female C57BL/6 mice. The Achilles tendons and quadriceps muscles
were removed at the end of the experiment and assessed histologically
and biomechanically.Objectives
Methods
Guiding growth by harnessing the ability of growing bone to undergo plastic deformation is one of the oldest orthopaedic principles. Correction of deformity remains a major part of the workload for paediatric orthopaedic surgeons and recently, along with developments in limb reconstruction and computer-directed frame correction, there has been renewed interest in surgical methods of physeal manipulation or ‘guided growth’. Manipulating natural bone growth to correct a deformity is appealing, as it allows gradual correction by non- or minimally invasive methods. This paper reviews the techniques employed for guided growth in current orthopaedic practice, including the basic science and recent advances underlying mechanical physeal manipulation of both healthy and pathological physes.