In 11 paediatric patients (seven girls and four
boys, from 12 to 15 years old) with unilateral obligatory patellar dislocation
and
The purposes of this study were to define the range of laxity of the interosseous ligaments in cadaveric wrists and to determine whether this correlated with age, the morphology of the lunate, the scapholunate (SL) gap or the SL angle. We evaluated 83 fresh-frozen cadaveric wrists and recorded the SL gap and SL angle. Standard arthroscopy of the wrist was then performed and the grades of laxity of the scapholunate interosseous ligament (SLIL) and the lunotriquetral interosseous ligament (LTIL) and the morphology of the lunate were recorded. Arthroscopic evaluation of the SLIL revealed four (5%) grade I specimens, 28 (34%) grade II, 40 (48%) grade III and 11 (13%) grade IV. Evaluation of the LTIL showed 17 (20%) grade I specimens, 40 (48%) grade II, 28 (30%) grade III and one (1%) grade IV. On both bivariate and multivariate analysis, the grade of both the SLIL and LTIL increased with age, but decreased with female gender. The grades of SLIL or LTIL did not correlate with the morphology of the lunate, the SL gap or the SL angle. The physiological range of laxity at the SL and lunotriquetral joints is wider than originally described. The intercarpal ligaments demonstrate an age-related progression of laxity of the SL and lunotriquetral joints. There is no correlation between the grades of laxity of the SLIL or LTIL and the morphology of the lunate, the SL gap or the SL grade. Based on our results, we believe that the Geissler classification has a role in describing intercarpal laxity, but if used alone it cannot adequately diagnose pathological instability. We suggest a modified classification with a mechanism that may distinguish physiological laxity from pathological instability.
We performed A total of 12 cadaveric lower limbs were tested with a commercial
image-free navigation system using trackers secured by bone screws.
We then tested a non-invasive fabric-strap system. The lower limb
was secured at 10° intervals from 0° to 60° of knee flexion and
100 N of force was applied perpendicular to the tibia. Acceptable
coefficient of repeatability (CR) and limits of agreement (LOA)
of 3 mm were set based on diagnostic criteria for anterior cruciate
ligament (ACL) insufficiency.Objectives
Methods
We have shown in a previous study that patients with combined lesions of the anterior cruciate (ACL) and medial collateral ligaments (MCL) had similar anteroposterior (AP) but greater valgus laxity at 30° after reconstruction of the ACL when compared with patients who had undergone reconstruction of an isolated ACL injury. The present study investigated the same cohort of patients after a minimum of three years to evaluate whether the residual valgus laxity led to a poorer clinical outcome. Each patient had undergone an arthroscopic double-bundle ACL reconstruction using a semitendinosus-gracilis graft. In the combined ACL/MCL injury group, the grade II medial collateral ligament injury was not treated. At follow-up, AP laxity was measured using a KT-2000 arthrometer, while valgus laxity was evaluated with Telos valgus stress radiographs and compared with the uninjured knee. We evaluated clinical outcome scores, muscle girth and time to return to activities for the two groups. Valgus stress radiographs showed statistically significant greater mean medial joint opening in the reconstructed compared with the uninjured knees (1.7 mm (
Anterior cruciate ligament (ACL) injuries are among the most common and debilitating knee injuries in professional athletes with an incidence in females up to eight-times higher than their male counterparts. ACL injuries can be career-threatening and are associated with increased risk of developing knee osteoarthritis in future life. The increased risk of ACL injury in females has been attributed to various anatomical, developmental, neuromuscular, and hormonal factors. Anatomical and hormonal factors have been identified and investigated as significant contributors including osseous anatomy,
There is a disparity in sport-related injuries between sexes, with females sustaining non-contact musculoskeletal injuries at a higher rate. Anterior cruciate ligament ruptures are between two and eight times more common than in males, and females also have a higher incidence of ankle sprains, patellofemoral pain, and bone stress injuries. The sequelae of such injuries can be devastating to an athlete, resulting in time out of sport, surgery, and the early onset of osteoarthritis. It is important to identify the causes of this disparity and introduce prevention programmes to reduce the incidence of these injuries. A natural difference reflects the effect of reproductive hormones in females, which have receptors in certain musculoskeletal tissues. Relaxin increases
We describe our experience with the ‘four-in-one’ procedure for habitual dislocation of the patella in five children (six knees). All the patients presented with severe generalised
Noise generation has been reported with ceramic-on-ceramic
articulations in total hip replacement (THR). This study evaluated
208 consecutive Delta Motion THRs at a mean follow-up of 21 months
(12 to 35). There were 141 women and 67 men with a mean age of 59
years (22 to 84). Patients were reviewed clinically and radiologically,
and the incidence of noise was determined using a newly described
assessment method. Noise production was examined against range of
movement,
Down’s syndrome is associated with a number of
musculoskeletal abnormalities, some of which predispose patients
to early symptomatic arthritis of the hip. The purpose of the present
study was to review the general and hip-specific factors potentially
compromising total hip replacement (THR) in patients with Down’s
syndrome, as well as to summarise both the surgical techniques that
may anticipate the potential adverse impact of these factors and
the clinical results reported to date. A search of the literature
was performed, and the findings further informed by the authors’
clinical experience, as well as that of the hip replacement in Down
Syndrome study group. The general factors identified include a high
incidence of
A cavovarus foot deformity was simulated in cadaver specimens by inserting metallic wedges of 15° and 30° dorsally into the first tarsometatarsal joint. Sensors in the ankle joint recorded static tibiotalar pressure distribution at physiological load. The peak pressure increased significantly from neutral alignment to the 30° cavus deformity, and the centre of force migrated medially. The anterior migration of the centre of force was significant for both the 15° (repeated measures analysis of variance (ANOVA), p = 0.021) and the 30° (repeated measures ANOVA, p = 0.007) cavus deformity. Differences in
Aims. Long-term clinical outcomes for ceramic-on-ceramic (CoC) bearings
are encouraging. However, there is a risk of squeaking. Guidelines
for the orientation of the acetabular component are defined from
static imaging, but the position of the pelvis and thus the acetabular
component during activities associated with edge-loading are likely
to be very different from those measured when the patient is supine.
We assessed the functional orientation of the acetabular component. Patients and Methods. A total of 18 patients with reproducible squeaking in their CoC
hips during deep flexion were investigated with a control group
of 36 non-squeaking CoC hips. The two groups were matched for the
type of implant, the orientation of the acetabular component when
supine, the size of the femoral head,
We prospectively evaluated 61 patients treated arthroscopically for anterior instability of the shoulder at a mean follow-up of 44.5 months (24 to 100) using the Rowe scale. Those with post-operative dislocation or subluxation were considered to be failures. Logistic regression analysis was used to identify patients at increased risk of recurrence in order to develop a suitable selection system. The mean Rowe score improved from 45 pre-operatively to 86 at follow-up (p <
0.001). At least one episode of post-operative instability occurred in 11 patients (18%), although their stability improved (p = 0.018), and only three required revision. Subjectively, eight patients were dissatisfied. Age younger than 28 years,
The aim of this study was to establish consensus statements on the diagnosis, nonoperative management, and indications, if any, for medial patellofemoral complex (MPFC) repair in patients with patellar instability, using the modified Delphi approach. A total of 60 surgeons from 11 countries were invited to develop consensus statements based on their expertise in this area. They were assigned to one of seven working groups defined by subtopics of interest within patellar instability. Consensus was defined as achieving between 80% and 89% agreement, strong consensus was defined as between 90% and 99% agreement, and 100% agreement was considered to be unanimous.Aims
Methods
The December 2024 Foot & Ankle Roundup360 looks at: Tibiotalar sector and lateral ankle instability; Isolated subtalar fusion and correction of progressive collapsing foot deformity; Diabetic control and postoperative complications following ankle fracture fixation; Are insoles of any benefit for plantar fasciitis?; Postoperative foot shape and patient-reported outcome following surgery for progressing collapsing foot deformity; Calcaneo-stop procedure for symptomatic flexible flatfoot in children.
Mid-level constraint designs for total knee arthroplasty (TKA) are intended to reduce coronal plane laxity. Our aims were to compare kinematics and ligament forces of the Zimmer Biomet Persona posterior-stabilized (PS) and mid-level designs in the coronal, sagittal, and axial planes under loads simulating clinical exams of the knee in a cadaver model. We performed TKA on eight cadaveric knees and loaded them using a robotic manipulator. We tested both PS and mid-level designs under loads simulating clinical exams via applied varus and valgus moments, internal-external (IE) rotation moments, and anteroposterior forces at 0°, 30°, and 90° of flexion. We measured the resulting tibiofemoral angulations and translations. We also quantified the forces carried by the medial and lateral collateral ligaments (MCL/LCL) via serial sectioning of these structures and use of the principle of superposition.Aims
Methods
Anterior cruciate ligament (ACL) graft failure from rupture, attenuation, or malposition may cause recurrent subjective instability and objective laxity, and occurs in 3% to 22% of ACL reconstruction (ACLr) procedures. Revision ACLr is often indicated to restore knee stability, improve knee function, and facilitate return to cutting and pivoting activities. Prior to reconstruction, a thorough clinical and diagnostic evaluation is required to identify factors that may have predisposed an individual to recurrent ACL injury, appreciate concurrent intra-articular pathology, and select the optimal graft for revision reconstruction. Single-stage revision can be successful, although a staged approach may be used when optimal tunnel placement is not possible due to the position and/or widening of previous tunnels. Revision ACLr often involves concomitant procedures such as meniscal/chondral treatment, lateral extra-articular augmentation, and/or osteotomy. Although revision ACLr reliably restores knee stability and function, clinical outcomes and reoperation rates are worse than for primary ACLr. Cite this article:
Knowledge on total knee arthroplasties (TKAs) in patients with a history of poliomyelitis is limited. This study compared implant survivorship and clinical outcomes among affected and unaffected limbs in patients with sequelae of poliomyelitis undergoing TKAs. A retrospective review of our total joint registry identified 94 patients with post-polio syndrome undergoing 116 primary TKAs between January 2000 and December 2019. The mean age was 70 years (33 to 86) with 56% males (n = 65) and a mean BMI of 31 kg/m2 (18 to 49). Rotating hinge TKAs were used in 14 of 63 affected limbs (22%), but not in any of the 53 unaffected limbs. Kaplan-Meier survivorship analyses were completed. The mean follow-up was eight years (2 to 19).Aims
Methods
Advanced 3D imaging and CT-based navigation have emerged as valuable tools to use in total knee arthroplasty (TKA), for both preoperative planning and the intraoperative execution of different philosophies of alignment. Preoperative planning using CT-based 3D imaging enables more accurate prediction of the size of components, enhancing surgical workflow and optimizing the precision of the positioning of components. Surgeons can assess alignment, osteophytes, and arthritic changes better. These scans provide improved insights into the patellofemoral joint and facilitate tibial sizing and the evaluation of implant-bone contact area in cementless TKA. Preoperative CT imaging is also required for the development of patient-specific instrumentation cutting guides, aiming to reduce intraoperative blood loss and improve the surgical technique in complex cases. Intraoperative CT-based navigation and haptic guidance facilitates precise execution of the preoperative plan, aiming for optimal positioning of the components and accurate alignment, as determined by the surgeon’s philosophy. It also helps reduce iatrogenic injury to the periarticular soft-tissue structures with subsequent reduction in the local and systemic inflammatory response, enhancing early outcomes. Despite the increased costs and radiation exposure associated with CT-based navigation, these many benefits have facilitated the adoption of imaged based robotic surgery into routine practice. Further research on ultra-low-dose CT scans and exploration of the possible translation of the use of 3D imaging into improved clinical outcomes are required to justify its broader implementation. Cite this article:
In patients with a failed radial head arthroplasty (RHA), simple removal of the implant is an option. However, there is little information in the literature about the outcome of this procedure. The aim of this study was to review the mid-term clinical and radiological results, and the rate of complications and removal of the implant, in patients whose initial RHA was undertaken acutely for trauma involving the elbow. A total of 11 patients in whom removal of a RHA without reimplantation was undertaken as a revision procedure were reviewed at a mean follow-up of 8.4 years (6 to 11). The range of motion (ROM) and stability of the elbow were recorded. Pain was assessed using a visual analogue scale (VAS). The functional outcome was assessed using the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score (OES), and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). Radiological examination included the assessment of heterotopic ossification (HO), implant loosening, capitellar erosion, overlengthening, and osteoarthritis. Complications and the rate of further surgery were also recorded.Aims
Methods
While residual fixed flexion deformity (FFD) in unicompartmental knee arthroplasty (UKA) has been associated with worse functional outcomes, limited evidence exists regarding FFD changes. The objective of this study was to quantify FFD changes in patients with medial unicompartmental knee arthritis undergoing UKA, and investigate any correlation with clinical outcomes. This study included 136 patients undergoing robotic arm-assisted medial UKA between January 2018 and December 2022. The study included 75 males (55.1%) and 61 (44.9%) females, with a mean age of 67.1 years (45 to 90). Patients were divided into three study groups based on the degree of preoperative FFD: ≤ 5°, 5° to ≤ 10°, and > 10°. Intraoperative optical motion capture technology was used to assess pre- and postoperative FFD. Clinical FFD was measured pre- and postoperatively at six weeks and one year following surgery. Preoperative and one-year postoperative Oxford Knee Scores (OKS) were collected.Aims
Methods
This study reports mid-term outcomes after periacetabular osteotomy (PAO) exclusively in a borderline hip dysplasia (BHD) population to provide a contrast to published outcomes for arthroscopic surgery of the hip in BHD. We identified 42 hips in 40 patients treated between January 2009 and January 2016 with BHD defined as a lateral centre-edge angle (LCEA) of ≥ 18° but < 25°. A minimum five-year follow-up was available. Patient-reported outcomes (PROMs) including Tegner score, subjective hip value (SHV), modified Harris Hip Score (mHHS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were assessed. The following morphological parameters were evaluated: LCEA, acetabular index (AI), α angle, Tönnis staging, acetabular retroversion, femoral version, femoroepiphyseal acetabular roof index (FEAR), iliocapsularis to rectus femoris ratio (IC/RF), and labral and ligamentum teres (LT) pathology.Aims
Methods
We evaluated the long-term outcome of isolated endoscopically-assisted posterior cruciate ligament reconstruction in 26 patients using hamstring tendon autografts after failure of conservative management. At ten years after surgery the mean International Knee Documentation Committee subjective knee score was 87 (. sd. 14) of a possible 100 points. Regular participation in moderate to strenuous activities was possible for only seven patients pre-operatively; this increased to 23 patients post-operatively. The mean Lysholm score improved from 64 (. sd. 15) to 90 (. sd. 14) at ten years (p = 0.001). At ten years endoscopic reconstruction of the posterior cruciate ligament with hamstring tendon autograft is effective in reducing knee symptoms. Of the series, 22 patients underwent radiological assessment for the development of osteoarthritis using the Kellgren-Lawrence grading scale. In four patients, grade 2 changes with loss of joint space was observed and another four patients showed osteophyte formation with moderate joint space narrowing (grade 3). These findings compared favourably with non-operatively managed injuries of the posterior cruciate ligament. This procedure for symptomatic patients with posterior cruciate
In this retrospective study, we assessed the outcome in 99 patients who underwent reconstruction of the lateral ligaments of the ankle for chronic anterolateral instability with a minimum follow-up of 15 years. Two techniques were compared: 54 patients had an anatomical reconstruction (AR group) and 45 had an Evans tenodesis (ET group). They were followed up for 19.9 ± 3.6 years and 21.8 ± 4.6 years, respectively. During follow-up, seven patients in the AR group and 17 in the ET group required a further operation (p = 0.004). At follow-up, significantly more patients (n = 15) in the ET group had limited dorsiflexion than in the AR group (n = 6, p = 0.007) and 18 in the ET group had a positive anterior drawer test compared with seven in the AR group (p = 0002). In the ET group 27 had tenderness on palpation of the ankle compared with 15 in the AR group (p = 0.001). Stress radiographs showed
As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30).Aims
Methods
The optimal bearing surface design for medial unicompartmental knee arthroplasty (UKA) remains controversial. The aim of this study was to compare outcomes of fixed-bearing (FB) and mobile-bearing (MB) UKAs from a single high-volume institution. Prospectively collected data were reviewed for all primary cemented medial UKAs performed by seven surgeons from January 2006 to December 2022. A total of 2,999 UKAs were identified, including 2,315 FB and 684 MB cases. The primary outcome measure was implant survival. Secondary outcomes included 90-day and cumulative complications, reoperations, component revisions, conversion arthroplasties, range of motion, and patient-reported outcome measures. Overall mean age at surgery was 65.7 years (32.9 to 94.3), 53.1% (1,593/2,999) of UKAs were implanted in female patients, and demographics between groups were similar (p > 0.05). The mean follow-up for all UKAs was 3.7 years (0.0 to 15.6).Aims
Methods
The mid-term results of kinematic alignment (KA) for total knee arthroplasty (TKA) using image derived instrumentation (IDI) have not been reported in detail, and questions remain regarding ligamentous stability and revisions. This paper aims to address the following: 1) what is the distribution of alignment of KA TKAs using IDI; 2) is a TKA alignment category associated with increased risk of failure or poor patient outcomes; 3) does extending limb alignment lead to changes in soft-tissue laxity; and 4) what is the five-year survivorship and outcomes of KA TKA using IDI? A prospective, multicentre, trial enrolled 100 patients undergoing KA TKA using IDI, with follow-up to five years. Alignment measures were conducted pre- and postoperatively to assess constitutional alignment and final implant position. Patient-reported outcome measures (PROMs) of pain and function were also included. The Australian Orthopaedic Association National Joint Arthroplasty Registry was used to assess survivorship.Aims
Methods
Total knee arthroplasty (TKA) may provoke ankle symptoms. The aim of this study was to validate the impact of the preoperative mechanical tibiofemoral angle (mTFA), the talar tilt (TT) on ankle symptoms after TKA, and assess changes in the range of motion (ROM) of the subtalar joint, foot posture, and ankle laxity. Patients who underwent TKA from September 2020 to September 2021 were prospectively included. Inclusion criteria were primary end-stage osteoarthritis (Kellgren-Lawrence stage IV) of the knee. Exclusion criteria were missed follow-up visit, post-traumatic pathologies of the foot, and neurological disorders. Radiological angles measured included the mTFA, hindfoot alignment view angle, and TT. The Foot Function Index (FFI) score was assessed. Gait analyses were conducted to measure mediolateral changes of the gait line and ankle laxity was tested using an ankle arthrometer. All parameters were acquired one week pre- and three months postoperatively.Aims
Methods
To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map.Aims
Methods
We have previously reported the mid-term outcomes of revision total knee arthroplasty (TKA) for flexion instability. At a mean of four years, there were no re-revisions for instability. The aim of this study was to report the implant survivorship and clinical and radiological outcomes of the same cohort of of patients at a mean follow-up of ten years. The original publication included 60 revision TKAs in 60 patients which were undertaken between 2000 and 2010. The mean age of the patients at the time of revision TKA was 65 years, and 33 (55%) were female. Since that time, 21 patients died, leaving 39 patients (65%) available for analysis. The cumulative incidence of any re-revision with death as a competing risk was calculated. Knee Society Scores (KSSs) were also recorded, and updated radiographs were reviewed.Aims
Methods
Dislocation is one of the most common causes
of patient and surgeon dissatisfaction following hip replacement
and to treat it, the causes must first be understood. Patient factors
include age greater than 70 years, medical comorbidities, female
gender,
1. Recurrent dislocation of the elbow is caused primarily by collateral
We reviewed 41 knees after arthroscopic lateral release for recurrent dislocation of the patella at a mean follow-up of four years, and graded the results according to the criteria of Crosby and Insall (1976). There were no dislocations after operation in 28 knees (68%); the less satisfactory results were in patients with subluxation of the patella on extension of the knee and those with generalised
Ten children who had clinically stable hips at birth were radiographed at one month because they had factors predisposing to hip dislocation. In all cases one or both hips gave rise to a suspicion of dysplasia, though clinical abnormalities were slow to appear. Four of these hips subsequently dislocated. We believe that infants with late presentation of acetabular dysplasia and clinical abnormality belong to a different aetiological group from those with neonatal instability due to
We analysed static footprints of 2300 children between the ages of four and 13 years to establish the influence of footwear on the prevalence of flat foot. The incidence among children who used footwear was 8.6% compared with 2.8% in those who did not (p less than 0.001). Significant differences between the predominance in shod and unshod children were noted in all age groups, most marked in those with generalised
It is unknown whether gap laxities measured in robotic arm-assisted total knee arthroplasty (TKA) correlate to load sensor measurements. The aim of this study was to determine whether symmetry of the maximum medial and lateral gaps in extension and flexion was predictive of knee balance in extension and flexion respectively using different maximum thresholds of intercompartmental load difference (ICLD) to define balance. A prospective cohort study of 165 patients undergoing functionally-aligned TKA was performed (176 TKAs). With trial components in situ, medial and lateral extension and flexion gaps were measured using robotic navigation while applying valgus and varus forces. The ICLD between medial and lateral compartments was measured in extension and flexion with the load sensor. The null hypothesis was that stressed gap symmetry would not correlate directly with sensor-defined soft tissue balance.Aims
Methods
At the time of publication sixty-three additional patients have been fitted with the patellar tendon bearing prosthesis. Twenty of these were new amputees, and forty-three were old amputees who had previously worn a conventional limb. Of this group, nine were considered failures. The contra-indications for fitting now include: 1) coincident knee derangement such as cruciate or collateral
We studied 47 patients with closed, displaced, diaphyseal fractures of the femur caused by blunt trauma, to determine the incidence of associated knee injuries, particularly of the meniscus. After femoral nailing, all patients had an examination under anaesthesia and an arthroscopy. There were 12 medial meniscal injuries (5 tears) and 13 injuries of the lateral meniscus (8 tears). Ten of the 13 tears were in the posterior third of the meniscus, and two patients had tears of both menisci. Synovitis was common at the meniscal attachments. Complex and radial tears were more common than peripheral or bucket-handle tears. Examination under anaesthesia revealed
1. A study has been made of the treatment of recurrent dislocation of the patella in 106 knees in seventy-six patients. 2. In young adults in whom degenerative changes in the knee were not severe at the time of operation transplant of the tibial tubercle gave the best results. 3. In older patients and in those in whom osteoarthritic changes were present in the knee transplant of the tibial tubercle was unsatisfactory, but patellectomy with rerouting of the quadriceps mechanism gave fair results. 4. Tibial tubercle transplant is contra-indicated in children because it may give a recurvatum deformity. 5. When the dislocation is permanent, operation may be unnecessary, but if it becomes inevitable simple patellectomy is the best procedure. 6. The results of plastic operations on the quadriceps expansion and of supracondylar femoral osteotomy are bad. 7. No operation can give consistently good results because the knee is usually congenitally weak, often as part of generalised
We assessed proprioception in the knee using the angle reproduction test in 20 healthy volunteers, ten patients with acute anterior instability and 20 patients with chronic anterior instability after reconstruction of the anterior cruciate ligament (ACL). In addition, the Lysholm-knee score,
We analysed the static footprints of 1846 skeletally mature individuals to establish the influence of the age at which shoe-wearing began on the prevalence of flat foot. The incidence was 3.24% among those who started to wear shoes before the age of six years, 3.27% in those who began between the ages of 6 and 15 and 1.75% in those who first wore shoes at the age of 16 (p <
0.001). Flat foot was highest in those who, as children, wore footwear for over eight hours each day. Obese individuals and those with
1. Thirty-three patients who had had stapling of the lower femoral and upper tibial epiphysis to correct inequality of the leg lengths were reviewed after maturity. The staples were inserted so that correction of the disparity would coincide with termination of growth. 2. The predicted corrections were found to be inaccurate. The error was 47 per cent in girls operated on between ten and twelve and 51 per cent in boys between ten and thirteen. In older children the prediction was more accurate. 3. Despite the inaccuracy of prediction only four patients were left with shortening of more than 3·5 centimetres. 4. Complications of the operation were deformity,
We reviewed 188 patients at one to 20 years (mean 9.5) after surgery for anterior shoulder instability. Twenty-one had shown bilateral instability at the time of surgery, and 26 of the remaining 167 subsequently developed instability of the contralateral shoulder, giving an overall incidence of 24% bilateral involvement. Fourteen of these patients ultimately required bilateral surgery. The onset of contralateral instability was at one month to 15 years (mean 5.7 years) after anterior repair of the operated shoulder, the cumulative incidence increasing with time (p less than 0.01). The incidence was significantly higher in those under 15 years at the time of initial dislocation or under 18 at the time of surgery. One-half of the patients with contralateral instability had signs of posterior instability at follow-up. Other predisposing factors included having sustained the initial injury to the operated shoulder as a result of minimal trauma, and persistence of a sensation of instability in the operated shoulder. Factors which were not statistically significant included sex, dominant side, athletic activity, work history, and whether the initial surgery was for recurrent subluxations or dislocations. The high prevalence of bilateral shoulder instability suggests an intrinsic abnormality such as capsular and
1. Osteogenesis imperfecta is characterised by osseous fragility. Patients with the "congenita" form have multiple fractures before birth; those with the "tarda" form have osteoporosis, and develop multiple fractures and milder deformities of long bones at varying times after birth. 2. The frequency of blue sclera, dentinogenesis imperfecta, bruising,
Neither a surgeon’s intraoperative impression nor the parameters of computer navigation have been shown to be predictive of the outcomes following total knee arthroplasty (TKA). The aim of this study was to determine whether a surgeon, with robotic assistance, can predict the outcome as assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain (KPS), one year postoperatively, and establish what factors correlate with poor KOOS scores in a well-aligned and balanced TKA. A total of 134 consecutive patients who underwent TKA using a dynamic ligament tensioning robotic system with a tibia first resection technique and a cruciate sacrificing ultracongruent TKA system were enrolled into a prospective study. Each TKA was graded based on the final mediolateral ligament balance at 10° and 90° of flexion: 1) < 1 mm difference in the thickness of the tibial insert and that which was planned (n = 75); 2) < 1 mm difference (n = 26); 3) between 1 mm to 2 mm difference (n = 26); and 4) > 2 mm difference (n = 7). The mean one-year KPS score for each grade of TKA was compared and the likelihood of achieving an KPS score of > 90 was calculated. Finally, the factors associated with lower KPS despite achieving a high-grade TKA (grade A and B) were analyzed.Aims
Methods
Total knee arthroplasty is an established treatment for knee osteoarthritis with excellent long-term results, but there remains controversy about the role of uncemented prostheses. We present the long-term results of a randomized trial comparing an uncemented tantalum metal tibial component with a conventional cemented component of the same implant design. Patients under the age of 70 years with symptomatic osteoarthritis of the knee were randomized to receive either an uncemented tantalum metal tibial monoblock component or a standard cemented modular component. The mean age at time of recruitment to the study was 63 years (50 to 70), 46 (51.1%) knees were in male patients, and the mean body mass index was 30.4 kg/m2 (21 to 36). The same cruciate retaining total knee system was used in both groups. All patients received an uncemented femoral component and no patients had their patella resurfaced. Patient outcomes were assessed preoperatively and postoperatively using the modified Oxford Knee Score, Knee Society Score, and 12-Item Short-Form Health Survey questionnaire (SF-12) score. Radiographs were analyzed using the American Knee Society Radiograph Evaluation score. Operative complications, reoperations, or revision surgery were recorded. A total of 90 knees were randomized and at last review 77 knees were assessed. In all, 11 patients had died and two were lost to follow-up.Aims
Methods
Varus-valgus constrained (VVC) implants are often used during revision total knee arthroplasty (TKA) to gain coronal plane stability. However, the increased mechanical torque applied to the bone-cement interface theoretically increases the risk of aseptic loosening. We assessed mid-term survivorship, complications, and clinical outcomes of a fixed-bearing VVC device in revision TKAs. A total of 416 consecutive revision TKAs (398 patients) were performed at our institution using a single fixed-bearing VVC TKA from 2007 to 2015. Mean age was 64 years (33 to 88) with 50% male (199). Index revision TKA diagnoses were: instability (n = 122, 29%), aseptic loosening (n = 105, 25%), and prosthetic joint infection (PJI) (n = 97, 23%). All devices were cemented on the epiphyseal surfaces. Femoral stems were used in 97% (n = 402) of cases, tibial stems in 95% (n = 394) of cases; all were cemented. In total, 93% (n = 389) of cases required a stemmed femoral and tibial component. Femoral cones were used in 29%, and tibial cones in 40%. Survivorship was assessed via competing risk analysis; clinical outcomes were determined using Knee Society Scores (KSSs) and range of movement (ROM). Mean follow-up was four years (2 to 10).Aims
Methods
A borderline dysplastic hip can behave as either stable or unstable and this makes surgical decision making challenging. While an unstable hip may be best treated by acetabular reorientation, stable hips can be treated arthroscopically. Several imaging parameters can help to identify the appropriate treatment, including the Femoro-Epiphyseal Acetabular Roof (FEAR) index, measured on plain radiographs. The aim of this study was to assess the reliability and the sensitivity of FEAR index on MRI compared with its radiological measurement. The technique of measuring the FEAR index on MRI was defined and its reliability validated. A retrospective study assessed three groups of 20 patients: an unstable group of ‘borderline dysplastic hips’ with lateral centre edge angle (LCEA) less than 25° treated successfully by periacetabular osteotomy; a stable group of ‘borderline dysplastic hips’ with LCEA less than 25° treated successfully by impingement surgery; and an asymptomatic control group with LCEA between 25° and 35°. The following measurements were performed on both standardized radiographs and on MRI: LCEA, acetabular index, femoral anteversion, and FEAR index.Aims
Patients and Methods
The purpose of this multicentre observational study was to investigate the association between intraoperative component positioning and soft-tissue balancing on short-term clinical outcomes in patients undergoing robotic-arm assisted unicompartmental knee arthroplasty (UKA). Between 2013 and 2016, 363 patients (395 knees) underwent robotic-arm assisted UKAs at two centres. Pre- and postoperatively, patients were administered Knee Injury and Osteoarthritis Score (KOOS) and Forgotten Joint Score-12 (FJS-12). Results were stratified as “good” and “bad” if KOOS/FJS-12 were more than or equal to 80. Intraoperative, post-implantation robotic data relative to CT-based components placement were collected and classified. Postoperative complications were recorded.Aims
Patients and Methods
Options for the treatment of intra-articular ligament injuries are limited, and insufficient ligament reconstruction can cause painful joint instability, loss of function, and progressive development of degenerative arthritis. This study aimed to assess the capability of a biologically enhanced matrix material for ligament reconstruction to withstand tensile forces within the joint and enhance ligament regeneration needed to regain joint function. A total of 18 New Zealand rabbits underwent bilateral anterior cruciate ligament reconstruction by autograft, FiberTape, or FiberTape-augmented autograft. Primary outcomes were biomechanical assessment (n = 17), microCT (µCT) assessment (n = 12), histological evaluation (n = 12), and quantitative polymerase chain reaction (qPCR) analysis (n = 6).Aims
Materials and Methods
Patient-specific instrumentation of total knee arthroplasty (TKA) is a technique permitting the targeting of individual kinematic alignment, but deviation from a neutral mechanical axis may have implications on implant fixation and therefore survivorship. The primary objective of this randomized controlled study was to compare the fixation of tibial components implanted with patient-specific instrumentation targeting kinematic alignment (KA+PSI) A total of 47 patients due to undergo TKA were randomized to KA+PSI (n = 24) or MA+CAS (n = 23). In the KA+PSI group, there were 16 female and eight male patients with a mean age of 64 years (Aims
Patients and Methods
There is little information about how to manage patients with a recurvatum deformity of the distal tibia and osteoarthritis (OA) of the ankle. The aim of this study was to evaluate the functional and radiological outcome of addressing this deformity using a flexion osteotomy and to assess the progression of OA after this procedure. A total of 39 patients (12 women, 27 men; mean age 47 years (28 to 72)) with a distal tibial recurvatum deformity were treated with a flexion osteotomy, between 2010 and 2015. Nine patients (23%) subsequently required conversion to either a total ankle arthroplasty (seven) or an arthrodesis (two) after a mean of 21 months (9 to 36). A total of 30 patients (77%), with a mean follow-up of 30 months (24 to 76), remained for further evaluation. Functional outcome, sagittal ankle joint OA using a modified Kellgren and Lawrence Score, tibial lateral surface (TLS) angle, and talar offset ratio (TOR) were evaluated on pre- and postoperative weight-bearing radiographs.Aims
Patients and Methods
Robotic-assisted unicompartmental knee arthroplasty (UKA) promises accurate implant placement with the potential of improved survival and functional outcomes. The aim of this study was to present the current evidence for robotic-assisted UKA and describe the outcome in terms of implant positioning, range of movement (ROM), function and survival, and the types of robot and implants that are currently used. A search of PubMed and Medline was performed in October 2018 in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Search terms included “robotic”, “knee”, and “surgery”. The criteria for inclusion was any study describing the use of robotic UKA and reporting implant positioning, ROM, function, and survival for clinical, cadaveric, or dry bone studies.Aims
Materials and Methods
The mucopolysaccharidoses (MPS) are a group of
inherited lysosomal storage disorders with clinical manifestations relevant
to the orthopaedic surgeon. Our aim was to review the recent advances
in their management and the implications for surgical practice. The current literature about MPSs is summarised, emphasising
orthopaedic complications and their management. Recent advances in the diagnosis and management of MPSs include
the recognition of slowly progressive, late presenting subtypes,
developments in life-prolonging systemic treatment and potentially
new indications for surgical treatment. The outcomes of surgery
in these patients are not yet validated and some procedures have
a high rate of complications which differ from those in patients
who do not have a MPS. The diagnosis of a MPS should be considered in adolescents or
young adults with a previously unrecognised dysplasia of the hip.
Surgeons treating patients with a MPS should report their experience
and studies should include the assessment of function and quality
of life to guide treatment. Cite this article:
The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) This prospective cohort study included 146 patients with symptomatic medial compartment knee osteoarthritis undergoing primary UKA performed by a single surgeon. This included 73 consecutive patients undergoing conventional jig-based mobile bearing UKA, followed by 73 consecutive patients receiving robotic-arm assisted fixed bearing UKA. All surgical procedures were performed using the standard medial parapatellar approach for UKA, and all patients underwent the same postoperative rehabilitation programme. Postoperative pain scores on the numerical rating scale and opiate analgesia consumption were recorded until discharge. Time to attainment of predefined functional rehabilitation outcomes, hospital discharge, and postoperative complications were recorded by independent observers.Aims
Patients and Methods
Guided growth using eight-plates is commonly used for correction
of angular limb deformities in growing children. The principle is
of tethering at the physeal periphery while enabling growth in the
rest of the physis. The method is also applied for epiphysiodesis
to correct limb-length discrepancy (LLD). Concerns have been raised
regarding the potential of this method to create an epiphyseal deformity.
However, this has not been investigated. The purpose of this study
was to detect and quantify the occurrence of deformities in the
proximal tibial epiphysis following treatment with eight-plates. A retrospective study was performed including 42 children at
a mean age of 10.8 years (3.7 to 15.7) undergoing eight-plate insertion
in the proximal tibia for correction of coronal plane deformities
or LLD between 2007 and 2015. A total of 64 plates were inserted;
48 plates (34 patients) were inserted to correct angular deformities
and 16 plates (8 patients) for LLD. Medical records, Picture Archive
and Communication System images, and conventional radiographs were
reviewed. Measurements included interscrew angle, lateral and medial
plateau slope angles measured between the plateau surface and the
line between the ends of the physis, and tibial plateau roof angle defined
as 180° minus the sum of both plateau angles. Measurements were
compared between radiographs performed adjacent to surgery and those
at latest follow-up, and between operated and non-operated plateaus. Statistical
analysis was performed using BMDP Statistical Software.Aims
Patients and Methods
This study reports the mid-term results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head (LDH) ceramic-on-ceramic (CoC) bearing. Of the 276 hips (246 patients) included in this study, 264 (96%) were reviewed at a mean of 67 months (48 to 79) postoperatively. Procedures were performed with a mini posterior approach. Clinical and radiological outcomes were recorded at regular intervals. A noise assessment questionnaire was completed at last follow-up.Aims
Patients and Methods
Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants.Aims
Patients and Methods
The objective of this study was to compare early postoperative
functional outcomes and time to hospital discharge between conventional
jig-based total knee arthroplasty (TKA) and robotic-arm assisted
TKA. This prospective cohort study included 40 consecutive patients
undergoing conventional jig-based TKA followed by 40 consecutive
patients receiving robotic-arm assisted TKA. All surgical procedures
were performed by a single surgeon using the medial parapatellar
approach with identical implant designs and standardized postoperative inpatient
rehabilitation. Inpatient functional outcomes and time to hospital
discharge were collected in all study patients.Aims
Patients and Methods
To determine the normal values and usefulness of the C1/4 space
available for spinal cord (SAC) ratio and C1 inclination angle,
which are new radiological parameters for assessing atlantoaxial
instability in children with Down syndrome. We recruited 272 children with Down syndrome (including 14 who
underwent surgical treatment), and 141 children in the control group.
All were aged between two and 11 years. The C1/4 SAC ratio, C1 inclination
angle, atlas-dens interval (ADI), and SAC were measured in those
with Down syndrome, and the C1/4 SAC ratio and C1 inclination angle
were measured in the control group.Aims
Patients and Methods
The role of high tibial osteotomy (HTO) is being questioned by
the use of unicompartmental knee arthroplasty (UKA) in the treatment
of medial compartment femorotibial osteoarthritis. Our aim was to
compare the outcomes of revision HTO or UKA to a total knee arthroplasty
(TKA) using computer-assisted surgery in matched groups of patients. We conducted a retrospective study to compare the clinical and
radiological outcome of patients who underwent revision of a HTO
to a TKA (group 1) with those who underwent revision of a medial
UKA to a TKA (group 2). All revision procedures were performed using
computer-assisted surgery. We extracted these groups of patients
from our database. They were matched by age, gender, body mass index,
follow-up and pre-operative functional score. The outcomes included
the Knee Society Scores (KSS), radiological outcomes and the rate
of further revision.Aims
Patients and Methods
Ligaments which heal spontaneously have a healing process that
is similar to skin wound healing. Menopause impairs skin wound healing
and may likewise impair ligament healing. Our purpose in this study
was to investigate the effect of surgical menopause on ligament
healing in a rabbit medial collateral ligament model. Surgical menopause was induced with ovariohysterectomy surgery
in adult female rabbits. Ligament injury was created by making a
surgical gap in the midsubstance of the medial collateral ligament.
Ligaments were allowed to heal for six or 14 weeks in the presence
or absence of oestrogen before being compared with uninjured ligaments. Molecular
assessment examined the messenger ribonucleic acid levels for collagens,
proteoglycans, proteinases, hormone receptors, growth factors and
inflammatory mediators. Mechanical assessments examined ligament
laxity, total creep strain and failure stress.Objectives
Methods
In patients undergoing medial opening wedge high tibial osteotomy
(MOWHTO), soft tissue opening on the medial side of the knee is
difficult to predict. When the load bearing axis is corrected beyond
a certain point, the knee joint tilts open on the medial side. We
therefore hypothesised that there is a tipping point and defined
this as the coronal hypomochlion. In this prospective study of 150 navigated MOWHTOs (144 consecutive
patients), data were collected before surgery and at three months
post-operatively. In order to calculate the hypomochlion, we compared
the respective changes to the joint line convergence angle (JLCA)
with the post-operative axis of the leg. The change to the medial proximal
tibial angle accounts for only about 80% of the change to the femorotibial
angle; 20% of the correction can therefore be attributed to non-osseous,
soft-tissue changes.Aims
Patients and Methods
Static radiostereometric analysis (RSA) using implanted markers is considered the most accurate system for the evaluation of prosthesis migration. By using CT bone models instead of markers, combined with a dynamic RSA system, a non-invasive measurement of joint movement is enabled. This method is more accurate than current 3D skin marker-based tracking systems. The purpose of this study was to evaluate the accuracy of the CT model method for measuring knee joint kinematics in static and dynamic RSA using the marker method as the benchmark. Bone models were created from CT scans, and tantalum beads were implanted into the tibia and femur of eight human cadaver knees. Each specimen was secured in a fixture, static and dynamic stereoradiographs were recorded, and the bone models and marker models were fitted to the stereoradiographs.Objectives
Methods
The Bereiter trochleoplasty has been used in our unit for 12
years to manage recurrent patellar instability in patients with
severe trochlea dysplasia. The aim of this study was to document
the outcome of a large consecutive cohort of patients who have undergone
this operation. Between June 2002 and August 2013, 214 consecutive trochleoplasties
were carried out in 185 patients. There were 133 women and 52 men
with a mean age of 21.3 years (14 to 38). All patients were offered
yearly clinical and radiological follow-up. They completed the following
patient reported outcome scores (PROMs): International Knee Documentation
Committee subjective scale, the Kujala score, the Western Ontario
and McMaster Universities Arthritis Index score and the short-form
(SF)-12. Aims
Patients and Methods
Dysplasia of the hip, hypotonia, osteopenia,
ligamentous laxity, and mental retardation increase the complexity
of performing and managing patients with Down syndrome who require
total hip replacement (THR). We identified 14 patients (six males,
eight females, 21 hips) with Down syndrome and degenerative disease
of the hip who underwent THR, with a minimum follow-up of two years
from 1969 to 2009. In seven patients, bilateral THRs were performed
while the rest had unilateral THRs. The mean clinical follow-up
was 5.8 years (standard deviation ( Cite this article:
We investigated whether an asymmetric extension
gap seen on routine post-operative radiographs after primary total
knee replacement (TKR) is associated with pain at three, six, 12
and 24 months’ follow-up. On radiographs of 277 patients after primary
TKR we measured the distance between the tibial tray and the femoral
condyle on both the medial and lateral sides. A difference was defined
as an asymmetric extension gap. We considered three groups (no asymmetric
gap, medial-opening and lateral-opening gap) and calculated the
associations with the Western Ontario and McMaster Universities
osteoarthritis index pain scores over time. Those with an asymmetric extension gap of ≥ 1.5 mm had a significant
association with pain scores at three months’ follow-up; patients
with a medial-opening extension gap reported more pain and patients
with a lateral-opening extension gap reported less pain (p = 0.036).
This effect was still significant at six months (p = 0.044), but had
lost significance by 12 months (p = 0.924). When adjusting for multiple
cofounders the improvement in pain was more pronounced in patients
with a lateral-opening extension gap than in those with a medial-opening extension
gap at three (p = 0.037) and six months’ (p = 0.027) follow-up. Cite this article:
The June 2014 Hip &
Pelvis Roundup360 looks at: Modular femoral necks: early signs are not good; is corrosion to blame for modular neck failures; metal-on-metal is not quite a closed book; no excess failures in fixation of displaced femoral neck fractures; noise no problem in hip replacement; heterotopic ossification after hip arthroscopy: are NSAIDs the answer?; thrombotic and bleeding events surprisingly low in total joint replacement; and the elephant in the room: complications and surgical volume.
A variety of operative techniques have been described as under
the term ‘Bristow-Latarjet’ procedure. This review aims to define
the original procedure, and compare the variation in techniques
described in the literature, assessing any effect on clinical outcomes. A systematic review of 24 studies was performed to compare specific
steps of the technique (coracoid osteotomy site, subscapularis approach,
orientation and position of coracoid graft fixation and fixation
method, additional labral and capsular repair) and detect any effect
this variability had on outcomes.Objectives
Materials and Methods
Patients with skeletal dysplasia are prone to
developing advanced osteoarthritis of the knee requiring total knee replacement
(TKR) at a younger age than the general population. TKR in this
unique group of patients is a technically demanding procedure owing
to the deformity, flexion contracture, generalised hypotonia and ligamentous
laxity. We retrospectively reviewed the outcome of 11 TKRs performed
in eight patients with skeletal dysplasia at our institution using
the Stanmore Modular Individualised Lower Extremity System (SMILES)
custom-made rotating-hinge TKR. There were three men and five women
with mean age of 57 years (41 to 79). Patients were followed clinically
and radiologically for a mean of seven years (3 to 11.5). The mean
Knee Society clinical and function scores improved from 24 (14 to
36) and 20 (5 to 40) pre-operatively, respectively, to 68 (28 to
80) and 50 (22 to 74), respectively, at final follow-up. Four complications
were recorded, including a patellar fracture following a fall, a
tibial peri-prosthetic fracture, persistent anterior knee pain,
and aseptic loosening of a femoral component requiring revision.
Our results demonstrate that custom primary rotating-hinge TKR in
patients with skeletal dysplasia is effective at relieving pain,
with a satisfactory range of movement and improved function. It compensates
for bony deformity and ligament deficiency and reduces the likelihood
of corrective osteotomy. Patellofemoral joint complications are
frequent and functional outcome is worse than with primary TKR in
the general population.
Acute angulation at the thoracolumbar junction
with segmental subluxation of the spine occurring at the level above
an anteriorly hypoplastic vertebra in otherwise normal children
is a rare condition described as infantile developmental thoracolumbar
kyphosis. Three patient series with total of 18 children have been
reported in the literature. We report five children who presented
with thoracolumbar kyphosis and discuss the treatment algorithm. We
reviewed the medical records and spinal imaging at initial clinical
presentation and at minimum two-year follow-up. The mean age at
presentation was eight months (two to 12). All five children had
L2 anterior vertebral body hypoplasia. The kyphosis improved spontaneously
in three children kept under monitoring. In contrast, the deformity
was progressive in two patients who were treated with bracing. The
kyphosis and segmental subluxation corrected at latest follow-up
(mean age 52 months; 48 to 60) in all patients with near complete
reconstitution of the anomalous vertebra. The deformity and radiological
imaging on a young child can cause anxiety to both parents and treating
physicians. Diagnostic workup and treatment algorithm in the management
of infantile developmental thoracolumbar kyphosis is proposed. Observation
is indicated for non-progressive kyphosis and bracing if there is evidence
of kyphosis and segmental subluxation deterioration beyond walking
age. Surgical stabilisation of the spine can be reserved for severe
progressive deformities unresponsive to conservative treatment. Cite this article:
We reviewed 34 consecutive patients (18 female-16 male) with
isthmic spondylolysis and grade I to II lumbosacral spondylolisthesis
who underwent in situ posterolateral arthodesis between the L5 transverse
processes and the sacral ala with the use of iliac crest autograft.
Ten patients had an associated scoliosis which required surgical correction
at a later stage only in two patients with idiopathic curves unrelated
to the spondylolisthesis. No patient underwent spinal decompression or instrumentation
placement. Mean surgical time was 1.5 hours (1 to 1.8) and intra-operative
blood loss 200 ml (150 to 340). There was one wound infection treated
with antibiotics but no other complication. Radiological assessment
included standing posteroanterior and lateral, Ferguson and lateral flexion/extension
views, as well as CT scans. Aims
Methods
Instability after total knee replacement (TKR)
accounts for 10% to 22% of revision procedures. All patients who
present for evaluation of instability require a thorough history to
be taken and physical examination, as well as appropriate imaging.
Deep periprosthetic infection must be ruled out by laboratory testing
and an aspiration of the knee must be carried out. The three main
categories of instability include flexion instability, extension instability
(symmetric and asymmetric), and genu recurvatum. Most recently,
the aetiologies contributing to, and surgical manoeuvres required
to correct, flexion instability have been elucidated. While implant
design and patient-related factors may certainly contribute to the
aetiology, surgical technique is also a significant factor in all
forms of post-operative instability. Cite this article:
Instability is the reason for revision of a primary
total knee replacement (TKR) in 20% of patients. To date, the diagnosis
of instability has been based on the patient’s symptoms and a subjective
clinical assessment. We assessed whether a measured standardised
forced leg extension could be used to quantify instability. A total of 25 patients (11 male/14 female, mean age 70 years;
49 to 85) who were to undergo a revision TKR for instability of
a primary implant were assessed with a Nottingham rig pre-operatively
and then at six and 26 weeks post-operatively. Output was quantified
(in revolutions per minute (rpm)) by accelerating a stationary flywheel.
A control group of 183 patients (71 male/112 female, mean age 69
years) who had undergone primary TKR were evaluated for comparison. Pre-operatively, all 25 patients with instability exhibited a
distinctive pattern of reduction in ‘mid-push’ speed. The mean reduction
was 55 rpm ( Cite this article:
Osteogenesis imperfecta is a rare inherited disorder of connective tissue which may present with recurrent fractures which are prone to nonunion and malunion resulting in deformity. Some patients develop osteoarthritis of the hip. Formation of hyperplastic callus after recurrent fractures may deform the shape of the femur and preclude the use of standard implants at joint replacement. Replacement can thus be technically demanding. We present a case of bilateral hip replacement in a patient with osteogenesis imperfecta and hyperplastic callus which was treated by the use of long femoral allografts and cemented femoral stems.
Mechanical alignment has been a fundamental tenet of total knee arthroplasty (TKA) since modern knee replacement surgery was developed in the 1970s. The objective of mechanical alignment was to infer the greatest biomechanical advantage to the implant to prevent early loosening and failure. Over the last 40 years a great deal of innovation in TKA technology has been focusing on how to more accurately achieve mechanical alignment. Recently the concept of mechanical alignment has been challenged, and other alignment philosophies are being explored with the intention of trying to improve patient outcomes following TKA. This article examines the evolution of the mechanical alignment concept and whether there are any viable alternatives.
The April 2014 Spine Roundup360 looks at: medical treatment for ankylosing spondylitis; unilateral TLIF effective; peg fractures akin to neck of femur fractures; sleep apnoea and spinal surgery; scoliosis in osteogenesis imperfect; paediatric atlanto-occipital dislocation; back pain and obesity: chicken or egg?; BMP associated with lumbar plexus deficit; and just how common is back pain?
A 20-year-old man sustained an open medial dislocation of the ankle without an associated fracture after a low-energy inversion injury. Prompt debridement and reduction with primary wound closure of the skin were performed without suture of the capsule. Immobilisation in a non-weight-bearing cast for 30 days followed by ankle bracing for two weeks and subsequent physiotherapy, produced full functional recovery by three months. At follow-up at one year there was a full range of pain-free movement, although the radiographs and MR scan showed early post-traumatic degenerative change at the medial aspect of the tibiotalar and the calcaneocuboid joints.
We describe a new method of stabilising a painful unstable sternoclavicular joint using the sternocleidomastoid tendon and passing it through the medial clavicle and onto the manubrium sternum. This method is simple, reproducible and avoids the potential risks of reefing the joint to the first rib. The technique was used in seven cases of sternoclavicular joint instability in six patients who were reviewed at a mean of 39.7 months (15 to 63). Instability was markedly reduced or eliminated in all cases, but in one there was occasional persistant subluxation. There were minor scar complications after two procedures and one patient had transient ulnar neuritis. This procedure provides satisfactory results in the medium term.
We describe the mid-term results of a prospective study of total knee replacement in severe valgus knees using an osteotomy of the lateral femoral condyle and computer navigation. There were 15 knees with a mean valgus deformity of 21° (17° to 27°) and a mean follow-up of 28 months (24 to 60). A cemented, non-constrained fixed bearing, posterior-cruciate-retaining knee prosthesis of the same design was used in all cases (Columbus-B. Braun; Aesculap, Tuttlingen, Germany). All the knees were corrected to a mean of 0.5° of valgus (0° to 2°). Flexion of the knee had been limited to a mean of 85° (75° to 110°) pre-operatively and improved to a mean of 105° (90° to 130°) after operation. The mean Knee Society score improved from 37 (30 to 44) to 90 points (86 to 94). Osteotomy of the lateral femoral condyle combined with computer-assisted surgery gave an excellent mid-term outcome in patients undergoing total knee replacement in the presence of severe valgus deformity.
Squeaking arising from a ceramic-on-ceramic (CoC)
total hip replacement (THR) may cause patient concern and in some
cases causes patients to seek revision surgery. We performed a meta-analysis
to determine the incidence of squeaking and the incidence of revision
surgery for squeaking. A total of 43 studies including 16 828 CoC
THR that reported squeaking, or revision for squeaking, were entered
into the analysis. The incidence of squeaking was 4.2% and the incidence
of revision for squeaking was 0.2%. The incidence of squeaking in
patients receiving the Accolade femoral stem was 8.3%, and the incidence
of revision for squeaking in these patients was 1.3%. Cite this article:
Recent reports have suggested an increase in
the number of anterior cruciate ligament (ACL) injuries in children, although
their true incidence is unknown. The prognosis of the ACL-deficient knee in young active individuals
is poor because of secondary meniscal tears, persistent instability
and early-onset osteoarthritis. The aim of surgical reconstruction
is to provide stability while avoiding physeal injury. Techniques
of reconstruction include transphyseal, extraphyseal or partial
physeal sparing procedures. In this paper we review the management of ACL tears in skeletally
immature patients. Cite this article:
Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.
The outcome of total knee replacement (TKR) using
components designed to increase the range of flexion is not fully
understood. The short- to mid-term risk of aseptic revision in high
flexion TKR was evaluated. The endpoint of the study was aseptic
revision and the following variables were investigated: implant
design (high flexion In a cohort of 64 000 TKRs, high flexion components were used
in 8035 (12.5%). The high flexion knees with tibial liners of thickness
>
14 mm had a density of revision of 1.45/100 years of observation,
compared with 0.37/100 in non-high flexion TKR with liners ≤ 14
mm thick. Relative to a standard fixed PS TKR, the NexGen (Zimmer,
Warsaw, Indiana) Gender Specific Female high flexion fixed PS TKR
had an increased risk of revision (hazard ratio (HR) 2.27 (95% confidence
interval (CI) 1.48 to 3.50)), an effect that was magnified when
a thicker tibial insert was used (HR 8.10 (95% CI 4.41 to 14.89)). Surgeons should be cautious when choosing high flexion TKRs,
particularly when thicker tibial liners might be required. Cite this article:
The February 2013 Spine Roundup360 looks at: complications with anterior decompression and fusion; lumbar claudication and peripheral vascular disease; increasing cervical instability in rheumatoids; kyphoplasty; cervical stenosis; exercise or fusion for chronic lower back pain; lumbar disc arthroplasty and adjacent level changes; and obese disc prolapses.
Like athletes, musicians are vulnerable to musculoskeletal
injuries that can be career ending or have a severe negative financial
impact. All ages are affected, with a peak incidence in the third
and fourth decades. Women are slightly more likely to be affected
than men. It is incumbent upon orthopaedic surgeons to be able to
complete a thorough physical assessment, be aware of the risk factors
associated with musculoskeletal symptoms in musicians, and have
a detailed knowledge of the specific syndromes they suffer and their
appropriate treatment. In this paper we review the common hand injuries that afflict
musicians and discuss their treatment. Cite this article:
We systematically reviewed the published literature
on the complications of closing wedge high tibial osteotomy for
the treatment of unicompartmental osteoarthritis of the knee. Publications
were identified using the Cochrane Library, MEDLINE, EMBASE and
CINAHL databases up to February 2012. We assessed randomised (RCTs), controlled
group clinical (CCTs) trials, case series in publications associated
with closing wedge osteotomy of the tibia in patients with osteoarthritis
of the knee and finally a Cochrane review. Many of these trials
included comparative studies (opening wedge
The Oxford mobile-bearing unicompartmental knee
replacement (UKR) is an effective and safe treatment for osteoarthritis
of the medial compartment. The results in the lateral compartment
have been disappointing due to a high early rate of dislocation
of the bearing. A series using a newly designed domed tibial component
is reported. The first 50 consecutive domed lateral Oxford UKRs in 50 patients
with a mean follow-up of three years (2.0 to 4.3) were included.
Clinical scores were obtained prospectively and Kaplan-Meier survival
analysis was performed for different endpoints. Radiological variables
related to the position and alignment of the components were measured. One patient died and none was lost to follow-up. The cumulative
incidence of dislocation was 6.2% (95% confidence interval (CI)
2.0 to 17.9) at three years. Survival using revision for any reason
and aseptic revision was 94% (95% CI 82 to 98) and 96% (95% CI 85
to 99) at three years, respectively. Outcome scores, visual analogue
scale for pain and maximum knee flexion showed a significant improvement
(p <
0.001). The mean Oxford knee score was 43 ( Clinical results are excellent and short-term survival has improved
when compared with earlier series. The risk of dislocation remains
higher using a mobile-bearing UKR in the lateral compartment when
compared with the medial compartment. Patients should be informed
about this complication. To avoid dislocations, care must be taken
not to elevate the lateral joint line.
The sternoclavicular joint (SCJ) is a pivotal
articulation in the linked system of the upper limb girdle, providing
load-bearing in compression while resisting displacement in tension
or distraction at the manubrium sterni. The SCJ and acromioclavicular
joint (ACJ) both have a small surface area of contact protected
by an intra-articular fibrocartilaginous disc and are supported
by strong extrinsic and intrinsic capsular ligaments. The function
of load-sharing in the upper limb by bulky periscapular and thoracobrachial
muscles is extremely important to the longevity of both joints.
Ligamentous and capsular laxity changes with age, exposing both
joints to greater strain, which may explain the rising incidence
of arthritis in both with age. The incidence of arthritis in the
SCJ is less than that in the ACJ, suggesting that the extrinsic
ligaments of the SCJ provide greater stability than the coracoclavicular
ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish
from medial clavicular physeal or metaphyseal fracture-separation:
cross-sectional imaging is often required. The distinction is important
because the treatment options and outcomes of treatment are dissimilar,
whereas the treatment and outcomes of ACJ separation and fracture
of the lateral clavicle can be similar. Proper recognition and treatment
of traumatic instability is vital as these injuries may be life-threatening.
Instability of the SCJ does not always require surgical intervention.
An accurate diagnosis is required before surgery can be considered,
and we recommend the use of the Stanmore instability triangle. Most
poor outcomes result from a failure to recognise the underlying
pathology. There is a natural reluctance for orthopaedic surgeons to operate
in this area owing to unfamiliarity with, and the close proximity
of, the related vascular structures, but the interposed sternohyoid
and sternothyroid muscles are rarely injured and provide a clear
boundary to the medial retroclavicular space, as well as an anatomical
barrier to unsafe intervention. This review presents current concepts of instability of the SCJ,
describes the relevant surgical anatomy, provides a framework for
diagnosis and management, including physiotherapy, and discusses
the technical challenges of operative intervention. Cite this article:
We describe the intermediate results of lateral ligamentous repair or reconstruction for posterolateral rotatory instability of the elbow. Between 1986 and 1999, we performed 12 direct repairs and 33 ligament reconstructions with a tendon autograft. One patient was lost to follow-up and 44 were retrospectively studied at a mean of six years (2 to 15). Surgery restored stability in all except five patients. In two the elbow became stable after a second procedure. The mean post-operative Mayo elbow performance score was 85 points (60 to 100). The result was classified as excellent in 19, good in 13, fair in seven and poor in five patients. Thirty-eight patients (86%) were subjectively satisfied with the outcome of the operation. Better results were obtained in patients with a post-traumatic aetiology (p = 0.03), those with subjective symptoms of instability at presentation (p = 0.006) and those who had an augmented reconstruction using a tendon graft (p = 0.04). Reconstruction using a tendon graft seems to provide better results than ligament repair and the results do not seem to deteriorate with time. The outcome of this procedure is less predictable in patients with no subjective instability.
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.