We describe our experience in the reduction of
dislocation of the hip secondary to developmental dysplasia using ultrasound-guided
gradual reduction using flexion and abduction continuous traction
(FACT-R). During a period of 13 years we treated 208 Suzuki type
B or C complete dislocations of the hip in 202 children with a mean
age of four months (0 to 11). The mean follow-up was 9.1 years (five
to 16). The rate of reduction was 99.0%. There were no recurrent
dislocations, and the rate of avascular necrosis of the femoral
head was 1.0%. The rate of secondary surgery for residual acetabular
dysplasia was 19.2%, and this was significantly higher in those
children in whom the initial treatment was delayed or if other previous
treatments had failed (p = 0.00045). The duration of FACT-R was significantly
longer in severe dislocations (p = 0.001) or if previous treatments
had failed (p = 0.018). This new method of treatment is effective and safe in these difficult
cases and offers outcomes comparable to or better than those of
standard methods. Cite this article:
To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically. A total of 209 children (mean age 6.84 years (SD 2.87)), who underwent surgical treatment for CMFs between March 2015 and March 2023 at six institutions, were retrospectively reviewed. Assessed risk factors included age, sex, laterality, dislocation direction and distance, preoperative proximal radial metaphysis width, time from injury to surgery, reduction method, annular ligament reconstruction, radiocapitellar joint fixation, ulnar osteotomy, site of ulnar osteotomy, preoperative and postoperative ulnar angulation, ulnar fixation method, progressive ulnar distraction, and postoperative cast immobilization. Independent-samples Aims
Methods
1. A case of fracture-dislocation of the atlas on the axis is presented in which the neck had been manipulated under anaesthesia for "rheumatism.". 2. Despite marked displacement there were no important neurological complications. 3. One-stage reduction by traction was carried out very slowly and with radiographic control. It is believed that this is less distressing to the patient, and safer, than
Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value.Aims
Methods
To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration. The OCD lesion was created on the trochlear groove of left articular cartilage of femur per rat (40 rats in total). The experimental groups were Sham, OCD, and ESWT (0.25 mJ/mm2, 800 impulses, 4 Hz). The animals were euthanized at 2, 4, 8, and 12 weeks post-treatment, and histopathological analysis, micro-CT scanning, and immunohistochemical staining were performed for the specimens.Aims
Methods
The treatment of developmental dysplasia of the hip diagnosed after the first year of life remains controversial. A series of 36 children (47 hips), aged between one and 4.9 years underwent
To provide normative data that can assess spinal-related disability and the prevalence of back or leg pain among adults with no spinal conditions in the UK using validated questionnaires. A total of 1,000 participants with equal sex distribution were included and categorized in five age groups: 20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 to 69 years. Individuals with spinal pathologies were excluded. Participants completed the Scoliosis Research Society-22 (SRS-22r), visual analogue scale (VAS) for back/leg pain, and the EuroQol five-dimension index (EQ-5D/VAS) questionnaires, and disclosed their age, sex, and occupation. They were also categorized in five professional groups: doctors, nurses, allied health professionals, office workers, and manual workers.Aims
Methods
Dislocation following total hip arthroplasty (THA) is a well-known and potentially devastating complication. Clinicians have used many strategies in attempts to prevent dislocation since the introduction of THA. While the importance of postoperative care cannot be ignored, particular emphasis has been placed on preoperative planning in the prevention of dislocation. The strategies have progressed from more traditional approaches, including modular implants, the size of the femoral head, and augmentation of the offset, to newer concepts, including patient-specific component positioning combined with computer navigation, robotics, and the use of dual-mobility implants. As clinicians continue to pursue improved outcomes and reduced complications, these concepts will lay the foundation for future innovation in THA and ultimately improved outcomes. Cite this article:
To benchmark the radiation dose to patients during the course of treatment for a spinal deformity. Our radiation dose database identified 25,745 exposures of 6,017 children (under 18 years of age) and adults treated for a spinal deformity between 1 January 2008 and 31 December 2016. Patients were divided into surgical (974 patients) and non-surgical (5,043 patients) cohorts. We documented the number and doses of ionizing radiation imaging events (radiographs, CT scans, or intraoperative fluoroscopy) for each patient. All the doses for plain radiographs, CT scans, and intraoperative fluoroscopy were combined into a single effective dose by a medical physicist (milliSivert (mSv)).Aims
Methods
When the present study was initiated, we changed the treatment for late-detected developmental dislocation of the hip (DDH) from several weeks of skin traction to markedly shorter traction time. The aim of this prospective study was to evaluate this change, with special emphasis on the rate of stable closed reduction according to patient age, the development of the acetabulum, and the outcome at skeletal maturity. From 1996 to 2005, 49 children (52 hips) were treated for late-detected DDH. Their mean age was 13.3 months (3 to 33) at reduction. Prereduction skin traction was used for a mean of 11 days (0 to 27). Gentle closed reduction under general anaesthesia was attempted in all the hips. Concurrent pelvic osteotomy was not performed. The hips were evaluated at one, three and five years after reduction, at age eight to ten years, and at skeletal maturity. Mean age at the last follow-up was 15.7 years (13 to 21).Aims
Methods
The direct posterior approach with subperiosteal dissection of the paraspinal muscles from the vertebrae is considered to be the standard approach for the surgical treatment of adolescent idiopathic scoliosis (AIS). We investigated whether or not a minimally-invasive surgery (MIS) technique could offer improved results. Consecutive AIS patients treated with an MIS technique at two tertiary centres from June 2013 to March 2016 were retrospectively included. Preoperative patient deformity characteristics, perioperative parameters, power of deformity correction, and complications were studied. A total of 93 patients were included. The outcome of the first 25 patients and the latter 68 were compared as part of our safety analysis to examine the effect of the learning curve.Aims
Methods
The aim of this study was to report a retrospective, consecutive
series of patients with adolescent idiopathic scoliosis (AIS) who
were treated with posterior minimally invasive surgery (MIS) with
a mean follow-up of two years ( We prospectively collected the data of 70 consecutive patients
with AIS treated with MIS using three incisions and a muscle-splitting
approach by a single surgeon between June 2013 and February 2016
and these were retrospectively reviewed. There were eight male and
62 female patients with a mean age of 15 years (Aims
Patients and Methods
We have observed clinical cases where bone is formed in the overlaying muscle covering surgically created bone defects treated with a hydroxyapatite/calcium sulphate biomaterial. Our objective was to investigate the osteoinductive potential of the biomaterial and to determine if growth factors secreted from local bone cells induce osteoblastic differentiation of muscle cells. We seeded mouse skeletal muscle cells C2C12 on the hydroxyapatite/calcium sulphate biomaterial and the phenotype of the cells was analysed. To mimic surgical conditions with leakage of extra cellular matrix (ECM) proteins and growth factors, we cultured rat bone cells ROS 17/2.8 in a bioreactor and harvested the secreted proteins. The secretome was added to rat muscle cells L6. The phenotype of the muscle cells after treatment with the media was assessed using immunostaining and light microscopy.Objectives
Materials and Methods
Successful management of late presenting hip
dislocation in childhood is judged by the outcome not just at skeletal
maturity but well beyond into adulthood and late middle age. This
review considers different methods of treatment and looks critically
at the handful of studies reporting long-term follow-up after successful
reduction. Cite this article
The Swansea Morriston Achilles Rupture Treatment
(SMART) programme was introduced in 2008. This paper summarises
the outcome of this programme. Patients with a rupture of the Achilles
tendon treated in our unit follow a comprehensive management protocol
that includes a dedicated Achilles clinic, ultrasound examination,
the use of functional orthoses, early weight-bearing, an accelerated
exercise regime and guidelines for return to work and sport. The
choice of conservative or surgical treatment was based on ultrasound
findings. The rate of re-rupture, the outcome using the Achilles Tendon
Total Rupture Score (ATRS) and the Achilles Tendon Repair Score,
(AS), and the complications were recorded. An elementary cost analysis
was also performed. Between 2008 and 2014 a total of 273 patients presented with
an acute rupture 211 of whom were managed conservatively and 62
had surgical repair. There were three
re-ruptures (1.1%). There were 215 men and 58 women with a mean
age of 46.5 years (20 to 86). Functional outcome was satisfactory.
Mean ATRS and AS at four months was 53.0
( The SMART programme resulted in a low rate of re-rupture, a satisfactory
outcome, a reduced rate of surgical intervention and a reduction
in healthcare costs. Cite this article:
Salter innominate osteotomy is an effective reconstructive
procedure for the treatment of developmental dysplasia of the hip
(DDH), but some children have a poor outcome at skeletal maturity.
In order to investigate factors associated with an unfavourable
outcome, we assessed the development of the contralateral hip. We retrospectively
reviewed 46 patients who underwent a unilateral Salter osteotomy
at between five and seven years of age, with a mean follow-up of
10.3 years (7 to 20). The patients were divided into three groups
according to the centre–edge angle (CEA) of the contralateral hip
at skeletal maturity: normal (>
25°, 22 patients), borderline (20°
to 25°, 17 patients) and dysplastic (<
20°, 7 patients). The
CEA of the affected hip was measured pre-operatively, at eight to
nine years of age, at 11 to 12 years of age and at skeletal maturity.
The CEA of the affected hip was significantly smaller in the borderline
and dysplastic groups at 11 and 12 years of age (p = 0.012) and
at skeletal maturity (p = 0.017) than in the normal group. Severin
group III was seen in two (11.8%) and four hips (57.1%) of the borderline
and dysplastic groups, respectively (p <
0.001). Limited individual development of the acetabulum was associated
with an unfavourable outcome following Salter osteotomy. Cite this article:
The aim of this study was to investigate the
incidence of dysplasia in the ‘normal’ contralateral hip in patients
with unilateral developmental dislocation of the hip (DDH) and to
evaluate the long-term prognosis of such hips. A total of 48 patients
(40 girls and eight boys) were treated for late-detected unilateral
DDH between 1958 and 1962. After preliminary skin traction, closed
reduction was achieved at a mean age of 17.8 months (4 to 65) in
all except one patient who needed open reduction. In 25 patients
early derotation femoral osteotomy of the contralateral hip had been
undertaken within three years of reduction, and later surgery in
ten patients. Radiographs taken during childhood and adulthood were
reviewed. The mean age of the patients was 50.9 years (43 to 55)
at the time of the latest radiological review. In all, eight patients (17%) developed dysplasia of the contralateral
hip, defined as a centre-edge (CE) angle <
20° during childhood
or at skeletal maturity. Six of these patients underwent surgery
to improve cover of the femoral head; the dysplasia improved in
two after varus femoral osteotomy and in two after an acetabular
shelf operation. During long-term follow-up the dysplasia deteriorated
to subluxation in two patients (CE angles 4° and 5°, respectively)
who both developed osteoarthritis (OA), and one of these underwent
total hip replacement at the age of 49 years. In conclusion, the long-term prognosis for the contralateral
hip was relatively good, as OA occurred in only two hips (4%) at
a mean follow-up of 50 years. Regular review of the ‘normal’ side
is indicated, and corrective surgery should be undertaken in those
who develop subluxation. Cite this article:
In the absence of patellar resurfacing, we have
previously shown that the use of electrocautery around the margin of
the patella improved the one-year clinical outcome of total knee
replacement (TKR). In this prospective randomised study we compared
the mean 3.7 year (1.1 to 4.2) clinical outcomes of 300 TKRs performed
with and without electrocautery of the patellar rim: this is an
update of a previous report. The overall prevalence of anterior knee
pain was 32% (95% confidence intervals [CI] 26 to 39), and 26% (95%
CI 18 to 35) in the intervention group compared with 38% (95% CI
29 to 48) in the control group (chi-squared test; p = 0.06). The
overall prevalence of anterior knee pain remained unchanged between
the one-year and 3.7 year follow-up (chi-squared test; p = 0.12). The
mean total Western Ontario McMasters Universities Osteoarthritis
Indices and the American Knee Society knee and function scores at
3.7 years’ follow-up were similar in the intervention and control
groups (repeated measures analysis of variance p = 0.43, p = 0.09
and p = 0.59, respectively). There were no complications. A total
of ten patients (intervention group three, control group seven)
required secondary patellar resurfacing after the first year. Our study suggests that the improved clinical outcome with electrocautery
denervation compared with no electrocautery is not maintained at
a mean of 3.7 years’ follow-up. Cite this article:
We have investigated whether early anatomical open reduction and internal fixation (ORIF) reduces the incidence of complications of fracture of the femoral neck in children, including avascular necrosis, compared with closed reduction and internal fixation (CRIF). We retrospectively reviewed 27 such fractures (15 type-II and 12 type-III displaced fractures) in children younger than 16 years of age seen in our hospital between February 1989 and March 2007. We divided the patients into three groups according to the quality of the reduction (anatomical, acceptable, and unacceptable) and the clinical results into two groups (satisfactory and unsatisfactory). Of the 15 fractures treated by ORIF, 14 (93.3%) had anatomical reduction and reduction was acceptable in one. Of the 12 treated by CRIF, three (25.0%) had anatomical reduction, eight had acceptable reduction (66.7%), and one (8.3%) unacceptable reduction. Of the 15 fractures treated by ORIF, 14 (93.3%) had a good result and one a fair result. Of the 12 treated by CRIF, seven (58.3%) had a good result, two (16.7%) a fair result and three (25.0%) a poor result. There were seven complications in five patients. ORIF gives better reduction with fewer complications, including avascular necrosis, than does CRIF in fractures of the femoral neck in children.
This review explores recent advances in fixator design and used in contemporary orthopaedic practice including the management of bone loss, complex deformity and severe isolated limb injury.
Malunion is the most common complication of the
distal radius with many modalities of treatment available for such
a problem. The use of bone grafting after an osteotomy is still
recommended by most authors. We hypothesised that bone grafting
is not required; fixing the corrected construct with a volar locked
plate helps maintain the alignment, while metaphyseal defect fills
by itself. Prospectively, we performed the procedure on 30 malunited
dorsally-angulated radii using fixed angle volar locked plates without
bone grafting. At the final follow-up, 22 wrists were available.
Radiological evidence of union, correction of the deformity, clinical
and functional improvement was achieved in all cases. Without the
use of bone grafting, corrective open wedge osteotomy fixed by a
volar locked plate provides a high rate of union and satisfactory
functional outcomes.
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.
There is no absolute method of evaluating healing
of a fracture of the tibial shaft. In this study we sought to validate a
new clinical method based on the systematic observation of gait,
first by assessing the degree of agreement between three independent
observers regarding the gait score for a given patient, and secondly
by determining how such a score might predict healing of a fracture. We used a method of evaluating gait to assess 33 patients (29
men and four women, with a mean age of 29 years (15 to 62)) who
had sustained an isolated fracture of the tibial shaft and had been
treated with a locked intramedullary nail. There were 15 closed
and 18 open fractures (three Gustilo and Anderson grade I, seven
grade II, seven grade IIIA and one grade IIIB). Assessment was carried
out three and six months post-operatively using videos taken with
a digital camera. Gait was graded on a scale ranging from 1 (extreme
difficulty) to 4 (normal gait). Bivariate analysis included analysis
of variance to determine whether the gait score statistically correlated
with previously validated and standardised scores of clinical status
and radiological evidence of union. An association was found between the pattern of gait and all
the other variables. Improvement in gait was associated with the
absence of pain on weight-bearing, reduced tenderness over the fracture,
a higher Radiographic Union Scale in Tibial Fractures score, and
improved functional status, measured using the Brazilian version
of the Short Musculoskeletal Function Assessment questionnaire (all
p <
0.001). Although further study is needed, the analysis of
gait in this way may prove to be a useful clinical tool.
Lengthening of the humerus is now an established
technique. We compared the complications of humeral lengthening
with those of femoral lengthening and investigated whether or not
the callus formation in the humerus proceeds at a higher rate than
that in the femur. A total of 24 humeral and 24 femoral lengthenings
were performed on 12 patients with achondroplasia. We measured the
pixel value ratio (PVR) of the lengthened area on radiographs and
each radiograph was analysed for the shape, type and density of
the callus. The quality of life (QOL) of the patients after humeral
lengthening was compared with that prior to surgery. The complication
rate per segment of humerus and femur was 0.87% and 1.37%, respectively.
In the humerus the PVR was significantly higher than that of the
femur. Lower limbs were associated with an increased incidence of
concave, lateral and central callus shapes. Humeral lengthening
had a lower complication rate than lower-limb lengthening, and QOL
increased significantly after humeral lengthening. Callus formation
in the humerus during the distraction period proceeded at a significantly
higher rate than that in the femur. These findings indicate that humeral lengthening has an important
role in the management of patients with achondroplasia.
Although bone and soft-tissue sarcomas are rare, early diagnosis and prompt referral to a specialised unit offers the best chance of a successful outcome both in terms of survival and surgical resection. This paper highlights the clinical and radiological features that might suggest the possibility of a bone or soft-tissue sarcoma and suggests a succinct management pathway for establishing whether a suspicious bone or soft-tissue lesion could be malignant.
Two-stage revision surgery for infected total knee replacement offers the highest rate of success for the elimination of infection. The use of articulating antibiotic-laden cement spacers during the first stage to eradicate infection also allows protection of the soft tissues against excessive scarring and stiffness. We have investigated the effect of cyclical loading of cement spacers on the elution of antibiotics. Femoral and tibial spacers containing vancomycin at a constant concentration and tobramycin of varying concentrations were studied The elution of tobramycin increased proportionately with its concentration in cement and was significantly higher at all sampling times from five minutes to 1680 minutes in loaded components compared with the control group (p = 0.021 and p = 0.003, respectively). A similar trend was observed with elution of vancomycin, but this failed to reach statistical significance at five, 1320 and 1560 minutes (p = 0.0508, p = 0.067 and p = 0.347, respectively). However, cyclically loaded and control components showed an increased elution of vancomycin with increasing tobramycin concentration in the specimens, despite all components having the same vancomycin concentration. The concentration of tobramycin influences both tobramycin and vancomycin elution from bone cement. Cyclical loading of the cement spacers enhanced the elution of vancomycin and tobramycin.
Extensive limb lengthening may be indicated in achondroplastic patients who wish to achieve a height within the normal range for their population. However, increasing the magnitude of lengthening is associated with further complications particularly adjacent joint stiffness and fractures. We studied the relationship between the magnitude of femoral lengthening and callus pattern, adjacent joint stiffness and fracture of the regenerate bone in 40 femoral lengthenings in 20 achondroplastic patients. They were divided into two groups; group A had lengthening of less than 50% and group B of more than 50% of their initial femoral length. The patterns of radiological callus formation were classified according to shape, type and features. The incidence of callus features, knee stiffness and regenerate bone fracture were analysed in the two groups. Group B was associated with an increased incidence of concave, lateral and central callus shapes, adjacent joint and stiffness and fracture. Statistically, the incidence of stiffness in adjacent joints and regenerate bone fracture was significantly associated with the magnitude of lengthening. We suggest that careful radiological assessment of the patterns of callus formation is a useful method for the evaluation and monitoring of regenerate bone.
The aim of this study was to determine the functional outcome and rate of re-tears following mini-open repair of symptomatic large and massive tears of the rotator cuff using a two-row technique. The 24 patients included in the study were assessed prospectively before and at a mean of 27 months (18 to 53) after surgery using the Constant and the Oxford Shoulder scores. Ultrasound examination was carried out at follow-up to determine the integrity of the repair. Patient satisfaction was assessed using a simple questionnaire. The mean Constant score improved significantly from 36 before to 68 after operation (p <
0.0001) and the mean Oxford Shoulder score from 39 to 20 (p <
0.0001). Four of the 24 patients (17%) had a re-tear diagnosed by ultrasound. A total of 21 patients (87.5%) were satisfied with the outcome of their surgery. The repair remained intact in 20 patients (83%). However, the small number of re-tears (four patients) in the study did not allow sufficient analysis to show a difference in outcome in relation to the integrity of the repair.
Multiple drilling is reported to be an effective treatment for osteonecrosis of the head of femur, but its effect on intra-osseous pressure has not been described. We undertook multiple drilling and recorded the intra-osseous pressure in 75 osteonecrotic hips in 60 patients with a mean age of 42 years (19 to 67). At a mean follow-up of 37.1 months (24 to 60), 42 hips (56%) had a clinically successful outcome. The procedure was effective in reducing the mean intra-osseous pressure from 57 mmHg (SD 22) to 16 mmHg (SD 9). Hips with a successful outcome had a mean pressure of 26 mmHg (SD 19). It was less effective in preventing progression of osteonecrosis in hips with considerable involvement and in those with a high intra-osseous pressure in the intertrochanteric region (mean 45 mmHg (SD 25)). This study is not able to answer whether a return of the intra-osseous pressure to normal levels is required for satisfactory healing.
Bone allografts can be used in any kind of surgery involving bone from minor defects to major bone loss after tumour resection. This review describes the various types of bone grafts and the current knowledge on bone allografts, from procurement and preparation to implantation. The surgical conditions for optimising the incorporation of bone are outlined, and surgeon expectations from a bone allograft discussed.
This study prospectively compared the efficacy of kyphoplasty using a Jack vertebral dilator and balloon kyphoplasty to treat osteoporotic compression fractures between T10 and L5. Between 2004 and 2009, two groups of 55 patients each underwent vertebral dilator kyphoplasty and balloon kyphoplasty, respectively. Pain, function, the Cobb angle, and the anterior and middle height of the vertebral body were assessed before and after operation. Leakage of bone cement was recorded. The post-operative change in the Cobb angle was significantly greater in the dilator kyphoplasty group than in the balloon kyphoplasty group (−9.51° ( These findings suggest that vertebral dilator kyphoplasty can facilitate better correction of kyphotic deformity and may ultimately be a safer procedure in reducing leakage of bone cement.