Aims

The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used.

Purpose of study and background

Psychological factors are considered to play a role in development and maintenance of chronic low back pain (CLBP). Stress or anxiety can change pain sensitivity; however, this has predominantly been studied in healthy individuals with limited work in individuals with musculoskeletal pain. The objective of this study was to quantify the effect of acute exposure to a psychosocial stressor on mechanical pain sensitivity in individuals with and without CLBP.

Recurrent anterior shoulder instability (RASI) is related to progressive bone loss on the glenoid and on the humeral head. Bone deficit magnitude is a well-recognized predictor of recurrence of instability after an arthroscopic Bankart surgery, but the best way to measure it is unknown. In this study, we want to determine which measurement method is the best predictor of recurrence of instability and function.

For 10 years now, all patients undergoing surgery for RASI in 4 centers are included in a prospective study: the LUXE cohort. Patients with a pre-operative CT-scan and a minimum of 1-year follow-up were included. ISIS score was used to stratify patients. WOSI and Quick-Dash questionnaires were used to characterise function. Bone defects were assessed using the Clock method, the Glenoid Ratio, the Humeral Ratio, the Glenoid Track method and the angle of engagement in the axial plane.

A total of 262 patients are now included in the LUXE study. One hundred and three patients met the inclusion criteria for analysis with a majority of male (79%) and a mean age is 28 years old. The median number of dislocations prior to surgery was 6. Seventy patients had an arthroscopic Bankart repair and 33 patients underwent an open Latarjet procedure. The ISIS score for these groups were of 2.7 and 4.8 respectively (p<0.001). The mean bone defect on the glenoid was of 1h51 with the Clock method (range: 0h-4h48; SD=1h46) and of 9% for the glenoid ratio (0–37%, 10%). On the humeral side, the bone defect was of 1h59 (0h-4h08; 0h49) for the Humeral clock method, 15% (0–36%; 6%) with the ratio method and 71 degrees of external rotation (SD=30 degrees) with the angle of engagement measurement. On the combined evaluations, 53 patients presented an off-track lesion, with mean combined hours of 3h53 (SD= 2h13). The greatest correlation obtained was between the glenoid ratio and the glenoid clock method (r=0.919, p<0.001). Eighteen patients had a recurrence of shoulder dislocation after the initial surgery, leading to a recurrence rate of 23% in arthroscopic surgery versus six percent after a Latarjet (OR= 4.6, p=0.034). No bone defect was correlated to Latarjet failure. For the arthroscopic group, the risk of recurrence was related to a smaller angle of engagement of the Hill-Sachs (p=0.05), a smaller Humeral clock measurement (p=0.034) and a longer follow-up (p=0.006). No glenoid or combined measurements were correlated with arthroscopic procedure failure. Recurrence of dislocation was associated to worst function according to the WOSI (1036 vs 573, p=0.002) and DASH (32 vs 15, p=0.03).

Even with lower ISIS score, arthroscopic procedures are still leading to high risk of recurrence in this “all comer” consecutive cohort study AND it is related to humeral side parameters. Recurrence is also affecting daily function and creating higher anxiety related to the shoulder.

Radial head fractures are relatively common, representing approximately one-third of all elbow fractures. Outcomes are generally inversely proportional to the amount of force involved in the mechanism of injury, with simple fractures doing better than more comminuted ones. However, the prognosis for these fractures may also be influenced by associated injuries and patient-related factors (age, body index mass, gender, tobacco habit, etc.) The purpose of this study is to evaluate which factors will affect range of motion and function in partial radial head fractures. The hypothesis is that conservative treatment yields better outcomes.

This retrospective comparative cohort study included 43 adult volunteers with partial radial head fracture, a minimum one-year follow up, separated into a surgical and non-surgical group. Risk factors were: associated injury, heterotopic ossification, worker's compensation, and proximal radio-ulnar joint implication. Outcomes included radiographic range of motion measurement, demographic data, and quality of life questionnaires (PREE, Q-DASH, MEPS).

Mean follow up was 3.5 years (1–7 years). Thirty patients (70%) had associated injuries with decreased elbow extension (−11°, p=0.004) and total range of motion (−14°, p=0.002) compared to the other group. Heterotopic ossification was associated with decreased elbow flexion (−9°, p=0.001) and fractures involved the proximal radio-ulnar joint in 88% of patients. Only worker's compensation was associated with worse scores. There was no difference in terms of function and outcome between patients treated nonsurgically or surgically.

We found that associated injuries, worker's compensation and the presence of heterotopic ossification were the only factors correlated with a worse prognosis in this cohort of patients. Given these results, the authors reiterate the importance of being vigilant to associated injuries.

Reoperations may be a better way of tracking adverse outcomes than complications. Repeat surgery causes cost to the system, and often indicate failure of the primary procedure resulting in the patient not achieving the expected improvement in pain and function. Understanding the cause of repeat surgery at the primary site may result in design improvements to implants or improvements to fusion techniques resulting in better outcomes in the future. The COFAS group have designed a reoperation classification system. The purpose of this study was to outline the inter and intra observer reliability of this classification scheme.

To verify the inter- and intra-observer reliability of this new coding system, six fellow ship trained practicing foot and ankle Orthopaedic surgeons were asked to classify 62 repeat surgeries from a single surgeons practice. The six surgeons read the operation reports in random order, and reread the reports 2 weeks later in a different order. Reliability was determined using intraclass correlation coefficients (ICC) and proportions of agreement. The agreement between pairs of readings (915 for inter observer for the first and second read – 61 readings with 15 comparisons, observer 1 with observer 2, observer 1 with observer 3, etc) was determined by seeing how often each observer agreed. This was repeated for the 366 ratings for intra observer readings (61 times 6).

The inter-observer reliability on the first read had a mean intra-class correlation coefficient (ICC) of 0.89. The range for the 15 comparisons was 0.81 to 1.0. Amongst all 1830 paired codings between two observers, 1605 (88%) were in agreement. Across the 61 cases, 45 (74%) were given the same code by all six observers. However, the difference when present was larger with more observers not agreeing. The inter-observer reliability test on the second read had a mean ICC of 0.94, with a range of 0.90. There were 43 (72%) observations that were the same across all six observers. Of all pairs (915 in total) there was agreement in 804 pairs for the first reading (88%) and disagreement in 111 (12%). For the second reading there was agreement in 801 pairs (86%) and disagreement in 114 (14%). The intra-observer reliability averaged an ICC value of 0.92, with a range of 0.86 to 0.98. The observers agreed with their own previous observations 324 times out of 366 paired readings (89% agreement of pairs).

The COFAS classification of reoperations for end stage ankle arthritis was reliable. This scheme potentially could be applied to other areas of Orthopaedic surgery and should replace the Claiden Dindo modifications that do not accurately reflect Orthopaedic outcomes. As complications are hard to define and lack consistent terminology reoperations and resource utilisation (extra clinic visits, extra days in hospital and extra hours of surgery) may be more reliable measures of the negative effects of surgery.

Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO.

The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome.

Cite this article: Bone Joint J 2013;95-B:95–100.

Background

Vitamin D deficiency may increase predisposition to a number of paediatric orthopaedic conditions and the prevalence of vitamin D deficiency is increasing in children in developed countries. The aim of this study was to determine the epidemiology of vitamin D deficiency and insufficiency in children presenting to a regional paediatric orthopaedic service. We also examined the relationships between vitamin D status, social deprivation and ethnicity

Introduction

Articular hyaline cartilage has a unique structural composition that allows it to endure high load, distribute load to bone and enables low friction movement in joints. A novel acellular xenogenic graft is proposed as a biological cartilage replacement, for repair of osteochondral defects. Acellular porcine cartilage has been produced using repeated freeze thaw cycles and washing using hypotonic buffers and sodium dodecyl sulphate solution (SDS; Keir, 2008). DNA content of the acellular matrix was reduced by 93.3% compared to native cartilage as measured by nanodrop spectrophotometry of extracted DNA, with a corresponding reduction in glycosaminoglycan (GAG) content.

Purpose This was an observational study to determine the prevalence of 25-hydroxyvitamin D (25[OH]D deficiency in our paediatric orthopaedic patient population.

Methods We have measured serum 25(OH)D levels in 44 paediatric patients who presented with bone pain. None of these patients had a pre-existing diagnosis of 25(OH)D deficiency. The age of patients ranged from 11 months to 16.5 years. There were 23 female and 21 male patients. The range of diagnoses included hip pain/irritable hip (4), Blount's disease (4), developmental hip dysplasia (7), genu valgum (3), Legg Calve Perthes’ disease (6), slipped capital femoral epiphysis (11), knee pain (3), other (6).

Those found to be 25(OH)D deficient underwent further biochemical investigation and were referred for paediatric endocrinology review with a view to vitamin D supplementation.

Results We found 9 patients (20%) with serum 25(OH)D levels of <20ng/mL indicating 25(OH)D deficiency. 17 patients (39%) had serum 25(OH)D levels in the range 20-30ng/mL indicating possible deficiency. The remaining 18 patients (41%) had a normal level of 25(OH)D. There was no association between low serum 25(OH)D level and any specific diagnosis, nor with gender or age of patient. There was, however, a statistically significant difference between the serum 25(OH)D level in those patients with unexplained joint pain (mean 22.5ng/mL) and those with other diagnoses (mean 30.7ng/ml) (P<0.05).

Conclusion Our results are consistent with other recent prevalence studies showing a concerning level of 25(OH)D deficiency among the paediatric population, and may suggest an increasing burden of disease in the coming years arising from the problem.

Purpose: The age of patients presenting with acetabular fracture has increased over the last ten years. Older patients tend to have patterns involving the anterior column with comminution of the quadrilateral plate. Our goal was to investigate the appropriateness of open reduction and internal fixation using the modified Stoppa approach for geriatric acetabular fractures.

Method: A retrospective review of patients over the age of 60 having presented to an academic level I trauma center over the course of four years. Twenty patients were identified and treated using the modified Stoppa approach with plating of the quadrilateral surface. Patients were evaluated clinically using both SF-36 and Harris Hip Score. Records and radiographs (using criteria described by Matta) were reviewed retrospectively.

Results: All patients were followed for a minimum of two years with no lost at follow-up. Mean age for patients at time of intervention was 68 years. Average blood lost was 800cc and surgical time was 130 minutes (range, 55–210). There was one traumatic injury to the obturator nerve and two patients were noted to have temporary weakness of the hip adductors postoperatively. Average Harris Hip Score and the SF-36 were improved significantly (p< 0.05). Significant lost of reduction was seen in two patients and was correlated to superior dome impaction (p < 0.0001). Three patients required re-intervention with a Total Hip Arthroplasty.

Conclusion: Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures of the anterior column in the elderly.

Objectives: It is common for breast surgeons to excise impalpable tumours and fine-wire localisation is commonly deployed by breast radiologists to facilitate such surgery. Pre-operative localisation can be achieved using conventional ultrasound but this necessitates co-ordination with the radiology department.

Methods: We have utilised the SonoSite (SonoSite Inc, Bothell, WA) portable ultrasound system available widely in operating theatres for insertion of vascular lines and perineural catheters, for localisation of deep impalpable tumours.

Results: Two patients who had undergone mid-forearm amputations for synovial sarcoma are presented. The first presented with axillary recurrence of his tumour. MRI scanning of his stump revealed two lesions suspicious of recurrence. Both were impalpable initially. The lesions were identified using the SonoSite and excision biopsy performed. Histologically the lesions were neuromata. The second patient had imaging in keeping with neuromata and again the Sonosite was utilised to detect the lesions and facilitate removal.

Discussion: Sonosite portable ultrasound machines are readily available in the operating theatre and may be utilised to aid removal of tumours. They do not replace other imaging but can make surgery less traumatic in that smaller incisions may be used.

Introduction: This study investigates whether the choose and book system satisfies the priorities of the local community and considers its implications for local elective primary lower limb arthroplasty.

Patients are offered a choice of 4 hospitals and time and date of outpatient appointment on referral from their GP practice. Research revealed that people want choice. Can popular centres still provide a service for the local population? What are the priorities of the local population when choosing a healthcare provider?

Method: A qualitative questionnaire was given to 100 people from the local community who were referred from their GP for a primary lower limb arthroplasty. This assessed patient’s opinions and priorities.

Results: 98% of patients wanted to choose their healthcare provider, 88% would not be content in any hospital other than their first choice

94% would not change hospitals if offered a shorter waiting time

Discussion: This study clearly indicates the local community want choice on referral for primary arthroplasty, but where they are operated is more important than when. The clinical quality of the provider is more important than the waiting time.

The government state patients want to choose the time and date of their first clinic appointment, however the majority of our population don’t.

The current ‘Choose and Book’ system does not fulfil patient’s priorities.

Purpose of study: ALL is the commonest childhood malignancy and current survival rates reach 80%. Consequently adverse effects of therapy may have significant long-term implications. Treatment is risk stratified with the higher intensity regimens B and C receiving more Dexamethasone and Methotrexate, both of which are known to have significant bony effects. The skeletal morbidity associated with ALL and its treatment, particularly AVN, is being increasingly identified. AVN is rare in paediatric practice. Its pathophysiology is largely unknown, although it is probably related to corticosteroid use.

Method: The records of a series of 7 out of 53 children treated with chemotherapy for ALL as per MRC ALL 99/01 and ALL 2003 protocols in a single tertiary paediatric oncology centre were reviewed. All 7 cases (3 male) had MRI confirmation of AVN (2 normal x-rays). All cases had been treated on higher intensity chemotherapy regimens and were at least 6 months from commencement of anti-leukaemic therapy. All presented with transient limb pain.

Results: The AVN was multi-focal (median 4 sites) and was associated with significant other bony abnormalities, including joint collapse, fracture, osteomyelitis and septic arthritis. In this series the dose of steroids did not correlate with the severity of the AVN. Treatment options were limited with all cases receiving conservative treatment

Conclusions: Careful consideration must precede a recommendation to stop steroids as this may compromise leukaemic cure. Although the long-term consequences of AVN on bone health are unknown, we recommend a high index of suspicion in professionals who are treating these children to ensure prompt diagnosis.

Introduction: Hip fractures are usually evident on plain radiographs. Some are not obvious and require further investigation. A review of the pertinent literature reveals different treatment algorithms for such patients but MRI is recommended as the investigation of choice. Little is stated about the clinical findings in patients with an occult fracture of the hip.

Aims: To investigate any correlation between clinical findings and the presence of fracture on MRI in occult fracture of the hip and use this as a means of speeding the diagnosis of such patients.

Methods: We report a prospective, multi-centre trial. 22 patients admitted with a suspected occult fracture of the hip were assessed clinically for evidence of resting deformity, ecchymosis, point tenderness, hip pain on heel percussion or pistoning and ability to straight leg raise (SLR). The same features were assessed in the contralateral limb. All patients were alert and orientated as to comply with examination. Plain radiograph and MRI findings of both hips were recorded in each case.

Results: Of 22 patients, 17 were unable to perform SLR on the affected side, 5 were able to do so. Of the 18 patients, all had a fracture of either the acetabulum or proximal femur on MRI. Of the group of 5, 2 had normal MRI scans, 1 had a pubic ramus fracture, 1 had bone marrow oedema secondary to osteoarthritis and 1 patient had a six week old valgus impaction fracture. All patients could SLR and had normal MRI of the contralateral hip.

Conclusions: Under the conditions of this study straight leg raise test is 95% sensitive and 95% specific for predicting the presence of fracture in either the acetabulum or proximal femur. We recommend that this simple test can be used to help speed up the diagnosis of and further management of occult fractures of the hip

Heterotopic Ossification (HO) is a common finding in the radiographs of patients who have had total hip replacement surgery (42–57%). HO is responsible for pain and limitation of postoperative motion in 3–10% of these patients. This study was initiated to find out if pulsed lavage affected the incidence of HO.

A prospective randomised double-blind trial was initiated consisting of 115 primary total hip arthroplasties. Intra-operative irrigation was provided by a 50 ml syringe and limited to 500 ml of room-temperature normal saline or pulsed lavage with three litres of room-temperature normal saline. The grade of HO at one year was classified according to Brooker et al. Statistical analysis of the results was made using the chi-squared test and the Kruskal-Wallis test.

The incidence of HO in this group of primary total hip arthroplasties was 57. 4%. The majority of cases with HO were graded 1 or 2 (42. 6%). No statistical significance was found to exist between the two methods of irrigation in relation to HO (chi-squared p value = 0. 456). From an analysis of the known risk factors for HO, only the type of osteoarthritis was shown to statistically influence the incidence of HO.

The process of HO is thought to be as a result of the differentiation of mesenchymal cells into osteoprogenitor cells. Theories have proposed that the inducing agent and/or the mesenchymal cells arise from bone at the time of the operation, although systemic agents have also been proposed. If the inducing agent or precursor cells were released from the bone intraoperatively, thorough irrigation could be expected to have an association with a lower incidence of HO. The lack of correlation between irrigation and incidence of HO indicates this is unlikely to be the mechanism.

We have tested the porosity and fatigue life of five commonly used bone cements: Simplex P, LVC, Zimmer regular, CMW and Palacos R. Tests were conducted with and without centrifugation and with the monomer at room temperature and, except for LVC, at 0 degrees C. We found that the fatigue life of different specimens varied by a factor of nearly 100. It did not depend on porosity alone, but was more influenced by the basic composition of the cement. Simplex P when mixed with monomer at 0 degrees C and centrifuged for 60 seconds had the highest fatigue life and was still sufficiently liquid to use easily.

Experimental evidence has accumulated in recent years to suggest that scoliosis can be caused by asymmetrical spinal muscle weakness due to sensorineural loss, though this suggestion has not achieved universal acceptance. The evidence is supported by histopathological observations on cases of clinical idiopathic scoliosis. A study is presented in which cynomolgus monkeys had one, two or three dorsal spinal nerve roots cut. Scoliosis developed, convex to the damaged side; its severity was dependent on the number of nerve roots cut. Section of the first lumbar dorsal spinal nerve root had a marked tendency to cause scoliosis. The study supports the view that scoliosis may be caused by asymmetrical paraspinal muscle weakness acting through loss of proprioception.