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This review is aimed at clinicians appraising
preclinical trauma studies and researchers investigating compromised bone
healing or novel treatments for fractures. It categorises the clinical
scenarios of poor healing of fractures and attempts to match them
with the appropriate animal models in the literature. We performed an extensive literature search of animal models
of long bone fracture repair/nonunion and grouped the resulting
studies according to the clinical scenario they were attempting
to reflect; we then scrutinised them for their reliability and accuracy
in reproducing that clinical scenario. Models for normal fracture repair (primary and secondary), delayed
union, nonunion (atrophic and hypertrophic), segmental defects and
fractures at risk of impaired healing were identified. Their accuracy
in reflecting the clinical scenario ranged greatly and the reliability
of reproducing the scenario ranged from 100% to 40%. It is vital to know the limitations and success of each model
when considering its application.
This review summarises the opinions and conclusions
reached from a symposium on infected total knee replacement (TKR)
held at the British Association of Surgery of the Knee (BASK) annual
meeting in 2011. The National Joint Registry for England and Wales
reported 5082 revision TKRs in 2010, of which 1157 (23%) were caused
by infection. The diagnosis of infection beyond the acute post-operative
stage relies on the identification of the causative organism by
aspiration and analysis of material obtained at arthroscopy. Ideal
treatment then involves a two-stage surgical procedure with extensive
debridement and washout, followed by antibiotics. An articulating
or non-articulating drug-eluting cement spacer is used prior to
implantation of the revision prosthesis, guided by the serum level
of inflammatory markers. The use of a single-stage revision is gaining popularity
and we would advocate its use in certain patients where the causative
organism is known, no sinuses are present, the patient is not immunocompromised,
and there is no radiological evidence of component loosening or
osteitis. It is our opinion that single-stage revision produces high-quality
reproducible results and will soon achieve the same widespread acceptance
as it does in infected hip arthroplasty.
Giant cell tumours (GCT) of the synovium and
tendon sheath can be classified into two forms: localised (giant
cell tumour of the tendon sheath, or nodular tenosynovitis) and
diffuse (diffuse-type giant cell tumour or pigmented villonodular
synovitis). The former principally affects the small joints. It
presents as a solitary slow-growing tumour with a characteristic
appearance on MRI and is treated by surgical excision. There is
a significant risk of multiple recurrences with aggressive diffuse
disease. A multidisciplinary approach with dedicated MRI, histological assessment
and planned surgery with either adjuvant radiotherapy or systemic
targeted therapy is required to improve outcomes in recurrent and
refractory diffuse-type GCT. Although arthroscopic synovectomy through several portals has
been advocated as an alternative to arthrotomy, there is a significant
risk of inadequate excision and recurrence, particularly in the
posterior compartment of the knee. For local disease partial arthroscopic
synovectomy may be sufficient, at the risk of recurrence. For both
local and diffuse intra-articular disease open surgery is advised
for recurrent disease. Marginal excision with focal disease will
suffice, not dissimilar to the treatment of GCT of tendon sheath.
For recurrent and extra-articular soft-tissue disease adjuvant therapy,
including intra-articular radioactive colloid or moderate-dose external
beam radiotherapy, should be considered.
We prospectively followed 191 consecutive collarless
polished tapered (CPT) femoral stems, implanted in 175 patients
who had a mean age at operation of 64.5 years (21 to 85). At a mean
follow-up of 15.9 years (14 to 17.5), 86 patients (95 hips) were
still alive. The fate of all original stems is known. The 16-year
survivorship with re-operation for any reason was 80.7% (95% confidence
interval 72 to 89.4). There was no loss to follow-up, with clinical
data available on all 95 hips and radiological assessment performed
on 90 hips (95%). At latest follow-up, the mean Harris hip score
was 78 (28 to 100) and the mean Oxford hip score was 36 (15 to 48).
Stems subsided within the cement mantle, with a mean subsidence
of 2.1 mm (0.4 to 19.2). Among the original cohort, only one stem
(0.5%) has been revised due to aseptic loosening. In total seven
stems were revised for any cause, of which four revisions were required
for infection following revision of the acetabular component. A
total of 21 patients (11%) required some sort of revision procedure;
all except three of these resulted from failure of the acetabular
component. Cemented acetabular components had a significantly lower
revision burden (three hips, 2.7%) than Harris Galante uncemented
components (17 hips, 21.8%) (p <
0.001). The CPT stem continues to provide excellent radiological and
clinical outcomes at 15 years following implantation. Its results
are consistent with other polished tapered stem designs.
We present a series of 35 patients (19 men and
16 women) with a mean age of 64 years (36.7 to 75.9), who underwent
total hip replacement using the ESKA dual-modular short stem with
metal on-polyethylene bearing surfaces. This implant has a modular
neck section in addition to the modular head. Of these patients,
three presented with increasing post-operative pain due to pseudotumour
formation that resulted from corrosion at the modular neck-stem
junction. These patients underwent further surgery and aseptic lymphocytic
vaculitis associated lesions were demonstrated on histological analysis. Retrieval analysis of two modular necks showed corrosion at the
neck-stem taper. Blood cobalt and chromium levels were measured
at a mean of nine months (3 to 28) following surgery. These were
compared with the levels in seven control patients (three men and
four women) with a mean age of 53.4 years (32.1 to 64.1), who had
an identical prosthesis and articulation but with a prosthesis that
had no modularity at neck-stem junction. The mean blood levels of
cobalt in the study group were raised at 50.75 nmol/l (5 to 145)
compared with 5.6 nmol/l (2 to 13) in control patients. Corrosion at neck-stem tapers has been identified as an important
source of metal ion release and pseudotumour formation requiring
revision surgery. Finite element modelling of the dual modular stem
demonstrated high stresses at the modular stem-neck junction. Dual
modular cobalt-chrome hip prostheses should be used with caution
due to these concerns.
We analysed 54 alumina ceramic-on-ceramic bearings
from total hip replacements retrieved at one centre after a mean
duration of 3.5 years (0.2 to 10.6)
Peri-prosthetic patellar fracture following resurfacing
as part of total knee replacement (TKR) is an infrequent yet challenging
complication. This case-control study was performed to identify
clinical, radiological and surgical factors that increase the risk
of developing a spontaneous patellar fracture after TKR. Patellar
fractures were identified in 74 patients (88 knees) from a series
of 7866 consecutive TKRs conducted between 1998 and 2009. After excluding
those with a previous history of extensor mechanism realignment
or a clear traumatic event, a metal-backed patella, any uncemented
component or subsequent infection, the remaining 64 fractures were
compared with a matched group of TKRs with an excellent outcome
defined by the Knee Society score. The mean age of patients with
a fracture was 70 years (51 to 81) at the time of TKR. Patellar
fractures were detected at a mean of 13.4 months (2 to 84) after
surgery. The incidence of patellar fracture was found to be strongly
associated with the number of previous knee operations, greater
pre-operative mechanical malalignment, smaller post-operative patellar
tendon length, thinner post-resection patellar thickness, and a
lower post-operative Insall-Salvati ratio. An understanding of the risk factors associated with spontaneous
patellar fracture following TKR provides a valuable insight into
prevention of this challenging complication.
We compared thromboembolic events, major haemorrhage
and death after knee replacement in patients receiving either aspirin
or low-molecular-weight heparin (LMWH). Data from the National Joint
Registry for England and Wales were linked to an administrative
database of hospital admissions in the English National Health Service.
A total of 156 798 patients between April 2003 and September 2008
were included and followed for 90 days. Multivariable risk modelling
was used to estimate odds ratios adjusted for baseline risk factors
(AOR). An AOR <
1 indicates that risk rates are lower with LMWH
than with aspirin. In all, 36 159 patients (23.1%) were prescribed aspirin
and 120 639 patients (76.9%) were prescribed LMWH. We found no statistically
significant differences between the aspirin and LMWH groups in the
rate of pulmonary embolism (0.49% These results should be considered when the existing guidelines
for thromboprophylaxis after knee replacement are reviewed.
Following arthroplasty of the knee, the patient’s
perception of improvement in symptoms is fundamental to the assessment
of outcome. Better clinical outcome may offset the inferior survival
observed for some types of implant. By examining linked National
Joint Registry (NJR) and patient-reported outcome measures (PROMs)
data, we aimed to compare PROMs collected at a minimum of six months
post-operatively for total (TKR: n = 23 393) and unicondylar knee
replacements (UKR: n = 505). Improvements in knee-specific (Oxford
knee score, OKS) and generic (EuroQol, EQ-5D) scores were compared
and adjusted for case-mix differences using multiple regression.
Whereas the improvements in the OKS and EQ-5D were significantly
greater for TKR than for UKR, once adjustments were made for case-mix
differences and pre-operative score, the improvements in the two
scores were not significantly different. The adjusted mean differences
in the improvement of OKS and EQ-5D were 0.0 (95% confidence interval (CI)
-0.9 to 0.9; p = 0.96) and 0.009 (95% CI -0.034 to 0.015; p = 0.37),
respectively. We found no difference in the improvement of either knee-specific
or general health outcomes between TKR and UKR in a large cohort
of registry patients. With concerns about significantly higher revision
rates for UKR observed in worldwide registries, we question the
widespread use of an arthroplasty that does not confer a significant
benefit in clinical outcome.
We report the ten-year survival of a cemented
total knee replacement (TKR) in patients aged <
55 years at the
time of surgery, and compare the functional outcome with that of
patients aged >
55 years. The data were collected prospectively
and analysed using Kaplan-Meier survival statistics, with revision
for any reason, or death, as the endpoint. A total of 203 patients
aged <
55 years were identified. Four had moved out of the area
and were excluded, leaving a total of 221 TKRs in 199 patients for
analysis (101 men and 98 women, mean age 50.6 years (28 to 55));
171 patients had osteoarthritis and 28 had inflammatory arthritis.
Four patients required revision and four died. The ten-year survival
using revision as the endpoint was 98.2% (95% confidence interval
94.6 to 99.4). Based on the Oxford knee scores at five and ten years,
the rate of dissatisfaction was 18% and 21%, respectively. This
was no worse in the patients aged <
55 years than in patients
aged >
55 years. These results demonstrate that the cemented PFC Sigma knee has
an excellent survival rate in patients aged <
55 ten years post-operatively,
with clinical outcomes similar to those of an older group. We conclude
that TKR should not be withheld from patients on the basis of age.
Tranexamic acid (TEA), an inhibitor of fibrinolysis,
reduces blood loss after routine total knee replacement (TKR). However,
controversy persists regarding the dosage and timing of administration
of this drug during surgery. We performed a prospective randomised
controlled study to examine the optimum blood-saving effect of TEA
in minimally invasive TKR. We randomly assigned 151 patients who underwent unilateral minimally
invasive TKR to three groups: 1) a placebo group (50 patients);
2) a one-dose TEA group (52 patients), who received one injection
of TEA (10 mg/kg) intra-operatively on deflation of the tourniquet;
and 3) a two-dose TEA group (49 patients), who received two injections
of TEA (10 mg/kg) given pre-operatively and intra-operatively. Total
blood loss was calculated from the maximum loss of haemoglobin.
All patients were followed clinically for the presence of venous
thromboembolism (VTE). The mean total blood loss was significantly higher in the placebo
group than in the other two groups (1222 ml (845 to 2043) Our prospective randomised controlled study showed that one intra-operative
injection of TEA is effective for blood conservation after minimally
invasive TKR.
This was a retrospective analysis of the medium-
to long-term results of 46 TC3 Sigma revision total knee replacements
using long uncemented stems in press-fit mode. Clinical and radiological analysis took place pre-operatively,
at two years post-operatively, and at a mean follow-up of 8.5 years
(4 to 12). The mean pre-operative International Knee Society (IKS)
clinical score was 42 points (0 to 74), improving to 83.7 (52 to
100) by the final follow-up. The mean IKS score for function improved
from 34.3 points (0 to 80) to 64.2 (15 to 100) at the final follow-up.
At the final follow-up 30 knees (65.2%) had an excellent result, seven
(15.2%) a good result, one (2.2%) a medium and eight (17.4%) a poor
result. There were two failures, one with anteroposterior instability
and one with aseptic loosening. The TC3 revision knee system, when used with press-fit for long
intramedullary stems and cemented femoral and tibial components,
in both septic and aseptic revisions, results in a satisfactory
clinical and radiological outcome, and has a good medium- to long-term
survival rate.
We present the electromyographic (EMG) results
ten years after open decompression of the median nerve at the wrist
and compare them with the clinical and functional outcomes as judged
by Levine’s Questionnaire. This retrospective study evaluated 115
patients who had undergone carpal tunnel decompression at a mean
of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis
was found in 77 patients (67%), including those who were asymptomatic
at ten years. It is necessary to include both clinical and functional results
as well as electromyographic testing in the long-term evaluation
of patients who have undergone carpal tunnel decompression particularly
in those in whom revision surgery is being considered. In doubtful
cases or when there are differing outcomes, self-administered scales
such as Levine’s Questionnaire should prevail over EMG results when
deciding on the need for revision surgery.
This study evaluates factors related to myelopathic
symptoms in patients with ossification of the posterior longitudinal
ligament (OPLL). A total of 87 patients with OPLL were included.
Of these, 53 (Group I) had no symptoms or presented with neck pain
and radiculopathy and 34 (Group II) had myelopathic symptoms. Gender, age,
and history of trauma were evaluated in the two groups. The range
of movement of the cervical spine was measured using plain radiographs.
The number of involved segments, type of OPLL, and maximal compression ratio
were analysed using CT and signal change in the spinal cord was
evaluated using MRI. The patients’ age was found to be significant (p = 0.001). No
difference was found between gender and the range of movement in
the two groups. The maximum compression of the spinal canal showed
a difference (p = 0.03). The signal change of the spinal cord was
different between the two groups. In patients with OPLL of the cervical
spine, myelopathic symptoms are not related to the range of movement
or the number of involved segments.
We report the results of vertebral column resection
(VCR) for paediatric patients with spinal deformity. A total of
49 VCRs in paediatric patients from four university hospitals between
2005 and 2009 with a minimum two-year follow-up were retrospectively
identified. After excluding single hemivertebral resections (n =
25) and VCRs performed for patients with myelomeningocele (n = 6),
as well as spondylectomies performed for tumour (n = 4), there were
14 patients who had undergone full VCR at a mean age of 12.3 years
(6.5 to 17.9). The aetiology was congenital scoliosis in five, neuromuscular
scoliosis in three, congenital kyphosis in two, global kyphosis
in two, adolescent idiopathic scoliosis in one and secondary scoliosis
in one. A total of seven anteroposterior and seven posterolateral approaches
were used. The mean major curve deformity was 86° (67° to 120°) pre-operatively
and 37° (17° to 80°) at the two-year follow-up; correction was a
mean of 54% (18% to 86%) in the anteroposterior and 60% (41% to
70%) in the posterolateral group at the two-year follow-up (p =
0.53). The mean Scoliosis Research Society-24 total scores were
100 (92 to 108) for the anteroposterior and 102 (95 to 105) for
the posterolateral group. There was one paraparesis in the anteroposterior
group necessitating urgent re-decompression, with a full recovery. Patients undergoing VCR are highly satisfied after a successful
procedure.
This prospective multicentre study was undertaken
to determine whether the timing of the post-operative administration
of bisphosphonate affects fracture healing and the rate of complication
following an intertrochanteric fracture. Between August 2008 and
December 2009, 90 patients with an intertrochanteric fracture who
underwent internal fixation were randomised to three groups according
to the timing of the commencement of risedronate treatment after
surgery: Group A (from one week after surgery), Group B (from one
month after surgery), and Group C (from three months after surgery).
The radiological time to fracture healing was assessed as the primary
endpoint, and the incidence of complications, including excessive
displacement or any complication requiring revision surgery, as
the secondary endpoint. The mean time to fracture healing post-operatively
in groups A, B and C was 10.7 weeks ( This study demonstrates that the timing of the post-operative
administration of bisphosphonates does not appear to affect the
rate of healing of an intertrochanteric fracture or the incidence
of complications.
A prospective study was performed to develop
a clinical prediction rule that incorporated demographic and clinical factors
predictive of a fracture of the scaphoid. Of 260 consecutive patients
with a clinically suspected or radiologically confirmed scaphoid
fracture, 223 returned for evaluation two weeks after injury and
formed the basis of our analysis. Patients were evaluated within
72 hours of injury and at approximately two and six weeks after injury
using clinical assessment and standard radiographs. Demographic
data and the results of seven specific tests in the clinical examination
were recorded. There were 116 (52%) men and their mean age was 33 years (13
to 95; Our study has demonstrated that clinical prediction rules have
a considerable influence on the probability of a suspected scaphoid
fracture. This will help improve the use of supplementary investigations
where the diagnosis remains in doubt.
A delay in establishing the diagnosis of an occult
fracture of the hip that remains unrecognised after plain radiography
can result in more complex treatment such as an arthroplasty being
required. This might be avoided by earlier diagnosis using MRI.
The aim of this study was to investigate the best MR imaging sequence
for diagnosing such fractures. From a consecutive cohort of 771
patients admitted between 2003 and 2011 with a clinically suspected
fracture of the hip, we retrospectively reviewed the MRI scans of
the 35 patients who had no evidence of a fracture on their plain
radiographs. In eight of these patients MR scanning excluded a fracture
but the remaining 27 patients had an abnormal scan: one with a fracture
of the pubic ramus, and in the other 26 a T1-weighted
coronal MRI showed a hip fracture with 100% sensitivity. T2-weighted
imaging was undertaken in 25 patients, in whom the diagnosis could
not be established with this scanning sequence alone, giving a sensitivity
of 84.0% for T2-weighted imaging. If there is a clinical suspicion of a hip fracture with normal
radiographs, T1-weighted coronal MRI is the best sequence
of images for identifying a fracture.
Patient expectations and their fulfilment are
an important factor in determining patient-reported outcome and satisfaction
of hip (THR) and knee replacement (TKR). The aim of this prospective
cohort study was to examine the expectations of patients undergoing
THR and TKR, and to identify differences in expectations, predictors
of high expectations and the relationship between the fulfilment
of expectations and patient-reported outcome measures. During the
study period, patients who underwent 346 THRs and 323 TKRs completed
an expectation questionnaire, Oxford score and Short-Form 12 (SF-12)
score pre-operatively. At one year post-operatively, the Oxford
score, SF-12, patient satisfaction and expectation fulfilment were
assessed. Univariable and multivariable analysis were performed.
Improvements in mobility and daytime pain were the most important
expectations in both groups. Expectation level did not differ between
THR and TKR. Poor Oxford score, younger age and male gender significantly
predicted high pre-operative expectations (p <
0.001). The level
of pre-operative expectation was not significantly associated with
the fulfilment of expectations or outcome. THR better met the expectations
identified as important by patients. TKR failed to meet expectations
of kneeling, squatting and stair climbing. High fulfilment of expectation
in both THR and TKR was significantly predicted by young age, greater
improvements in Oxford score and high pre-operative mental health
scores. The fulfilment of expectations was highly correlated with satisfaction.
We analysed the outcome of patients with primary
non-metastatic diaphyseal sarcomas who had Extracorporeal irradiation is an oncologically safe and inexpensive
technique for limb salvage in diaphyseal sarcomas and has good functional
results.
Between 2005 and 2010 ten consecutive children
with high-energy open diaphyseal tibial fractures were treated by early
reduction and application of a programmable circular external fixator.
They were all male with a mean age of 11.5 years (5.2 to 15.4),
and they were followed for a mean of 34.5 months (6 to 77). Full
weight-bearing was allowed immediately post-operatively. The mean
time from application to removal of the frame was 16 weeks (12 to
21). The mean deformity following removal of the frame was 0.15°
(0° to 1.5°) of coronal angulation, 0.2° (0° to 2°) sagittal angulation,
1.1 mm (0 to 10) coronal translation, and 0.5 mm (0 to 2) sagittal
translation. All patients achieved consolidated bony union and satisfactory
wound healing. There were no cases of delayed or nonunion, compartment
syndrome or neurovascular injury. Four patients had a mild superficial
pin site infection; all settled with a single course of oral antibiotics.
No patient had a deep infection or re-fracture following removal
of the frame. The time to union was comparable with, or better than,
other published methods of stabilisation for these injuries. The
stable fixator configuration not only facilitates management of
the accompanying soft-tissue injury but enables anatomical post-injury
alignment, which is important in view of the limited remodelling
potential of the tibia in children aged >
ten years. Where appropriate
expertise exists, we recommend this technique for the management
of high-energy open tibial fractures in children.
An 81-year-old woman presented with a fracture
in the left femur. She had well-fixed bilateral hip replacements
and had received long-term bisphosphonate treatment. Prolonged bisphosphonate
use has been recently linked with atypical subtrochanteric and diaphyseal
femoral fractures. While the current definition of an atypical fracture
of the femur excludes peri-prosthetic fractures, this case suggests
that they do occur and should be considered in patients with severe
osteopenia. Union of the fracture followed cessation of bisphosphonates
and treatment with teriparatide. Thus, this case calls into question
whether prophylactic intramedullary nailing is sufficient alone
to treat early or completed atypical femoral fractures.
For the treatment of ununited fractures, we developed
a system of delivering magnetic labelled mesenchymal stromal cells
(MSCs) using an extracorporeal magnetic device. In this study, we
transplanted ferucarbotran-labelled and luciferase-positive bone
marrow-derived MSCs into a non-healing femoral fracture rat model
in the presence of a magnetic field. The biological fate of the
transplanted MSCs was observed using luciferase-based bioluminescence
imaging and we found that the number of MSC derived photons increased
from day one to day three and thereafter decreased over time. The
magnetic cell delivery system induced the accumulation of photons at
the fracture site, while also retaining higher photon intensity
from day three to week four. Furthermore, radiological and histological
findings suggested improved callus formation and endochondral ossification.
We therefore believe that this delivery system may be a promising
option for bone regeneration.
The FRCS (Tr &
Orth) examination has three components: MCQs, Vivas and Clinical Examination. The Vivas are further divided into four sections comprising Basic Science, Adult Pathology, Hands and Children’s Orthopaedics and Trauma. The Clinical Examination section is divided into Upper and Lower limb cases. The aim of this section in the Journal is to focus specifically on the trainees preparing for the exam and to cater to all the sections of the exam. The vision is to complete the cycle of all relevant exam topics (as per the syllabus) in four years.