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The pathology of the RAshoulder differs from that of the OA shoulder. In addition to replacement of the glenohumeral joint, procedures have to be performed to deal with disorders specific for the RA shoulder, such as bone deficiency of the glenoid, thinning or rupture of the rotator cuff, and severe internal rotation defomity. Timing of shoulder arthroplasty in the rheumatoid patient is stilla controversial issue. Clinical symptoms are more important than the radiographic destruction for timing of surgery. The status of the rotator cuff and the glenoid will predict the functional result.
Controversial issues ar whether the synovitis of the AC-joint and the subacromial area should be treated arthroscopically early to prevent destruction of the cuff, whether repair of the rotator cuff or tendon transfers effect the end result, and whether replacement of the glenoid is beneficial.
The surgical management of advanced destruction of the rheumatoid elbow differs from one center to the next, as controversy exists regarding the success of synovectomy. Total elbow arthroplasty in patients with advanced joint destruction has gained popularity. Controversial issues and new developments will be discussed.
Modern pharmaceutical treatment of RA seems to result in less need of prophylactic surgery but the burden of secondary osteoarthrosis of the the large joints in the lower extremity will be present for a foreseeable future. The results of hip an knee arthroplasty are well known from the Swedish Arthroplasty Registers. Severe deformities of the hip and knee are nowadays very seldom seen, but the same does not hold true for the ankle and foot. As more RA patients are offered hip and knee replacement they will start loading their feet to an extent which the feet are not always able to withstand. Effetcive pain-killing pharmaceuticals also means a possibility to put weight even on an arthritic deformed foot. Thus, severe foot and ankle deformities are still rather frequently seen. Improved surgical methods for correction have evolved and in most cases reconstructive ankle and foot surgery will restore the weightbearing capacity of the RA foot.
There is a lack of uniform systems for assessing outcomes after surgery in patients with RA.
Factors known to affect outcome are disease activity, pharmacological treatment, comorbidities, desires and motivation.
The consequences of disease influence to a high degree the patients’ quality of life, their ADL, working ability and recreational activities. That makes it important to measure the result from the patient’s perspective as well as reporting demographic data, disease activity, co-morbidities, functional status and surgical data.
We have found that patients with RA assigned for orthopaedic surgery seem to be most concerned about pain relief. The SF-36 scores also indicate that the patients’ physical function, pain and general health were more deteriorated than their social function and mental health. By following patients prospectively we will have the opportunity to find out whether expectations and perception of health influence the outcome after surgery.
Wrist fusion, ulna head resection and fusion of the MP or PIP joints are not anymore the only operations that can be offered to patients with RA. The modern medical treatment has changed the course of the disease and we are not anymore in front of patients with major joint destruction, very bad hand function and low demands. Young ladies with well controlled disease expect surgery to result in restitution of function which allows a life close to normal in terms of work and leisure time activities. If pain relief remains the main indication it has to be associated with reconstruction of function, preserving mobility and increasing grip strength. For these reasons it appears necessary to limit fusions and increase the use of joint implants. Accurate evaluation of the patients’ need and expectations will help in the choice of the appropriate surgical procedure to achieve the treatment goal.
The incidence of hip fractures is rising, and at the same time the patients are getting increasingly frail and elderly. Patients in Europe have a median hospitalization time of as much as 28 days, and the peri-operative morbidity and mortality is high
Postoperative epidural analgesia can be provided without restrictions on patient mobility and rehabilitation, provides superior dynamic pain relief and reducing the influence of pain as a restricting factor on physiotherapy
The cumulated evidence for the peri-operative care of this patient group is scarce and fast-track rehabilitation regimens should look to other operational procedures for available evidence
The Scottish Hip Fracture Audit (
Audit data are used locally to document care and support and monitor service developments. Synergy between the guidelines and the audit provides a means of improving care locally and monitoring care nationally. External review by the quality assurance body shows to what extent guideline-based standards relating to A& E care, pre-operative delay, multidisciplinary care and audit participation are met.
Three national-level initiatives on hip fracture care have delivered: reliable and largescale comparative information on case-mix, care and outcomes; evidence-based recommendations on care; and nationally accountable standards inspected and reported by the national health quality assurance authority. These developments are linked and synergistic, and enjoy both clinical and managerial support. They provide an evolving framework for clinical governance and quality assurance, with methods for casemix-adjusted outcome assessment for hip fracture care also now developed.
The new S.I.C.O. (Italian Society for Surgery of Osteoporosis) is trying to establish a register for osteoporotic complications, namely for Hip fractures, in fact at the moment only limited epidemiological data are available about the incidence of hip fractures in Italy. These data vary widely across the Italian Regions.
In the last five years E.S.O.P.O. study allowed us to have epidemiological data about osteoporosis in Italy, and from then a group of Orthopedic Units, distributed along all the country, are collecting data to better understand the epidemiological relevance of Hip Fractures.
84.188 Hip fractures were registered in 2001 from the Italian Ministry of health, which meant 1.48 fracture every 1.000 citizen, 25% of which were males.
From some areas through relating fractures and age was possible to establish that there were 3.7 fractures every 1.000 people over 50 years of age, 4.5 fractures every 1.000 females over 50 years of age, 1.9 every 1.000 males over 50.
From the Units working at the project few significant data were obtained: mean time between hospital arrival and surgery was 3.9 days, considered very high, the mean time of Hospital stay was 9.5 days for all patients, but 14.5 days for patients that underwent to an operation.
55% were lateral fractures for which a new “Italian” undersized titanium nail was introduced in February 2003, which rapidly was adopted in many hospital for its simplicity and low cost.
Controversial among Orthopedic surgeons arose because some of them are treating lateral fractures with total or partial hip replacement.
Because of different health organization between Regions of North, Center and South of Italy the patients are discharged to rehabilitation Unit mainly in North of Italy, less in Southern part where for a lack of Rehabilitation Units, most of the patients go back home, supported from public health operators at their family place.
ProFaNE, Prevention of Falls Network Europe, is a four year project, funded by the European Community Framework 5. It is a thematic network, coordinated by the University of Manchester, UK, with 25 partners across Europe. There are also Network Associates from a number of EU and non-EU countries who give their advice and experience at meetings, seminarsand conferences.
The aim is to bring together workers from around Europe to focus on a series of tasks aimed at developing multi-factorial prevention programmes to reduce the incidence of falls and fractures amongst elderly people. The work of ProFaNE is practical, both in terms of developing the evidence base for implementation of effective interventions and encouraging best practice across Europe. The task of each work package is to convene workshops, undertake personnel exchanges and set up collaborative studies, data sharing in order to develop evidence based protocols and publications which can be used to implement change.
To gain an understanding of the current issues surrounding falls prevention across Europe and to embrace at national and international level, the different political and health service agendas in each country such that recommendations can ultimately be translated into working models of practice in each country. To establish a robust network of key members across Europe to facilitate the effective and efficient promulgation of evidence likely to influence service developments at national and local level. To derive a consensus approach to assessment and management of older people at risk of falling in a variety of clinical settings using the existing evidence base as well as experts in the field To ultimately facilitate a pan-European approach to assessment and management of falls whilst minimising impact on clinical autonomy and paving the way for further research activity within member states.
During the last 2 decades it has been recognized that scoliosis may start de novo during adult life as a result of advanced degenerative disc disease, osteoporosis or both. In some the degenerative process is superimposed on a previous adolescent curve. Aside from the disfigurement caused by the spinal deformity, pain and disability are usually the major clinical problem.
The prevalence of adult scoliosis rises with age: from 4% before age 45, 6% at age 59 to 15% in-patients older than 60 years. More than two thirds of the patients are females and the prevalence of right lumber curves is higher than in comparable series of patients with adolescent scoliosis.
Adult scoliosis is characterized by vertebral structural changes with translatory shifts i.e. lateral olisthesis accompanied by degenerative disc and facet joint arthrosis.
Although the magnitude of these curves is usually mild (20–30 degrees) lateral spondylolisthesis is observed frequently. It is also common to observe degenerative spondylolisthesis in patients with degenerative lumbar scoliosis. The annual rate of curve progression ranges from 0.3 to 3%.
Patients present with a history of a spinal deformity accompanied by loss of lumbar lordosis, trunk imbalance and significant mechanical back pain. Pain may arise not only from degenerative disc disease and facet arthritis leading to symptoms of spinal stenosis, but also from muscle fatigue due to the altered biomechanics secondary to a deformity in the coronal and sagittal planes. Root entrapment is common and occurs more often on the concavity of the curve. Symptoms of neurogenic claudication are also common in adults with lumbar scoliosis.
Non-operative care includes exercises, swimming, NSAIDs, and occasional epidural injections. Brace treatment can be tried as well. Curve progression as well as axial or radicular pain not responding to non-operative care are indications for surgical intervention.
Surgery may include decompression alone or in conjunction with curve correction and stabilization. Posterior instrumentation may be supplemented with interbody cages. Fusion is usually carried down to L5 but occasional instrumentation to the sacropelvis is mandatory. Problems with a high pseudoarthrosis rate are common with sacral fixation. Even in the best of hands a long recovery period (6–12 month) and moderate pain relief should be expected. As summarized by Dr. Bradford “despite recent advancements evaluation and successful management of patients with adult spinal deformity remains a significant challenge”
Isthmic spondylolisthesis with pars interarticularis defect is a “ fatigue” fracture. In most cases there is no instability and moderate pain, with no need for treatment. Twenty per cent of the patients have severe back pain, and some also radicular pain, while some young patients have progressive lumbosacral kyphosis and instability with high grade spondylolisthesis. The sacral deformity and kyphosis result from the fracture and could be avoided by healinfg of the defect. Histological studies have shown that the pars defect can be a source of pain.
Patients with severe back pain and some with radicular pain or increasing deformity are candidate to surgery. Since many years, the only treatment was fusion with or without instrumentation and with or without correction of the deformity, by anterior or posterior approach. Fusion was mandatory in case of associated disc degeneration, including all the pathological discs into the fusion area. Isthmic repair has been done since many years using several techniques, but only in the absence of olisthesis and disc degeneration. However, it is known that many adult or senile subjects have degenerated discs and no back pain. Thus, what is the rationale to perform fusion in all patients with spondylolisthesis? The problem is to know the source of pain and to treat patients rather than x-rays. This can be achieved by anaesthetic injection of the lytic zone, MRI and discography, which can be helpful to differentiate patients who need fusio from those who do not need it. Initially we used, for isthmic repair, the Morscher hook-screw instrumentation, but in the last ten years we are using DOS instrumentation, which is stiffer. The indications and surgical technique, as well as the results of a comparative study between fusion (91 patients with 40-month follow-up) and repair (95 patients with 30-month followup), wil be presented in terms of duration of surgery, hospital stay, complication rate, number of revisions and return to previous activities.
This study shows less postoperative complications and higher rate of return to work or sports for pars repair versus lumbar fusion in a rather similar population. Therefore, isthmic repair seems to be the first surgical option for mild isthmic spondylolisthesis even in the presence of degenerated discs.
Degenerative spondylolisthesis is consistently responsible for narrowing of the spinal canal, but only in a part of the cases it causes lateral or central stenosis. The presence, type and severity of stenosis is related to several factors, such as the constitutional dimensions of the spinal canal, the orientation and severity of degenerative changes of the facet joints, and the amount of vertebral slipping. The type of stenosis, that is whether stenosis is central or lateral, depends on the orientation of the articular processes, and the length of the pedicles. Usually stenosis is lateral initially and central in later stages. Instability, that is hypermobility on flexion-extension adiographs is one of the main characteristics of degenerative spondylolisthesis. However, in many cases there is no appreciable hypermobility of the slipped vertebra. We consider the latter condition as a potential instability, which can become a manifest instability as a result of surgery, or when destabilizing factors unable to destabilize a normal vertebra intervene, such as disc degeneration or severe degenerative changes of the facet joints.
There is no indication for surgery in patients with no significant symptoms. In patients with an unstable motion segment who have only back pain it is usually sufficient to perform a fusion alone if stenosis is mild and asymptomatic. Neural decompression should be performed if stenosis is severe. Bilateral laminotomy, or even total laminectomy, may be carried out with no concomitant fusion in patients with mild olisthesis, no vertebral hypermobility on functional radiographs, mild central stenosis or any degree of isolated lateral stenosis, and mild or no back pain. The indications for monolateral laminotomy with no fusion are: moderate central stenosis in elderly patients with unilateral symptoms; lateral stenosis only on one side; and unilateral additional pathology, such as a synovial cyst. Patients with moderate or severe olisthesis, vertebral hypermobility even of mild degree, and/or severe central stenosis and chronic back pain should undergo decompression and fusion. The association of an arthrodesis allows decompression of the neural structures as widely as necessary.
Posterolateral instrumented fusion, using pedicle screw fixation, is the most common procedure, that can be done at multiple level when olisthesis is present at more than one level. In both cases it requires no, or a short, postoperative immobilization Posterolateral fusion may be replaced by PLIF. This procedure, associated with pedicle screw instrumentation, gives excellent results and a high rate of solid fusion. The devices inserted in the disc space are normally represented by cages filled with bone chips. An alternative are the use of blocks of porous tantalum (hedrocel), the stiffness of which is very similar to that of subchondral bone. We are using blocks of hedrocel since 3 years with excellent results in terms of intersomatic fusion. In 20 cases followed for at least 2 years we never observed mobilization of the implant or loosening of the pedicle screws, and we almost consistently found a tight union between the implant and the adjacent vertebrae.
As a level I trauma hospital, OOU receives an increasing number of knee dislocations. This study evaluates acute knee dislocations seen at OOU from May 1. 1996 through Dec 2004.
In addition one patient had a ruptur of the patellar tendon and one a patella dislocation. Two of the patients in this group had a vascular injury. On admittance the patients underwent a diagnostic exam in the emergency room.. All the patients then had a MRI. The patients were the placed in a brace and on a CPM 2 hours 2 times a day for 7 days, and the vascular status was monitored closely. After 7–10 days the patients underwent surgery including arthroscopic reconstruction of the ACL and PCL with auto or preferably, if available allograft. Results for patient with a followup for more than 6 months are presented including IKDS, Cincinatti, Tegner and a clinical exam with KT1000.
Combined anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) disruptions are uncommon orthopaedic injuries. They are usually caused by high- or low-velocity knee dislocations. Because knee dislocations might spontaneously reduce before initial evaluation, the true incidence is unknown. Dislocation involves injury to multiple ligaments of the knee. Both of the cruciate ligaments are usually disrupted, and they are often combined with a third ligamentous disruption (medial collateral ligament or lateral collateral ligament and/or posterior lateral complex). Associated neurovascular, meniscal, and osteochondral injuries are often present and complicate treatment.
The most common injury patterns include both cruciate ligaments and either medial collateral ligament (MCL) or lateral collateral ligament (LCL) and/or posterolateral structures. Less commonly both collateral ligaments are disrupted. Our policy has been early (from 7 to 21 days) simultaneous reconstruction of both cruciate ligaments and repairing of grade III LCL and posterolateral structures. Most acute grade III MCL tears are successfully treated with brace treatment when ACL and PCL are reconstructed early.
Most cruciate ligament injuries are midsubstance tears that need to be reconstructed with autografts or allografts. Repairs can be done in cases of bony avulsion of cruciate ligaments or grade III collateral ligament or capsular injuries. Bone-patellar tendon-bone (BPTB) autograft has mainly used in our clinics to reconstruct the ACL. In some cases BTPB allograft or hamstring tendon autografts has been used. For PCL reconstruction, BPTB allograft (11 mm in diameter) or Achilles tendon allograft has been used.
Intrasubstance grade III tears of the LCL can be repaired (in early state) but may need to be augmented with tendon allograft. The LCL and/or the popliteofibular ligament are reconstructed either with an Achilles tendon allograft, hamstring tendon autograft/allograft, tibialis anterior tendon allograft, or the BPTB allograft.
Both cruciate ligaments are reconstructed arthroscopically. The ACL tunnels are placed in the center of its anatomic insertion in tibia and in its isometric or anatomic insertion in femur. A transtibial tunnel technique for PCL reconstruction is used. The PCL tibial tunnel is drilled first under arthroscopic guidance using the PCL guide. The ACL tibial guide is drilled at least 2 cm proximal to the PCL tunnel to ensure that wide enough bone bridge remains between these tunnels. Fluoroscopy is used to ensure the right guidewire placement.
Sequence of bicruciate ligament reconstruction with BPTB grafts
Drill PCL tibial tunnel first, then ACL tibial tunnel Drill ACL femoral tunnel, then PCL femoral tunnel Pass PCL graft through tibial tunnel and fix in femoral tunnel Pass ACL graft through tibial tunnel and fix in femoral tunnel Fix PCL graft on tibia at 90° of flexion with anteromedial step off Fix ACL graft on tibia at extension
Lateral Collateral Ligament (LCL) Primary stabilizer to varus opening Femoral attachment – proximal/posterior to lateral epicondyle Fibular attachment – midway along lateral fibular head Popliteus Complex Important stabilizer to posterolateral rotation Stabilizer to varus opening Popliteus attachment on femur 18mm anterior/distal to LCL anterior fifth of popliteal sulcus Popliteofibular ligament (PFL) originates at musculo-tendinous junction of popliteus attaches at medial aspect of fibular styloid Mid-Third Lateral Capsular Ligament Secondary stabilizer to varus opening Thickening of lateral midline capsule Meniscotibial portion often injured. Segond injury Biceps Femoris Complex Short head of biceps Long head of biceps Lateral Meniscus
Rarely isolated injury Usually as a combined ligamentous injury ACL/PLC PCL/PLC Knee Dislocation Hyperextension Varus blow Noncontact twisting
Grade III injuries do not heal Lead to instability and osteoarthritis Compromise cruciate ligament reconstructions
History Usually due to varus/hyperextension injuries 15 % have a peroneal nerve injury Usually combined ligamentous injury Clinical exam Varus stress test External rotation recurvatum test Posterolateral drawer test Dial test Reverse pivot shift test Varus thrust gait Radiographs MRI Arthroscopic evaluation
Acute grade I and II injuries Brace 6 weeks Full ROM Partial weight bearing Acute grade III injuries Repair/reconstruct within 2 weeks after injury Attempt anatomic repair Each structure repaired individually Consider augmentation in midsubstance tears Anatomic reconstruction
Assess for varus alignment Proximal tibial opening wedge osteotomy Reassess after 6 months for need for soft tissue reconstruction Anatomic reconsruction of posterolateral structures Two tailed reconstruction of LCL, PFLand popliteus tendon Biomechanically restores function of native ligaments
Prophylaxis with a low-molecular-weight heparin (LMWH) was administered perioperatively in 97.6% and for at least four weeks in 69.5% (median prophylaxis duration: 6 weeks). The rate of symptomatic VTE at 3 months was 1.34% (95% CI: 1.04– 1.64). There were 16 PE (rate 0.25%) and 3 were fatal. The rate of major bleeding was 1.2%. At 6 months, 1006 patients (14.7%) were dead. Significant risk factors for symptomatic VTE were: history of VTE (OR 2.9), induction of anesthesia until arrival in the recovery room > 2 hrs (OR 2.5), and varicose veins/post-thrombotic syndrome (OR 2.2). LMWH prophylaxis significantly reduced the risk of symptomatic VTE (OR 0.2).
Significant predictive factors for mortality were: cancer (OR 2.3), surgical complications requiring re-intervention (OR 1.8), confusion before fracture (OR 1.8), ASA score ≥3 (OR 1.7), BMI ≤18 kg/m2 (OR 1.6), congestive heart failure (OR 1.6), atrial fibrillation (OR 1.6) and age > 80 years (OR 1.1).
According to the 2004 ACCP guidelines on antithrombotic and thrombolytic therapy general extended prophylaxis with low molecular weight heparins, vitamin K antagonists, or fondaparinux is recommended after major orthopedic surgery. This recommendation is based on a number of placebo controlled, clinical studies using venographic screening for deep vein thrombosis (DVT), as a surrogate end-point for pulmonary embolism (PE), other vascular thrombotic events were not considered. In a recent meta-analysis on these studies the overall event rate of symptomatic venous thromboembolism 30–42 days after a joint arthroplasty was 2.7% DVT and 0.6 % PE in patients having short-term prophylaxis and it was significantly reduced by extended prophylaxis. Bleeding episodes were seen in 4% of cases having extension. Taking into consideration the risk benefit for the individual patient do these findings justify that extended prophylaxis is used on a general basis? To answer this question also compliance, adverse event profile, and cost of the prophylactic regimens have to be addressed. It would be very attractive to be able to individualize the duration of the prophylactic period by assessing the thrombotic potential of every patient in order to balance the risks and benefits of continued prophylaxis.
Major bone surgery causes damage to the bone marrow cells and destruction of blood vessels. This induces a tremendous local and systemic thrombin generation. This may trigger vascular instability during surgery that in seldom cases may be fatal in susceptible patients in particular if bone cement is implanted. The overall mortality following elective hip replacement is low since the patients are selected for the procedure and medically optimized. Following emergency hip fracture surgery the patients are substantially older, many have co-morbid conditions and the mortality is markedly higher. Vascular events dominate. Pulmonary embolism, and myocardial infarction are prominent together with pneumonia (a condition that trigger the coagulation system).
Postoperatively, thrombin continues to be generated for a long time after surgery as a part of the inflammatory healing process. Vascular complications dominate and epidemiological studies have shown a general complication risk period lasting for nearly 3 months and significantly longer in subgroups. Although, mortality has decreased in recent years, morbidity continues to play an important and less focused role although with substantial health economic implications.
The supporting structures on the medial side of the knee consist of:
- Layer I, the superficial fascia. - Layer II, the superficial Medial Collateral Ligament (sMCL) with parallel fibers running from the femoral epicondyle to the anteromedial tibial crest 5–7 cm below the joint line. - Layer III, the deep capsular layer.
The pes tendons are situated between Layer I and II–III. Beneath the sMCL Layer III thickens and forms the deep MCL (dMCL) from femur condyle to meniscus and from meniscus to tibia.
More dorsally Layer II and III fuse and form the Postero Medial Capsule (PMC) which is connected to the meniscus and tibia. The PMC is augmented by the semimembranosus tendon.
The sMCL is the primary restraint against valgus and transsection causes 2–5 degrees laxity in flexion or approximately 3–5 mm joint opening. Additional cutting of the PMC gives additional laxity of 7–8 degrees up to 10 degrees. An isolated sMCL lesion causes more laxity in flexion and a combination of sMCL with a PMC lesion causes also laxity in extension. The dMCL does provide some stability in 45 dg. of flexion but is not very strong.
The goal of MCL-PMC reconstruction should be functional anatomical repair of the pathology and retention of the meniscus. After treating the pathology the medial side of the knee should be stable in extension (by repair PMC) and in flexion (by repair sMCL).
The PMC – meniscus – semimembranosus complex should be refixated at the posteromedial tibia corner if it is loose.
Bony avulsions should be fixed with washer and screw or anchors. Ligamentous avulsions can be fixed at the anatomical insertion site with trans-osseous non-resorbable sutures or bone anchors or screws with toothed washers. A distalisation of a ligament insertion (sMCL) with its bony attachment is also an elegant solution in chronic cases. If the surgeon wants to tension the SMCL at the femoral side, the bony insertion with the ligament attached to it can be recessed at its original position. Allografts and double stranded hamstring autografts can be used when native tissue is lacking.
Patients who suffer a fracture of the proximal femur are high risk for developing venous thromboembolism. They require effective anti-thrombotic prophylaxis. In an audit of 11,900 patients a mortality of 17% occurred 3 months after the injury. Although post mortem examination was rare, it was estimated that nearly 50% of 753 deaths were thrombosis related, 6.9% specifically attributed to pulmonary embolus. It is likely that many of the other deaths, attributed to various respiratory problems were also at least in part due to PE. Comparing the data with actuarial tables demonstrated an excess mortality in both gender and in nearly all age groups. In a second audit, although many patients were receiving some form of prophylaxis, many were given ineffective agents and probably using an ineffective regime. In many patients a fracture of the proximal femur is regarded as a terminal event. However, the data from these 2 audits would suggest that many of these patients are dying unnecessarily and that effective prophylaxis would reduce the risk of death. Chemical prophylaxis commenced immediately after surgery and continued for 5 weeks would be appropriate.
Wear and wear debris induced osteolysis is recognised as a major cause of long term failure in hip prostheses. Historically ultra high molecular weight polyethylene acetabular cups produced micron and submicron wear particles which accumulated in peri prosthetic tissues, and stimulated macrophages to generate wear debris induced osteolysis. Acceleration of wear and osteolysis was caused in historical materials by oxidative degradation of the polyethylene following gamma irradiation in air, and by third body damage and scratching of metallic femoral heads. Current conventional ultra high molecular weight polyethylene cups are irradiated in an inert atmosphere to reduce oxidative degradation and are articulated against ceramic femoral heads to reduce third body wear. More recently modified highly cross linked polyethylene has been developed, and while these materials produce a four to five fold reduction in wear volume the wear particles have been found to be more reactive, resulting in only a two fold reduction in functional osteolytic potential. The question remains as to whether this performance is adequate for high demand patients, particularly if larger diameter femoral heads are to be used.
Recent interest in improved function, stability and reducing dislocations has generated interest in using larger diameter heads and hard on hard bearings.
Alumina ceramic on ceramic bearings have shown a one hundred fold decrease in wear compared to highly cross linked polyethylene materials, and cell culture studies have shown the wear particles to be more bio-compatible and less osteolytic potential.
Metal on metal bearings also produced very low wear rates compared to polyethylene. The wear particles are very small, 10 to 50 nanometers in size, some concern remains about the systematic release of metallic ions. These are lubrication sensitive bearings, and they unlike polyethylene wear decreases as the head size increases due to improved lubrication. Size 36 mm metal bearings are now commonplace for total joint replacements with even larger head sizes being used for surface replacement solutions.
The demand for increased function and improved stability is leading to increased use of hard on hard bearings with larger diameter heads.
Osteolysis and periprosthetic bone loss have been a concern since Charnley’s original reports of metal on Teflon. Willart and Semlitch were the first investigators to propose a biologic mechanism for osteolysis associated with particulate wear debris. Harris in 1976 and Goldring 1983 describe the presence of macrophages and giant cells in the synovial membrane at the bone cement interface in loose THR. Initially it was associated with cement and it was called cement disease. Reports of resorption around cementless implants led to the realization that PE alone was good enough to create bone loss.
Cellular mediators playing significant role in osteolysis are IL-1, IL-6, TNF-a, PGE2. These mediators lead to stimulation and differentiation of osteoclasts and inhibition of osteoblasts.
These factors together assist in the dissolution of bone at the interface allowing for micromotion of the prosthesis that leads to further generation of wear debris.
On top of the above there is release of collagenase, stromelysin, gelatinase which further destroy the bone. Another active area of research involves roles at Rank, Rank and osteoprotegerin. Recently there is extensive work done as far as it concerns the role of endotoxin in osteolysis and periprosthetic bone loss. It still remains a controversial issue.
Other researchers have studied the effects of elevated periarticular hydrostatic pressure and fluid access in the development of osteolysis (effective joint space).
Rheumatoid arthritis is the most common inflammatory disease of the joints affecting about 0.5% of adults, women more often than men with a peak age of onset of 35–45 years. It is usually progressive affecting further joints and the destructive disease process causes irreversible bony erosions and the joints become structurally deformed, with long-term pain and disability. It has an early and significant impact on the person’s ability to work and socio-economic status with work capacity restricted in a third within a year and within 3 years almost half 40 may be registered work disabled.
The aims of management of rheumatoid arthritis are to reduce pain an inflammation; reduce disability; prevent joint damage and progression; and to reduce the comorbidities that are associated with the disease. As joint damage is irreversible it is important to diagnose the disease and institute disease modifying anti-rheumatic therapy as soon as possible. There is as yet no way of preventing the disease.
Lifestyle interventions of avoiding obesity, maintaining physical activity and avoiding smoking may improve outcome. Symptoms can be effectively controlled with analgesics and NSAIDs and joint damage can be reduced with disease modifying antirheumatic therapy with consequent benefits to quality of life. Biological therapies, such as anti TNF, are the latest advance that is dramatically improving the outlook for those developing RA. Rehabilitation interventions can improve and maintain function, including dynamic training. Surgery also has an important role, predominantly arthroplasty when pharmacological therapies have not adequately prevented joint damage.
Effective management of rheumatoid arthritis requires early diagnosis and treatment by recognising those with early inflammatory arthritis and for expert assessment within 6 weeks to decide about disease modifying anti-rheumatic therapy. This should be in addition to symptomatic therapy, rehabilitation and education to improve understanding of their chronic disease and to encourage self management. Such management should be provided through a multiprofessional and multidisciplinary group. People with RA need regular monitoring to ensure optimal disease management. This will reduce the risk of longterm joint damage and disability and will lessen indirect costs of RA. This approach requires systems for early diagnosis and for referral to experts, which includes education of primary care physicians to enable them to recognise synovitis. Public education is also needed to ensure early presentation to the primary care physician at the onset of symptoms.
Osteoarthritis is a slowly progressive musculoskeletal disorder that can occur in any joint and is characterised by symptoms of pain, stiffness or loss of function. Studies showed that the work related disability rate with osteoarthritis varied from 30 to 50%, it is also a frequent cause of early retirement.
Age is the strongest predictor of the development and progression of radiographic osteoarthritis. Further risk factors are physical activity, injuries, high bone mass index and intensive sport activities.
Targets that are most important in the prevention or management of osteoarthritis are to reduce pain, disability and to prevent radiological progression.
There are various life style factors that increase the risk of developing osteoarthritis, increase its rate of progression and may increase pain and functional limitation. Preventable or modifyable risk factors are obesity and mechanical aspects of the joint f.e. joint laxity or malalignment. Tears of menisci or ligaments may lead to at normal loading of articular cartilage and result in the increased deveopment of osteoarthritis. Further risk factors are certain occupations (f.e. farmers for hip- and knee osteoarthritis), intensive sport participation, muscle weakness and nutritional factors.
Pharmacological interventions are mainly to treat the symptom of pain and have nearly no effect on tissue damage. Nevertheless activity and participation is improved as well as using simple analgesics, antiinflammatory drugs, disease modifying therapies, hyaluronic acid and intraarticular steroids. There is no evidence that pharmacological interventions can prevent osteoarthritis as defined by radiological changes.
Biomechanic deficiencies may lead to joint damage and result in pain and disability. Therefore surgical correction of these abnormalities can relief pain and improve function. Further surgical interventions to reduce the impact of osteoarthritis include cartilage repair and joint preserving surgeries. For severely damaged joints, partial or total replacement of the joint is now possible for all those joints that are commonly affected by osteoarthritis.
Osteoarthritis is commonly associated with limited function that can be improved with a wide variety of rehabilitative interventions. Symptoms of pain may be reduced by joint specific exercises, transient immobilisation, heat or cold packings and braces or other devices. Further attention can be put on modifiying the environment as adaptions at home and at work, support services or other social interventions. Eduction and self managements play an important role as well in early as in late stages of the disease.
The number of people suffering from pain or limitation of daily activities as a result of conditions related to the musculoskeletal system is increasing in Europe and worldwide. It is therefore essential to develop strategies to prevent both the occurrence of these conditions and the impact of these conditions.
Most musculoskeletal conditions occur in the elderly and as the elderly population will reach above 20% within the next 20 years this will further augment the problem within Europe, particularly as these conditions also increase with advancing age. It must be recognized that at most levels within the health care systems or within society, the impact of these conditions today and for the future is underestimated, both regarding number and regarding consequences; disability, handicap, social implications and costs. The major challenge is, however, not to make recommendations for preventive strategies but to implement them in order to secure a change, leading to improved care and improved quality of life for patient, regardless of age.
The first step in order to make a change is to define the size of the problem – the burden of musculoskeletal conditions. With respect to the incidence and prevalence the size of the problem is relatively well known. The size of the problem when it comes to the impact on the individual is less well known, as is the burden in terms of economic and societal costs. For many conditions the risk factors are identified and common to many conditions.
The second step involves evidence – evidence for the effectiveness of the interventions available today. When evaluating evidence it is useful to define population in terms of the normal or healthy population, those at risk, those at early or moderate stage and those at late stage of the condition since this will translate into preventive strategies appropriate for each level.
The final step is implementation and this is the major challenge at all levels, from policies trying to influence the entire population to adopt a healthier life style, to change the management of the individual patient in the doctor’s office. Based on knowledge of size and evidence, it is possible to transform recommendations into an actual action plan at national, regional and local levels. The principles for successful implementations are to a large extent similar for all levels.
The tools for success need to be identified and they may include financial or economic mechanisms, regulatory mechanisms, and educational or organisational mechanisms. It is particularly important to identify barriers and facilitators that will influence the outcome of the proposed strategy.
Musculoskeletal conditions have many risk factors and interventions in common with other conditions that affect public health, such as diabetes and cardiovascular conditions. In primary prevention it is therefore key to collaborate not only within the musculoskeletal field but also with other fields in order to improve also musculoskeletal health.
Traditional polyethylene oxidizes, wears and generates particles over time, which most probably contributes to increased risk of periprosthetic osteolysis. Even contemporary sterilization methods such as radiation and package in oxygen reduced or oxygen substituted environment do not eliminate oxidation over time. Thus, there is a need for alternative bearing in total hip replacement surgery and especially in patients with high activity and long life expectancy.
All three major alternate bearings, ceramic-on-ceramic, metal-on-metal and highly crosslinked polyethylene produce major reductions in volumetric wear. The electron beam, melted highly cross-linked polyethylene has an in vivo penetration rate after the bedding in period, which is less than 8 microns per year. This is not substantially different from ceramic on ceramic or metal on metal. Therefore, the inherent risk of periprosthetic osteolysis with these alternate bearings is probably smaller than observed with conventional polyethylene.
In the competition between different articulations highly cross-linked polyethylene has some advantages. The polyethylene is more
Impingement should also be avoided with use of polyethylene, but if it occurs, the consequences are often more benign at least in the short term perspective. Micro-separation results in less material damage with use of polyethylene than with the 2 other types of articulations. A few degrees of additional abduction above the geometrical limits for a particular socket is far less harmful if it is made of polyethylene compared to the situation in ceramic-on-ceramic or metal-on-metal bearings. Polyethylene is also more
On the other hand using highly cross-link polyethylene carries some risks. Particles generated from this new material are smaller with higher inflammatory response. Compared with joints including conventionally sterilised polyethylene the total particle production is, however, reduced with more than 85%, which has implications for the magnitude of the inflammatory response.
The significance and importance of the irradiation and melting induced changes of the mechanical properties of the polyethylene is not known. Long term follow-up is needed to evaluate this issue.
Charnley preferred small head sizes in total hip replacement because they resulted in transmittance of low frictional torque to the acetabular implant. Mueller advocated larger head sizes with improved joint stability and lower contact pressure. Large heads do, however, imply increased volumetric wear. Therefore, 32 mm heads were abandoned in the early 90ties in favour of 28 mm heads. Another consequence of using larger heads is that polyethylene liners are relatively thin. The highly cross-link polyethylene and the hard bearings can be used with bigger femoral heads, which increases the range of motion and the hip joint stability.
Amorphous diamond coatings has been studied as an alternative bearing surface in the laboratory (Santavirta 2003). Such coatings may provide wear rates 104 to 105 times lower than conventional THR articulations, because of their extremely hard surface and low coefficient of friction without any corrosion paths (Santavirta et al. 1999 Lappalainen et al. 2003).
Oxidized Zirconium (OxZr) is another material, which has similar advantages. Oxinium materials are the results of a process that allows thermally–driven oxygen to diffuse and transform the metallic zirconium alloy surface into a durable low-friction oxide. The Oxinium material is harder than commonly used cobalt chrome, and with only the surface changing during the manufacturing process, the rest of the implant remains metal to maintain its overall strength. OxZr provides superior abrasion resistance without the risk of brittle fracture, thereby combining the benefits of metal and ceramics. Knee simulator tests have shown that OxZr can reduce polyethylene wear substantially (Ries et al. 2002). Although promising, these two coatings still lack clinical documentation.
During the last decade it has become evident that many designs of total hip arthroplasty can in patients with normal bone quality be fixed to the bone with a high degree of reproducibility. This has had the effect that younger patients have been operated on in increasing numbers. Wear and periprosthetic bone loss have remained a serious and comparatively frequent complications. The introduction of more wear resistant articulations has the potential to solve these problems making the procedure safer also among these patients. So far there is no or very scarce evidence that these articulations can be used safely during decades without complications causing progressive and often silent bone destruction resulting in difficult revisions with high morbidity. In the case of metal on metal articulations release and accumulation of ions remains a long term concern and especially if the patients will suffer from a temporary or permanent disease associated with impaired renal function.
Because evidence of long term superiority of these new articulations is lacking it is of utmost importance that these new implants and materials are introduced into clinical practice in a controlled way. Careful surveillance of preclinical and gradually enlarged randomised studies followed by multicenter trials is necessary to avoid disastrous mistakes so common in the past.
Joint replacement implants, especially in their modular forms, are subjected to wear and corrosion at various sites in their articulation, such as the bearing surfaces, the undersurface of the insert, the femoral head-neck junction and the implant or polymethylmethacrylate-bone interface. Movement of the bearing surfaces is not the only cause, as faulty implant positioning can initiate wear through impingement between two parts of the articulation.
These wear products of polyethelene or metal, in particulate form, are influential to the ultimate fate of the prostheses through the initiation of local and systemic immune reactions.
These debris are phagocytised by macrophages and phagocytised proteins are partly degraded in intracellular vesicles, where they become associated with the major histocompatability complex molecule HLA-DR. This molecule when transported to the cell membrane, interacts with CD4+ lymphocytes to activate an immune response and initiate the production of interleukin1b, interleukin 6 and tumor necrosing factor a. These cytokines mediate the inflammatory response and activate osteoclasts causing periprosthetic osteolysis.
Polyethelene and metal wear particles, in addition to their local effects, can be disseminated beyond the periprosthetic tissues and reach distant organs and regional lymphnodes. The concentrations of certain elements of metallic implants, such as iron, cobalt, chromium or titanium have been detected in lymphnodes, the liver and the spleen in levels a lot higher than normal, especially in patients with loose prostheses and, less so, in patients with stable prostheses.
The reported values of metal ions in published series vary. Thus certain investigators (Brodner et al) have reported continuous systemic cobalt release during a five year follow-up period and in levels slightly above detection values, while others (Clarke et al, Lohtka et al) have reported consistently high levels of cobalt and chromium ions in metal on metal articulations. The diameter of the femoral head appears to be a significant factor. In surface hip replacements with large diameter heads the amount of detected metal ions was significantly higher compared with total hip replacements with use of 28mm diameter femoral heads. In that type of replacement the levels of cobalt was 50 times higher than normal and of chromium 100 times higher.
Polyethelene particles, similarily have been detected in paraaortic lymphnodes in percentages similar to metal ions. However the detection of PE particles in the liver or the spleen was less, compared to metal ions, possibly due to the difficulty of modern methods to detect PE particles of submicrometre size. The relevance of the dissemination of metal ions and of PE wear debris in organs distal to the operated joint need to be carefully evaluated since certain of these elements are known carcinogens. Two studies have reported slight increase of haemopoeitic cancers in patients with cobalt alloy implants and in patients with metal on metal devices, while others have documented the development of malignant tumours in the vicinity of total hip replacements.
Since prostheses with metal on metal bearing surfaces are used more and more frequently in younger patients, these patients require careful monitoring for longer periods.
Interest on acetabular version arose from unstable developmental dysplastic hips. Initial studies and clinical observations described the dysplastic hip as being excessively anteverted.
The advent of computed tomography allowed further detailed analysis of the acetabulum in the axial plane, yet these studies failed to determine conclusively whether or not the dysplastic acetabulum is abnormally anteverted. Much controversy evolved from different methods of measuring and from the fact that a more anteriorly located acetabular deficiency results in excessive anteversion while a more posteriorly located deficiency in retroversion. It remains inconclusive to what extent acetabular dysplasia is due to a mal-orientation of an otherwise normal configured acetabulum or to a deficient acetabulum which is otherwise normally orientated. Furthermore, the acetabular opening spirals gradually from mild anteversion proximally to increasing anteversion distal to it and therefore render its measurement dependent from pelvic inclination and from the level of the transverse CT scan slice.
On an orthograde pelvic X-ray, both, pelvic inclination and rotation can be controlled. Therefore, acetabular version is best estimated from the relationship of the anterior and posterior acetabular rim to each other on an orthograde pelvic X-ray.
The main hip pathologies, acetabular rim overload and anterior femoro-acetabular impingement, both occur in the superior part of the acetabulum, the acetabular dome, and that’s where version is best measured. We called this version of the acetabular dome.
Interest on retroversion of the acetabular dome arose from analysis of complications such as persistent posterior subluxation after acetabular reorienting procedures. They resulted in the hypothesis that the site of acetabular deficiency may vary and be more posteriorly located in some cases resulting in a rather retroverted than anteverted acetabular dome.
In fact, retroversion of the acetabular dome was found to be a characteristic feature of specific hip disorders. A review of ten patients with posttraumatic premature closure of the triradiate cartilage before age 5 showed beside a bowed hemipelvis with lateralized and caudalized acetabulum a mean retroversion of the acetabular dome of 27°. A review of 14 patients suffering from proximal femoral focal deficiency with a functional hip joint revealed a mean retroversion of the acetabular dome of 24°. Typically this was accompanied by femoral retrotorsion and coxa vara.
Finally, bladder exstrophy, when treated without pelvic osteotomy, typically end up with externally rotated or retroverted acetabula (Sponseller, 1995) Even in DDH, retroversion of the acetabular dome has been shown to be a significant variation as 40 of 232 such acetabula showed to have a retroverted dome (Li, 2003).
Furthermore retroversion typically can result from pelvic osteotomy in childhood as 26 from 97 subjects, who underwent either Salter or Le Coeur osteotomy in childhood ended up with retroverted acetabular domes after closure of the pelvic bone growth plates. In the context of neuromuscular or genetic disorders, dysplastic hips also may have retroverted acetabular domes and may additionally be influenced from fixed spine deformities. Finally, retroverted acetabular domes may be found in otherwise non dysplastic hips.
The relevance of acetabular retroversion is both technical and clinical: First, it calls for a more individual approach to acetabular dysplasia because presence of retroversion will affect the manner in which corrective osteotomy will be done. Salter-like reorientation maneuvers will result in worsening the pre-existing posterior deficiency or acetabular rim overload and risk continued posterior subluxation or dislocation of a previously reduced hip (Lee, 1991). Second, anterior overcorrection of a primarily retroverted acetabula may necessitate a further intervention to remove bone from the anterior aspect of the acetabulum or anterior part of the femoral head-neck junction due to limited hip flexion (Crockarell 1999, Myers 1999). Third, evidence that the long-term effect of retroversion of the acetabular dome is harmful is increasing: An association between decreased acetabular anteversion and osteoarthritis was found as soon as 1991 (Menke, 1991) and the prevalence of retroversion among patients with idiopathic hip osteoarthritis has been found to be 20% versus 5% among the general population (Giori, 2003). Furthermore, decreased acetabular and femoral anteversion was found to be a major cause of altered rotation, hip pain and osteoarthritis (Tönnis, 1999). A positive impingement test was the key clinical finding (Reynolds,1999). This anterior impingement of the femoral head-neck junction against the border of the prominent anterior acetabular wall which over a long period of time may lead to fatiguing and destruction of the acetabular labrum and the adjacent cartilage is thought to initiate groin pain and early osteoarthritis. Finally, even for total hip replacement, severe retroversion of the acetabular dome will make surgery more difficult.
Lesions of the acetabular rim have been implicated as a cause of hip pain in various pathologic conditions and are considered to predispose the hip to development of accelerated degenerative disease. In developmental dysplasia of the hip (DDH) and anterior femoroacetabular impingement (FAI), intrinsically normal intraarticular soft tissue structures are exposed to joint loading forces that physically exceed their tolerance level posing these pathomorphologies as precursors of osteoarthritis. In DDH, the deficient acetabular coverage of the femoral head has been related to osteoarthrosis, while the orientation of the femoral head is considered to play a less important role. The resulting instability and anterolateral migration tendency of the femoral head leads to chronic shear stresses at the acetabular margin. In FAI, repetitive peak contact pressures occur when the femoral head-neck junction abuts against the acetabular rim during joint flexion. Predisposing morphologies are femoral abnormalities such as an insufficient femoral head-neck offset seen in head tilt or pistol grip deformities, slipped capital femoral epiphysis, or malunited femoral neck fractures with the orientation and shape of the acetabulum contributing to this pathology. In classical DDH and FAI, diagnosis is primarily based on clinical signs and symptoms and conventional radiography. However, in cases of clinical and radiographic borderline disease establishment of the correct diagnosis is sometimes difficult. This presentation reports how the MRarthrographic appearance of acetabular rim pathologies can be used to differentiate both conditions. In DDH and FAI, labral pathologies localize identically with a predilection to the anterosuperior quadrant of the acetabulum. Labral tears are found in 64% in both groups. The volume of the labrum is increased in 86% DDH hips but in none of the FAI hips. Ganglion formation in the periacetabular area is seen in 71% DDH and 21% FAI hips. These findings provide evidence that the anterosuperior acetabular rim represents the initial fatiguing site of the hip under both DDH and FAI. The capability of MR-arthrography to depict differences in labral pathologies suggests this method as a helpful diagnostic tool to define the most appropriate treatment strategy specifically in borderline cases.
A number of radiographic indices were measured and compared including the VCE angle, LCE angle, and acetabular angles of Tönnis and Sharp. Variation in both the VCE and LCE angle was evaluated by measuring the index using two different reference points. This included (1) the traditional mark of the furthest point along the sclerotic density of the weight bearing zone and (2) an alternate point representing the furthest extent of lateral or anterior bony coverage. Additional sources of measurement error were determined. The relationships between the centre-edge angles and other radiographic indices were determined. An evaluation of the indices and correction on post osteotomy radiographs was also performed.
Nineteen of these cases displayed a “classic” lateral and anterior deficiency. However, 19 cases displayed a more uniform deficiency and 12 cases were in fact retroverted.
Evaluation of the radiographic indices revealed:
A mean VCE angle of 2.3 degrees (SD±12.7) and LCE angle of 3.4 degrees (SD±9.3). These were corrected to 25.8 degrees (SD±11.6) and 28.6 degrees (SD±8.7) following osteotomy. The VCE and LCE angles did not appear to be correlated (r=0.35). This is contrary to previous studies evaluating non-dysplastic pelvi (Chosa No correlation was seen either in the post osteotomy values, or in the absolute degree of correction. The A similar variation was seen when comparing the LCE angle and the The mean VCE in hips with primarily anterior and lateral deficiency (−6.7°±12.5) was significantly lower (p<
0.01) than those with uniform deficiency (5.1°±8.3) or those with retroverted acetabuli (8.9°±13.3) Dysplastic hips with a decreased LCE angle but relatively normal Tönnis angle should be treated carefully as osteotomy may result in excessive angular correction in the coronal plane, thus creating a negative Tönnis angle. This can ultimately lead to problems with lateral and/or anterolateral impingement.
Potential sources of error in measurement that were identified include:
Deformity of the acetabulum and occasional abnormalities of the femoral head limit the ability to identify the center of the rotation necessary to measure the centre-edge angles. Subluxation of the femoral head also creates a degree of error. These difficulties were observed in over 20% of cases. Alteration in pelvic tilt and rotation theoretically decreases the accuracy of measurement. Practically over 30% of radiographs were seen as less than ideal. The absolute reference point for VCE and LCE angles as the end of the sclerotic line in the weight bearing area can be (1) difficult to define (2) does not always represent the most anterior or lateral extent of the acetabular margin. This discrepancy appears to increases in dysplastic hips. This has been suggested previously (Fabeck et al.,1999) and is now supported by our findings.
Radiodense structures resembling ossicles at the acetabular rim have received multiple names including “Os acetabuli, Os supertilii, Os marginale superius acetabuli, and Os coxae quartum”.
Various theories regarding their origin have been postulated. These structures commonly are observed in dysplastic hips and hips suffering from femoro-acetabular impingement and represent fractures of the acetabular rim. In our series we observed acetabular rim fragments in 4.9% of the dysplastic hips and in 6.4% of the hips with femoro-acetabular impingement.
Two different pathomechanics are responsible for the occurrence of these rim fragments. In dysplasia the short acetabular roof reduces the amount of available loading surface which leads to an overload on the lateral margin of the acetabulum, propagating the development of a fatigue fracture. However, as in all hips additional cysts were visible, it must be postulated, that cysts have to be present additionally and act as stress risers through which the rim bone eventually will fail. In hips with femoro-acetabular impingement the mode of failure is different. The relative anterior overcover in retroverted hips is subjected to stress during flexion of the hip, which is further increased by the frequent presence of an non-spheric extension of the femoral head as seen in cam impingement. The nonspheric femoral head-neck junction is jammed into the rim area. By repetitive traumatization the anterior rim eventually will fracture.
The clinical importance of acetabular rim fractures in the dysplastic hip is readily understood even by an unexperienced observer. However, it has to be considered as a sign that the hip has decompensated and it usually goes with significant articular cartilage damage. Because the radiographic appearance of the hip with femoro-acetabular impingement seems normal at first sight, the mechanism leading to anterior rim fracture may be overlooked. However, recognition and adequate treatment is important to prevent further degeneration of the hip.
Alignment, coverage and congruency are traditional keywords for the morphological interpretation of the hip joint. Most of the collected information come from ill-defined radiographs and are mainly used to characterize the capacity of a hip for load transmission. Accordingly threshold values for undercoverage are more precise than the definition of overcoverage.
The understanding of what is a normal hip anatomy is changing rapidly; other parameters have to be included as well. The impingement concept introducing motion as an important initiator of osteoarthritis is based on relatively minor morphological abnormalities of the hip which were of little interest until now. With high quality MRI we recently learned that a hip joint may have substantial cartilage damages although it looks radiographically normal.
This Symposium is a first attempt to update on our standards Puloski et al. point to weak radiographic parameters. Dora discusses hitherto barely noticed indicators like the acetabular version which has a high potential for morbidity. Beck et al explain the acetabular rim fragment, a structure which can be seen in dysplastic as well as in impinging hips. Finally Leunig et al. use the MRI-morphology of the labrum to distinguish between dysplasia and hip impingement in borderline hips.
Fracture is the only clinically relevant aspect of osteoporosis—a major public health problem in many countries. The strongest predictor for a new fragility fracture is a previous one. For instance, a patient with one osteoporotic vertebral compression fracture has about a seven-fold increased hip fracture risk; a patient with two compression fractures a 14-fold hip fracture risk. Today, we have evidence based and efficient osteoporosis drugs as well as non-pharmacologic methods for fracture prophylaxis. In risk group patients it often is possible to halve the fracture risk.
The orthopaedic surgeon is the first and sometimes the only doctor a fracture patien sees. Therefore, as orthopaedic surgeons, we have a great opportunity—and indeed an onus—to identify patients with increased fracture risk, and to do something about it.
Imagine patients with myocardial infarction or stroke discharged from hospital without blood pressure control or having a biochemical profile taken? Such negligence is, alas, not uncommon for patients with fragility fractures. We must think in terms of absolute fracture risk, and implement today’s evidence based knowledge.
Secondary prophylaxis should be an integrated part in fracture treatment. And this calls for a multidisciplinary and multiprofessional teamwork including surgeons, geriatricians, endocrinologists and general practitioners, as well as nurses, physiotherapists and a wide range of other paramedical specialists. Such “fracture chains” will reduce the number of unnecessary and preventable injuries and will have a great impact in terms of cost and suffering. This symposium will give an overveiw of fracture-preventing strategies.
In the trend to operate hip fractures with less invasive procedures it is important to realise that the semi-percutaneous approach to make osteosynthesis with two screws or hook pins for femoral neck fractures, actually is a mini invasive procedure. It is well proven since decades.
The major question is to select the right patients for osteosynthesis versus arthroplasty (unipolar hemi, bipolar hemi or total hip arthroplasty). It is depending on the damage to the blood supply of the femoral head. There is at the moment no methods for this in routine use, but with the development of MRI techniques it might be possible. The goal is to select the right patients for osteosynthesis to minimise the healing complications and the need for secondary hip arthroplasties.
The hook pin procedure has been extensively used in Sweden through decades. Since the last 5 years there is an increasing trend for the most displaced fractures in older patients to be operated with a hemi arthroplasty. Previously a primary osteosynthesis was the first choice in all patients. The results of 10 years use of this procedure in Lund 1988–1997 shows that for the total of femoral neck (cervical) hip fractures the need for a secondary arthroplasty within 2 years was 20%. Previously published need for secondary arthroplasty was 13% when only well trained surgeons operated. There is thus no need to behead all displaces femoral neck fractures because some fail. In Norway the principles of primary osteosynthesis still mostly prevail. In a randomised comparison between hook pins and screws it was found that the rates of early failure of fixation, non-union and need for reoperation did not differ significantly between the two osteosynthesis methods. The use of hook pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6) and a lower incidence of necrosis of the femoral head (odds ratio 3.5). The technique of performance was of significant importance. There was a highly significant relationship between poor reduction and poor fixation of the fracture and subsequent reoperation. Likewise per-operative drill penetration of the femoral head was associated with a greater risk of reoperation. In total 22% of these patients needed a major reoperation (usually hemi arthroplasty). In 7% of the cases the fixation device needed to be removed after a healed fracture. In another randomised study between hook pins and three screws 57% of the patients were operated within 6 hours from admission to hospital and 92% within 24 hours. The mean (median) time for operation was 36 (30) minutes for the hook pins and 40 (35) minutes for the AO screws. After 2 years 77% of the hook pin patients had not needed any reoperation compared to 73% in the AO screw group. In total a secondary hemiarthroplasty had been performed in 7% and a total hip arthroplasty in 12% of the patients. Extraction only of osteosynthesis material had been performed in 5%. Again, healing was much higher if the reposition and positioning of the osteosynthesis material was optimised.
Osteosynthesis is a mini invasive procedure. It is indicated for all undisplaced cervical fractures and for less displaced fractures, particularly in younger patients. Attention to the reposition and positioning of the osteosynthesis material is necessary. An image intensifier with large field of view and good resolution facilitates this, preferably a biplanar. The future goal is to select the patients better for the different procedures osteosynthesis or arthroplasty.
The risk of further fractures increases 2–10 times after the first fracture. Actual fracture risk for the given person (absolute fracture risk) can be calculated from data collected in 10-year prospective studies (NHANES or Kanis 2001). To calculate absolute fracture risk one has to multiply age-related risk factor ascertained in above studies by the coefficient estimated for particular factors influencing possible fracture (relative fracture risk). The most commonly used factors are: age (RR 2.0 for each 5 yrs over 65), low BMD (RR/SD 1.4–2.6), low-energy fracture after the age of 40 (RR 4.0), proximal femur fracture in mother (*RR 1.9), body mass lower than 58 kg (*RR 1.9), early menopause – before the age of 45, smoking (RR 1.2), susceptibility to falls (*RR 3.5), corticosteroids intake.
Absolute fracture risk in 60-year-old woman whose foreseen 10-year probability of femoral neck fracture is 2.3% with normal BMD but burden by factors marked by asterisks would be: 2.3% x 1.9 x 1.9 x 3.5 =
We can increase bone mineral density by pharmacological intervention. Every patient should be given calcium and vit. D supplementation and a specific medication, which should be adjusted to: age, sex and presence of hot flashes and fractures. HRT is preferred in women aged 50–60 yrs suffering from hot flashes. HRT decreases the risk of spine (50%) and proximal femur fracture (40%). However some risk of breast and uterine cancer has to be taken into consideration. Selective estrogen modulators (SERM; raloxifene) act as estrogen agonists on bone and cardiovascular system but as antagonists on breast tissue. Decrease of spinal fracture (45%) and breast cancer incidence (70%) is proven but no positive action on proximal femur is reported.
In women who underwent osteoporotic fracture one can apply bisphosphonates, strontium ranelate or PTH. Alendronate reduces spine fractures (47%) and proximal femur fractures (51%). Similar effects are documented for risedronate (spine – 60% and proximal femur 40–56%). Strontium ranelate not only inhibits bone resorption but also stimulates bone formation. Decrease of spine and proximal femur fractures occurrence has been proven (41%). PTH injected sc. in daily doses is the most powerful compound which rebuilds bone trabeculae in severe cases and reduces incidence of peripheral fractures (53%). Calcitonin is effective in spine fractures but not in proximal femur.
Fall prevention program should be implemented in all patients with osteoporosis independently from pharmacological intervention.
The incidence of reported cases of whiplash has risen dramatically in many Western Countries.There was an initial increase, in the United Kingdom, following the compulsory wearing of seatbelts for drivers and front seat passengers but since then the incidence has increased even more. This pattern has been reported in other regions.
Many factors have been proposed to account for this increased incidence, including changes in car design, increased traffic density, psychosocial aspects and increased litigation.
Although whiplash injury is defined as a “minor” injury it may be associated with prolonged morbidity. The factors causing chronicity are not well understood but do include the severity of the initial injury (WAD 3 injuries doing significantly worse than WAD 1 and 2 injuries), the development of psychological symptoms, age and bio-social factors. Prolonged litigation and prolonged inappropriate treatment also lead to chronicity.
Because of the decreased holding power of the screws, fixation of osteoporotic fractures has a high failure rate (10%–25%). It should also be reported that even if fixation does not fail, several osteoporotic patients with fractures have unsatisfactory functional results due to bony malunion.
Elderly patients with osteoporosis demand better fixation techniques. Treatment goals in this particular patient population include: proper fracture alignment, stable fixation and early rehabilitation. A surgeon should adopt a minimally-invasive technique in order to relieve the patient of physiological stress and allow for full-weight bearing of the fractured limb. Several fixation augmentation techniques have been proposed such as the use of PMMA, calcium phosphate cement, oblique screw insertion and cannulated ported screws.
Our studies indicated that osteoporotic bone fixation can be greatly improved by using implants coated with calcium phosphates such as hydroxyapatite. Hip fractures are the most severe form of fracture in patients with osteoporosis. Cut-out of the load-bearing implant is seen more frequently compared to patients with good bone quality often leading to revision surgery. We compared dynamic hip screw (DHS) fixation with hydroxyapatite(HA)-coated AO/ASIF screws to DHS fixation with standard AO/ASIF screws in osteoporotic trochanteric fractures. One-hundred-andtwenty patients were divided into two groups and randomized to receive 135° 4-hole DHS with either standard lag and cortical AO/ASIF screws (Group A) or HA-coated lag and cortical AO/ASIF screws (Group B). Inclusion criteria were: female, age >
65 years, AO/OTA fracture type A1 or A2 and a bone mass density (BMD) T-score lower than −2.5. Exclusion criteria included lag screw extension into the proximal third of the femoral head. Between the two groups, there were no differences in patient age, BMD, screw position in the femoral head, tip apex distance, quality of reduction and fracture impaction at the 6-month follow-up. In Group A, femoral neck shaft angle (FNSA) reduced over time (134
External fixation could be a viable treatment option in elderly trochanteric fracture patients since it typically involves a low energy trauma. However post-operative complications associated with inadequate pin fixation have limited its use. Because of the development of HA-coated screws, we compared external fixation with HA-coated screws (H-CP) to DHS with AO/ASIF stainless-steel screws in osteoporotic trochanteric fractures. Forty patients were divided into two groups and randomized for treatment with either 135° 4-hole DHS (Group A) or external fixation with 4 H-CP (Group B). Inclusion criteria were: female, age > 65 years, AO/OTA fracture type A1–2 and a BMD T-score lower than −2.5. All fixators were removed at 3 months. There were no differences in patient age, fracture type, BMD, ASA, hospital stay and quality of reduction. Average number of blood transfusions was 2 ± 0.1 in Group A, whereas no blood transfusions were required in Group B (p < 0.005). Post-operative FNSA was 134 ± 6 ° in Group A and 132 ± 4° in Group B (ns). In Group A, the varus collapse of the fracture at 6 months was 6 ± 8° and in Group B 2 ± 1° (p = 0.002). The Harris hip score was 62 ± 20 in Group A and 63 ± 17 in Group B (ns). In Group B, no screw infection occurred.
Several studies document what we all know – that, in the vast majority of patients treated in fracture units for low-trauma fractures, there is no attempt to identify and treat factors predisposing to further fractures. We treat
Equally, it is completely unrealistic to expect orthopaedic surgeons, focused on surgically treating a tide of challenging osteoporotic fractures, to assess the risk in each patient of further falls and the degree to which bone strength is compromised, and be responsible for prescribing treatments which will reduce risk in a cost-effective way. Yet the fracture unit is absolutely the best (and most cost-effective) place to identify the group of patients who will benefit most from preventive measures.
The answer is to work in a system, which connects up the right people to give each patient what they need. Surgeons to heal the current fracture (together with rehabilitationists to restore function and confidence) and physicians to assess and treat falls risk and osteoporosis.
Making this happen in practice requires answers to questions only you can answer:
who are the best physicians for our fracture unit to work with? what is the best mechanism for selecting the appropriate patients to refer? how do we persuade the commissioners to pay for it?
This is an issue in which it is worth us investing a lot of effort: we will ourselves soon be old and we must get this right in time for when we need it!
Whiplash associated Disorder is a clinical entity that is well recognised by doctors patients and the legal profession. It is however a clinical syndrome that has few of the characteristics that are normally associated with the epidemiology and pathology of injury.
The dilemma of Whiplash is the absence of hard evidence of any pathological process that would normally be considered evidence of a disease process.
Epidemiology exposes some of the gaps in the current models of whiplash. There are unexplained cultural variations. The different legal mechanisms of claim should not influence a physical traumatic disorder.
There is normally a clear relationship between the kinetic energy involved in injury and the tissue disruption that occurs. Experimental models using crash tests produce conflicting results. Studies of polytrauma reveal a very low incidence of post traumatic neck pain.
A range of opinions are available in the literature on pathology and biomechanical factors. Systematic analysis reveals the level of evidence for the establishment of the disease of whiplash in the 1960’s to be level two or three, while the evidence for discarding whiplash as a physical disease in the modern literature is level one or two. It is much harder for physicians to discard a cultural fixed belief in a disease that may never have existed rather than to accept the verifiable logic of modern models of disease.
Various historical arguments that have been used to support a physical basis for whiplash associated disorder have a flawed logic. The current best evidence would suggest that the acute phase of a whiplash disorder may be the result of a minor soft tissue injury, the natural history of which is recovery. There is little or no evidence to support a physical basis for chronic symptoms, which on the balance of probability are due to psychosocial factors. Whiplash is a ‘convenient’ model of illness which results in ‘gain’ for all those involved in its manifestations. It is a convenient disease.
Victims of motor vehicle accidents often seek health care following whiplash injuries. Their complaints (whiplash associated disorders, WAD) are classified on a 1–4 scale developed by the Quebec task force (QTF) in 1995
Responding to the acute symptoms with activity (act-as-usual and exercise) results in improved outcome
Approximately 50 % of patients with chronic WAD suffer from zygapophyseal joint pain that will be relieved for a period of several months if treated with percutaneous radiofrequency neurotomy
State-of-the-art treatment for acute WAD is available and needs to be implemented.
Further research on the treatment of chronic WAD should focus on the patients’ cognitions and movement behavior.
The cost of claims for personal injury after whiplash injury costs the economy of the United Kingdom some £3 billion per year. The majority of vehicle occupants subjected to rear-end shunt either suffer no effects or make a complete recovery however a minority suffer adverse psychological and social consequences which may be largely unrelated to the severity of the initial physical insult.
The early psychological reactions include feelings of being shocked, frightened and angry which are related to the victim’s subjective perception of accident severity. During the days after many victims continue to experience anxiety and distress manifest in physical, emotional, cognitive and social complaints – which may be severe enough to constitute the diagnosis of acute stress disorder which has a high risk of subsequent PTSD (Post – Traumatic Stress Disorder)
Ongoing apparently disproportionate disability can take a number of forms but is usually an unconscious process resulting from the interaction of physical, psychological and social variables.
The risk factors for a poor psychological outcome include pre-accident characteristics, the nature of the accident, beliefs favouring chronicity, quality of care along with independent post-accident events and in many cases the effect of litigation.
Surgical treatment of degenerative disc disease (DDD) has been widely modified in the last decade. The clinical evaluation of back pain has been improved by the use of functional scores and VAS. The discography is an adjunct for decision-making, but CT scan and MRI are the keys to evaluate the aging process.
The conservative treatment with physiotherapy and exercise programs is always the first and very useful treatment. Percutaneous therapy like facets injection, laser, IDET, radiofrequency in the disc can be a solution in some specific cases. Their efficacy has been evaluated in different studies and is sometimes controversial but there aren’t contraindications for further treatment and their complication rate is low. Dynamic posterior stabilization devices using pedicular screws and ligament tension band are proposed to try to put the disc in rest and some histological analyzes confirmed this hypothesis. Interspinous devices have been evaluated since many years but there indications need to be established as the literature available doesn’t provide clear indication criteria. Partial disc replacement is a new challenge for DDD. Many devices have in clinical evaluation but only few have prospective studies demonstrating their efficacy. The PDN was the pioneer and as the other in the evaluation process it has to solve the problem of the stability of the device. The last products on the market are promising. The total disc replacement is the last solution before fusion. Many studies including prospective and randomized have demonstrated the efficacy of total disc replacement. The indication is the key point of success. The training to perform the approach safely is mandated. Finally the fusion: anterior, posterior or combined is the ultimate solution to treat DDD. This was the gold standard and is still the most widely used treatment. As a dead end fusion is used only if other solutions cannot be proposed or used. DDD therapy has to be considered with the help of an algorithm including all motion preservation treatment before fusion.
The multiplicity of factors that influence the clinical evolution of discopathies, determine a great diversity in its presentation.
The barely known genetic predisposition, the individual morphological aspects, the age and sex, the associated co-morbidities as well as the patient environment define in its all an individual context that influences decisively the treatment for each patient.
On the other hand, the identification in each case of the different stages of the multilevel DDD, causes doubts regarding the involvement of each segment in the respective clinical condition.
To singly identify all sources of pain, and not only each painful level, is the main challenge poised to the spine surgeon when defining the treatment strategy.
The diagnosis aggressiveness must be proportional to its doubts, and the discography, the disco-scanner and the facet blocks are fundamental when the conventional clinical investigation is inconclusive.
The use of minimal invasive techniques such as IDET or Coblation can be considerate as alternatives, especially in the early stages of single-level DDD.
The nucleoplasthy – nuclear prosthesis- is an interesting alternative in the intermediate stages of the discogenic pain DDD, as well as in the predominant facet pain or in the foraminal dynamic stenosis is the dynamic stabilization. Those are techniques with controversial results and which liability in some cases is yet to be proven.
Last, the use of different techniques in different levels in the context of multi-level DDD – ex: fusion + disc replacement; disc replacement + dynamic stabilization with or without decompression procedures in the spinal canal- must be rigorously considered according to the specific dysfunction of each segment and considering the anatomical and functional reconstruction of the spine.
The incidence of major hand injuries has fortunately declined in Europe in recent years owing to the enforcement of Health and Safety Regulations and the automation of many manual tasks. As the numbers of major injuries decline so too does the surgical skill and experience of the surgeon. Yet, major injuries will still occur and patient expectation will always be driven higher as media encompasses dramatic results from around the world. This symposium draws together experts from Europe and especially from Turkey and India where experience with these injuries is so much greater nowadays than in Western Europe.
Classification is difficult but necessary if outcome comparisons are to be made. A brief outline of available classifications will be given. The speakers will then cover the topic on an anatomical basis including the priorities in the acute management.
Fusion has been the surgical reference for treating degenerative disc disease, nevertheless in the last two decades the recognition of it’s inconvenients, such as the degenerescence of the adjacent level, the growing demand for a better life quality by the patients and the evolution of the knowledge regarding the biomechanics of the spine and of the intervetebral disc itself, have stimulated the development of new technologies for the treatment of DDD among which the Disc Replacement.
In this symposium will be analysed the biomechanics of the disc and disc replacement, enhancing the already known benefits of the movement preservation, by discussing the different philosophies of the available systems: non-constraint; semi-constraint; and constraint.
The analysis of the overview results in the literature of fusion in comparison with disc replacement will also proportionate a fundamental actualization when deciding over the current perspectives in the treatment of DDD, considering the treatment alternatives developed in the meanwhile.
The disc replacement is an actual challenge with believers all over the world as an important step forward towards better life quality of patients with incapacitant low back pain. But with indications and limits that must be well known. Besides that it’s a demanding technique with potential risks associated and that demands specialization in this domain for its practice.
Always considering the different phases of evolution of the DDD, which can occur simultaneously in the same patient, different therapeutics solutions are considerate and which application deserves a profound reflexion according to the diagnosis characteristics, its staging, the ponderation of risks and benefits and as well its socioeconomics consequences.
Most of the major acute injuries of the hand will involved the tendons, either flexor or tendon lesions or both.
In programming the repair of tendons we have to evaluate all the others structures affected that need to be repair and remember that we should provide a good coverage of these structures.
In some situations it will be possible to suture the tendons directly, but in others we might need tendon grafts or to transfer some motor units for reconstruction of others, including the use of tendons of amputated parts. In other situations with grate tissue destruction and loss of pulleys of the flexor tendons it might be reasonable to do the reconstruction at a later procedure and to utilize silicone rods to maintain the space for a later reconstruction.
Tendon adhesions, joint stiffness, boutonniere and swan neck deformities are some of the complications that we might expect to have, even with a good rehabilitation program, and to solve at a later surgical procedure.
An informed consent document signed by a patient before surgery is supposed to provide evidence that he effectively received adequate information to be able to give informed consent. In fact, it only provides limited legal protection to the surgeon. Although the situation may vary from one country to another and, within each country, from one court to another, a standard consent form is usually considered inadequate, and a procedure-specific consent form appears as a minimal requirement. Even this will provide limited protection if a patient has presented a complication not listed. When confronted to a determined lawyer who pleads the absence of informed consent, a surgeon will most often not be able to give evidence for disclosure of some specific items to the patient.
This raises a number of questions:
- How extensive should the information be? Should compliance with a legal obligation always prevail over common sense? - How much information can the average patient understand, store up and recall? How make sure that information has transformed into knowledge? - Is it fair to require a surgeon to decide himself that his patients have been adequately informed, without being suspected to have faced a conflict of interest? Or should an independent authority be responsible for attesting, after an examination interview, that patients have received adequate information and are eligible for surgery? - Should disclosure of all complications be forced on a patient who does not wish to know about them? Common sense and legal obligations may diverge on this point. - Should preoperative consultations be (video) taped so as to procure objective evidence to serve in case of subsequent litigation?
In litigation cases, the burden of proof used to bear on the patient but has now more or less overtly been transferred to the surgeon, while he is not offered the possibility to face such demands in the current organisation of health care in most countries. Even though paternalistic medicine is no longer politically accepted, many patients still expect counselling rather than just information; law makers and lawyers have decided that these patients are wrong, but it is difficult for physicians who have been trained in the spirit of Hippocrates’ oath to behave merely as informers and technical care providers.
Medical activity takes place nowadays under ambiguous conditions. There is a politically accepted vision of medicine in which choices and decisions are made by the patients, as it is supposedly possible to bring all of them to a level of knowledge and understanding which makes this possible; when going in the field, things are different, and most patients are still looking for expert counselling in addition to or in lieu of information. As compared to the situation which prevailed a few decades ago, patients are much less ignorant about medicine in general, but the problem is that medicine has progressed far more rapidly than the layman’s medical knowledge.
Besides, a number of studies have shown that retention of information by patients decreases rapidly over time and is fragmentary, with potential benefits from surgery being recalled much better than possible complications. Patients have also been shown to ingenuously deny receiving information despite documented evidence; ingenuous fabrication, i.e. affirmation of an untruth, is also a classical observation
We know all too well that a number of our patients come to surgery without a proper comprehension of their pathology and therapy, and we have to pretend that we are not aware of it, otherwise we would have to deny those patients the benefit of surgery. To change this would require a major involvement not only of the medical profession but also of the almighty health care administrations and of the funds providers
Commercial aviation has recognized since long time that the so called “human factor” is the main responsible for the majority of accidents or near-accidents, which are always reported in aviation but almost never in medicine. Therefore I strongly support the idea that we could much learn from aviation in order to cope with the major cause of our accidents. Like airmen, pilots, air traffic controllers and so on, we also make errors. The first step to reduce the burden of our errors is to be able to admit them in order to analyse their causes, which up to now we are unable to do. Only one medical journal, the Lancet, has started to publish our errors. But beware not to make confusion between, complication, negative outcome and medical error.
The “human factor” must not be understood as human error; on the contrary the human factor is related to the majority of accidents, where the human error is only a minor and final cause.
To understand how “human factors” can play a role in determining the “accident”, we must first distinguish between active and latent failures. Active failures are unsafe acts committed by those at the sharp end of the system: the pilot, air traffic controller, anaesthetist, surgeon.
Latent failures arise from fallible decisions, usually taken within the higher levels of the organization or within society at large. A clear example is the crash of the SAS aircraft in Milano Linate with a small aircraft of the general aviation on the same runaway. No ground radar was available and the fog made the rest. But only the “sharp end” of the system, i.e. the traffic controllers paid for their error, not those responsible for not buying the ground radar.
We must develop a new culture of error but this will remain difficult until our legal systems do not change their approach towards negative outcomes. This vicious circle needs to be cut for the benefit of all, patients and doctors.
Most major Upper limb injuries are invariably associated with significant skin and soft tissue loss. With the recent technical advances, it is possible to cover most defects. This allows salvage of limbs which were being amputated before. Primary reconstruction of composite defects is also possible thereby shortening the reconstructive process. The ten key points are
Debridement is the key to success. The quality of the bed determines the infection rate and the ultimate functional outcome. Good debridement is essential irrespective of the type of skin cover provided. You make it or miss it at this stage. Cover the wound as early as possible, preferably within 48 hours and certainly before infection sets in. Tendons and bones do not tolerate exposure. Dried and dead bones and tendons must be excised before providing skin cover. While providing skin cover, make the complete plan and not decide for the day. The cover provided should facilitate the next stage of reconstruction (bone or tendon graft or transfers) Good skeletal stability is a must before providing skin cover. In the upper limb stable internal fixation is preferable. Loose fixation is the beginning of the end. If secondary procedures are to be done, skin flaps provide better access than fascial flaps covered with graft. Composite defects need not always be reconstructed with composite flaps. One need not try every known flap. Do what you are good at. Repetition is the mother of skill. Having said that one must also recognize the inherent limitation of any technique. Be willing to change or try alternate plans when faced with problems. Don’t forget donor site morbidity. Initial patient satisfaction is dependent on wound healing. Long term satisfaction is dependent upon donor site morbidity. Do not give up reconstruction of a major hand injury for fear of inability to cover the wound. Never hesitate to seek help. A well healed reconstructed hand is functionally far better than the best available prosthesis.
Patients seek more and more actively compensation for treatment injuries, accidents, infections, and even because of unsatisfied results. Injuries or mistreatment are quite frequently seen in orthopaedic surgery, because operations are increasing and unsatisfactory results can be easily recognised from radiographic documentation.
Compensation can be theoretically sought by three main routes: directly from the orthopaedic surgeon or his insurance company, secondly, from the institution where he is working (or its insurance company) and thirdly, from a statutory system if there is one available. The first two direct compensation mechanisms are based on direct link between the patient and the physician involved. A statutory system can be universal and act more as a no fault compensation system.
Statutory patient insurance was introduced in1987 in Finland (Patient Insurance Act). This act covers all medical treatment, both public and private care in Finland including examination, surgical and nonoperative treatment, inpatient ward treatment, physiotherapy, rehabilitation as well as patient transportation.
All hospitals and companies dealing with medical care need to be insured. The institutions or companies responsible of the medical work owe the policyholder status. Therefore workers in the medical field need not to make their own insurance agreements nor pay any insurance fees to the companies.
The Finnish Patient Insurance Centre handles all claims in Finland, about 7.000 cases yearly, of which about 2.000 will give compensation to the patients. An independent Patient Injury Board stated by the Ministry of Health supervises the Centre.
So far, orthopaedics and traumatology has been the leading speciality in producing injuries. The injuries are divided into six subgroups: 1) treatment injury, 2) infection, 3) equipment-related injury, 4) accident related injury, 5) wrong delivery of pharmaceuticals and 6) unreasonable injury (severe complication with permanent disability after accurate treatment).
The evaluation of patient injury is concentrated on the case itself. The personnel involved to the treatment will not be accused or sued whenever a patient injury has been recognised. This no-guilt principle has been adopted well in Finland.
In the treatment injuries the level of acceptable care is determined by standard of an experienced professional of that speciality he/she represents. That means that an orthopaedic operative or diagnostic procedure will be evaluated compared to the level, which a graduated and experienced orthopaedic surgeon could have normally reached. Infection injuries are considered acceptable and do not lead to compensation when being superficial, or if a deep infection heels within a couple of weeks or months with adequate treatment and without any permanent disability. Traumatic accidents are quite rare as well as breakage of medical equipment and error of delivery of pharmaceuticals in pharmacies. Unreasonable injuries are seen a few yearly.
The prerequisite for compensation is that there has to be an objectively recognised harm to the patient due to a diagnostic or treatment procedure. Patient insurance covers the following costs: 1) medical treatment expenses, 2) other necessary expenses caused by the injury, 3) loss of income on maintenance, 4) pain and suffering, 5) permanent functional defect, and 6) permanent cosmetic injuries.
In 2004 the total costs of compensation paid was 24.2 million e (public health care 88% and private health care12%).
The yearly claim and compensation data is used for comparative analysis between the hospital districts and given also to the medical and surgical societies in order to enhance medical knowledge and skills and prevention of similar injuries in the future.
Patients owe still the possibility to sue the hospital or doctors involved. However, these cases will be normally handled by the Patient Insurance Centre and not by the medical personnel individually. In fact, the amount of trials against medical units or personnel has diminished dramatically after adoption of the Patient Insurance Act in Finland.
Pediatric hand surgery in general requires special considerations and this is even more true when planning surgery in children with CP. It is important for the surgeon to realize that the functional problems these children exhibit have their cause in a brain damage which is not amenable to hand surgical treatment. Therefore it is crucial to carefully analyze each child’s impairment including the voluntary motor control and the child’s specific needs before endeavoring into surgery. Associated impairments, such as mental retardation, nutritional problems, epilepsy, dystonia or severe sensory deficits may influence decision-making, but the crucial factor is often the child’s own wish for an improved function. A child that completely neglects his or her extremity is usually not helped by surgery, at least not in an attempt to get a better hand function.
Hand surgery in CP mainly comes down to three techniques: 1. Reducing strength in spastic muscles by release operation, either at the origin of the muscle, at the insertion or as a fractional lengthening at the musculo-tendinous junction, 2. Increasing strength in weak antagonists by tendon transfer or 3. Stabilizing joints through an arthrodesis or a tenodesis. Most often a combination of these techniques is used. Almost all hand surgeons in this field have acquired their personal choice of procedures and scientific support for the benefits of the different techniques is scarce. My personal arsenal will be described in the panel but includes biceps-brachialis muscle release at the elbow, pronator teres rerouting, flexor carpi ulnaris to extensor carpi radialis brevis (Green’s) transfer and adductor pollicis muscle release in the palm combined with extensor pollicis longus rerouting for the thumb-in-palm deformity. In my mind, it is not most important which tendon transfer that is selected, but the choice of which child to operate and at what age. It is also important to tension the tendon transfers exactly right and to plan the postoperative treatment properly. The surgeon should, of course, also make sure that the child’s and the parent’s expectations on the results are realistic.
Botulinum toxin A has now been used for several years in the treatment of children with cerebral palsy and the drug has been shown to be safe and effective in reducing muscle tone both in the lower and the upper extremities. It has been more difficult to show effects on hand function especially in the long-term perspective. I will present our treatment protocol for botulinum toxin injections.
In 1994, a population-based health care program for children with CP was started in Lund in southern Sweden. All children in our region with a diagnosis of CP, born after Jan 1st 1990 are invited to follow the program which includes regular measurements of range of motion in extremity joints, standardized radiographic examinations of the hip joints and registration of surgery and spasticity treatments. The program, called CPUP has been very successful in the prevention of spastic hip dislocation, wind swept position and contractures. Some early results from the upper extremity part of CPUP will be presented. We believe that the program in time will give us valuable information on the natural course of joint motion and impairment of hand function in children with CP.
In Sweden 99 % of all complaints against doctors are handled by a public authority, The Medical Responsibility Board (HSAN). This way it is very rare fore a medical complaint to reach the judicial courts in Sweden. HSAN is a national authority that assesses medical negligence. If health care staff is at fault, the Board can take disciplinary action against them.
The Board is made up of nine members. The chairman is a lawyer with judicial experience and the other members have experience from various sectors of the health services. Anyone who is or has been a patient can file a complaint to HSAN. The National Board of Health and Welfare, the Parliamentary Ombudsman and the Chancellor of Justice can also file complaints to HSAN. The complaint must contain details of the actual examination, care or treatment referred to, when and where it took place and, if possible, who was at fault and what the fault is considered to be. HSAN must be informed of the subject of complaint within two years of the incident’s occurrence. If this is not the case, disciplinary responsibility will have lapsed.
HSAN’s decisions are always public. A case is prepared by getting the opinion of the accused doctor and a copy of the patient records.
When a case has been prepared medical experts with links to HSAN review it. HSAN subsequently examines the case and arrives at a decision. The chairman alone examines certain cases following a review by medical experts. Copies of the decision are sent both to the person who filed the complaint and those to the person(s) cited.
If the person filing the complaint is not happy with the decision, it may be appealed. The appeal must be lodged within three weeks from the date the decision is made public. The court of appeal is the county administrative court.
HSAN does not handle requests for economical compensation. If the plaintiff wants money he/she has to go to court. This happens extremely seldom.
HSAN handles about 3000 cases a year and in less that 6–10 % a decision against the accused is made. 70 % of the cases concern doctors and 30 % dentists, nurses and others. The number of orthopaedics cases is about 300 per year and a ruling against the surgeon happens in less than 10 %. The complaints in orthopaedics concern clinical examination, faulty diagnostics (usually that x-rays were not taken), faulty treatment and misconduct. Most of the cases in orthopaedics originate in the emergency department.
Congenital Hand Deformities are probably the most frequent cause of non-traumatic complaint in consultations on paediatric hand surgery.
The incidence of occurrence is about 1 in 500 live births. Some of these abnormalities are minor and do not interfere with function. Many, however, have a significant functional and/or cosmetic deformity.
Only a few congenital malformations have a regular single gene mode of transmission, most have an irregular and unpredictable pattern of inheritance; sometimes occurs as part of a malformation syndrome or skeletal dysplasia, or in a sporadic way.
In fact, the cause for 40 to 50% of these anomalies is “unknown”.
Themes like handling the patient and parents and the psychological effects of the anomaly, the general principles of treatment, timing of surgery and the principles of reconstructive surgery are discussed.
The classification proposed by A.B. Swanson and revised with the assistance of the Congenital Anomalies Committee of the International Federation of Societies fo Surgery of the Hand will be used to propose the general guides of treatment.
The most common anomalies will be approached in more detail and the option of treatment is discussed in base of experience of the author.
Hand surgery is rarely indicated in children with arthritis, but presents specific problems. The initial diagnosis can be difficult due to discrete clinical symptoms and limited radiological signs. A decreased wrist extension or finger joint stiffness can be early signs of arthritis in a child. Destruction of joint surfaces are difficult to evaluate since many skeletal parts in the hand, e.g. the carpal bones, are still not ossified in young children. Accelerated skeletal maturation can often be the only radiological sign of an active synovitis in the joint. The hands and wrists are often involved at an early stage of juvenile arthritis and different growth disturbances may occur, the most commonly seen is a shortening of the distal ulna. Surgery itself may also affect growth. When performing soft tissue surgery, like synovectomies or arthrolyses on the juvenile arthritic hand, a significant risk of postoperative joint stiffness has to be considered. Surgical treatment of arthritic hands in children are often delayed until adolescence, and doing any kind of surgery in a teenager is a difficult task which requires special attention and finesse. Personal experience from the Children’s Hospital in Lund, Sweden will be presented.
Traditional surgical treatment of hallux valgus is based around distal soft tissue realignment and distal metatarsal osteotomies. Over the decades several osteotomies have been practiced, but currently the Scarf osteotomy is gaining popularity.
This presentation will discuss the various procedures for proximal correction of the hallux valgus, the scope of the Scarf osteotomy, its pitfalls and published results. Our own experience of the Scarf osteotomy runs to several hundred patients and the overall satisfaction rate from realignment of hallux valgus is over 80%.
The concept of a congruent and incongruent joint will be introduced and the results of various distal osteotomies will be presented. The differential diagnosis of pain around the 1st metatarsophalangeal joint will also be discussed.
Although not exclusively a complication of distal osteotomies, the correction of acquired hallux varus will also be presented.
The current concepts of proximal femoral fixation in hip arthroplasty can be divided into three groups: the surface replacement concept, the femoral neck prostheses, and the short stems prostheses.
Between 1999–2004 more than 500 short stems prostheses (Mayoä) were implanted at the Orthopaedic department of the Martin-Luther-University, Halle, Germany.
To investigate the early functional results, a prospective randomized study was performed comparing 40 cementless short stem prostheses (Mayoä 1) with 40 cementless anatomical standard stem prostheses (ABGä 2) implanted in patients with unilateral hip osteoarthritis.
Age, gender, diagnoses, and body mass index showed no significant difference between both groups. In all patients, an uncemented acetabular press-fit cup was used. The implantations were performed by 4 orthopaedic consultants. A standardized anterolateral approach to the hip was used in all cases. In the short stem group, the femoral neck was preserved to achieve a multi-point fixation of the double-tapered stem in the intertrochanteric region.
The patients were followed clinically and radiographically at 3, 6, and 12 months postoperatively. Differences between both groups were tested using Student’s t-test. No specific complications occurred neither during surgery nor during the follow-up (FU). No patient was lost for FU. The radiograhic FU showed a correct implant position in all cases.
Concerning the Harris hip score (HHS), a statistically significant difference (< 0.01) was found at 3 months: the HHS for the short stem group averaged 93.87 points (range, 60–100 points), for the ABG group 87.02 points (range, 60–100 points). Preoperatively, at 6, and at 12 months, no statistically significant difference could be found between both groups.
In this study, patients having a short stem prosthesis returned faster to work and normal daily activities. We attribute this to the femoral neck approach without involvement of the greater trochanter and the abductor muscles. With its good functional results and its bone-saving concept, the short stem is an attractive design particularly for young patients.
Hip Resurfacing has always been an attractive concept for the treatment of hip arthritis in younger patients. Introduction of modern metal-on-metal hip resurfacing in 1991 in Birmingham, UK made this concept a reality.
In the early years, resurfacings were used only by a few experienced surgeons. From 1997, Birmingham Hip Resurfacings (BHRs) are being widely used in younger and more active patients. A breakdown of the ages at operation in the regional NHS hospital in Birmingham during the period April 1999 to March 2004 show that the mean age of metal-metal resurfacings is 51 years and the mean age of total hip replacements is 70 years.
At a 3.7 to 10.8 year follow-up (mean follow-up 5.8 years), the cumulative survival rate of metal-metal resurfacing in young active patients with osteoarthritis is 99.8%. In the long term, none of these patients were constrained to change their occupational or leisure activities as a result of the procedure. The overall revision rate of BHRs in all ages and all diagnoses is also very low (19 out of 2167 [0.88%] with a maximum follow-up of 7.5 years).
Improvements in instrumentation and a minimally invasive approach developed by the senior author have made this successful device even more attractive. Although objective evidence does not support the fact that the longer approach was any more invasive than the minimal route, patient feedback shows that it is very popular with them. While minimal approach is indeed appealing, it has a steep learning curve. In the early phase of this curve, care should be taken to avoid the potential risk of suboptimal component placement which can adversely affect long-term outcome.
It is true that metal-metal bearings are associated with elevated metal ion levels. In vitro studies of BHRs show that they have a period of early run-in wear. This is not sustained in the longer term. These findings are found to hold true in vivo as well, in our studies of 24- hour cobalt output and whole blood metal ion levels. Epidemiological studies show that historic metal-metal bearings are not associated with carcinogenic effects in the long-term.
Metal ion levels in patients with BHRs are in the same range as the levels found in those with historic metal-metal total hip replacements.
The management of adolescent hallux valgus presents a considerable challenge for the orthopaedic foot surgeon. Those presenting fall into two groups, idiopathic and neuromuscular. The management of the symptomatic hallux in neuromuscular cases is more clearly defined with arthrodeses of the first metatarsal-phalangeal joint being the treatment of choice. This affords the most consistent long-term results and the greatest degree of correction.
In the idiopathic symptomatic hallux valgus the treatment is more variable depending on the severity of the deformity and the underlying pathological changes. The demographics of adolescent hallux valgus and its associated abnormalities are discussed. There is a higher incidence of an increase in the distal metatarsal articular angle in severe cases where combined surgical intervention in the form of double and triple osteotomies may be required to achieve long-term correction and a treatment algorithm is presented. Since approximately half of symptomatic patients will be under 10 years of age with significant residual growth early surgical intervention has a higher recurrence than in the mature foot.
In addition to “conventional” total hip replacement with cemented or cementless stems more recently different implant designs have been proposed by Orthopaedic Surgeons in Europe and US. Especially surface replacement and short stem prosthesis are believed to overcome the disadvantages of conventional THR in younger patients.
The symposium “MINIMAL DEVICE OR REPLACEMENT FOR THE HIP” is trying to summarize current implant philosophies and to review critically the available data of functional as well as radiographic outcome.
With the advent of new hip implants (resurfacing and short stem prosthese) current treatment recommendations have to be reevaluated. The indication for surgical treatment in hip osteoarthritis as well as the choice of implants is mainly based on personal experience of the surgeoun (internal evidence) and clinical data (external evidence). Experimental studies can support the information from clinical trials and are necessary to evaluate the mechanical properties of an implant. They do not replace the clinical evaluation, however.
The level of evidence depends on type, quality and quantity of available data from published investigations. Recent innovations like surface replacement and short stem prostheses have mainly been investigated in single center observational studies with a relatively short followup.
Wider introduction of new implants, however, needs continuous evaluation of clinical and radiographic performance. Examples are given, how this monitoring should be performed in a clinical setting.
Incoming of a spine metastasis remains a major bad prognosis factor in cancer evolution. Consensus over the years is now well accepted in most of European teams dealing with spinal metastasis. Two major opportunities exist in the treatment of spine metastasis:
Conservative treatment with an association of radio and or chemotherapy and or hormonotherapy. Efficiency of such treatments is well documented and must not be considered as a patient abandon.
Surgical treatment is based on two major options. The first one is palliative with the aim of decompression and stabilization. Aim is to cure pain and neurological involvement. The second one is curative with total or partial vertebrectomy in the aim to cure the cancer.
In all cases decision must be made considering age- general condition histo – pathology – neurological status
Considering surgical indications through out this symposium we would like to address three controversial points.
The first topic to be addressed will be: “Total vertebrectomy: when?” presented successively Doctor MARTIN BENLLOCH and Professor BORIANI. The goal of this presentation is to determine the indications of total vertebrectomy more than the surgical technique. These indications appearing essential within the framework of the metastatic patients, while insisting not only on the natural history, but also on the tumoral extension which determines the feasibility of the vertebrectomy. Professor POINTILLART and Professor BORIANI will then discuss about the strategy to adopt when confronted with multi-metastatic patients “Multi-metastatic patients: what strategy?”. This topic will focus primarily on the problem of multi level spinal metastatic lesions: the strategies to be adopted with respect to the patients presenting other metastatic lesions, as well as on a functional forecast (fragility of the long bone), or on the other hand, on metastasis without immediate functional incidence. We also would like to discuss the treatment of the primitive tumour, i.e. if it is the metastasis which is revealing cancer, is it necessary to first treat the primitive tumour, than proceed to the treatment of the metastatic lesions? The third topic of this session will be “When Not to Operate on Metastatic Patients?”, presented by Professor POINTILLART. The goal of this discussion is to be able to give a progress report on the surgical indications within the framework of a spinal metastatic patient. In a certain number of cases surgery is questionable with the discovery of lesions, because of their extended character, or the extreme malignity of the primitive tumour. In other situations, too many lesions will make surgery disputable. Last case scenario is a recurring tumor, because of its extension, its development, even its neurological complications, will make surgery challenging. All these points in our opinion should be openly discussed. Each session will be followed by a 10 minute discussion
Strategy means coordination of techniques and technicians facing a problem in which the solution is unclear and uncertain.
The only secured point is that there is no hope for curing the patient, and thus, his own opinion will have to be included in the decision making process.
Situations in which that question arises are extremely different from one case to the other and we will be able only to give our own guidelines.
In emergency, if a neurologic deficit occurs and increases, the goal is to decompress and limit the surgery to the most limited aggression and then to return to a more comfortable situation to take the proper decisions.
Elements to be taken in account
Situation is different according to the type of scattering.
Regional scattering accessible by a single approach ( similar if this scattering is associated to a second localization treatable by an isolated radiotherapy plus vertebroplasty if necessary) which is a situation closed to a single level metastasis, or general diffusion leading to a whole spine metastasis where radiotherapy plus general treatment if any are the only solutions. The schedule for these will be decided according to the risks of fracture or neurologic compression and the pain
The whole question is about the potential risks induced by these. Bone fracture, brain oedema, hypoxemia, increased bleeding linked to liver incapacity.
The time to obtain a complete map of localizations is usually too long in these situations and therefore clinical situation should guide complementary exams to remain reasonable. When looking at the scoring of the patient with Tokuashi score When having no clinical significance, others metastases should be underscored and compared to the potential risk benefit comparison of surgery. One should not refuse surgery just because of a low Tokuashi grading since some surgeries like a two level cervical corpectomy through an anterior approach induces a minimal “cost” for the patient.
Sometimes, the cancer is already known and the strategy has to be decided according to the treatments already done locally and in general (hormonotherapy, chemotherapy…). The primary response to these treatments is usually a good predictive key for the future. Depending on the expectable response to the other therapies, surgery could be the only technique that could help the patient or on the contrary only a second line technique if you may hope a good result from others.
In other cases, the metastases reveal the cancer. If no primary tumor can be easily found, the lesions should be treated first to ensure the best quality of life since it is known that the risk for a short life expectancy is high (same in case of a large lung cancer).
Participation of the patient in this decision is mandatory.
The first part of the answer to this question is easy: when the risk benefit balance is negative !
How to determine elements to be taken in account and what is their specific weight is another question which is unsolved yet.
A first group is easy to determine: those whose problem can be solved with non surgical techniques, i.e. metastases responsive to radiotherapy and if too fragile accessible to vertebroplasty. This group underlines the interest of an early diagnosis through a wide use of MRI. By that mean, diagnosis of metastases is possible at the stage of cell penetration in the cancellous bone, before any kind of destruction. This would not be the case by the use of CT scan, where destruction only can be seen, bone scintigraphy where bone reconstruction is shown or even worse plain X rays where a wide range of destruction can only be shown.
On the contrary, MRI T1 hyposignal and even better STIR sequences allow a secured early diagnosis, opening all ways of treatment before surgery is indicated.
If the primary tumor is known as radio/chemo therapy resistant, surgery will done in better conditions than in emergency facing all major complications.
A second group is also easy to determine: those who won’t get any benefit from surgery. These have a complete thoracic paraplegia, lasting for one day with almost no pain. Hope for neurologic recovery is almost zero, risk for infection, skin problems major and the post op pain will be greater than the preop.
If the pain is important and resists to WHO grade 3 pain killers, fixation can be proposed, risks clearly explained.
For the others, the discussion between all members of the team is the only way to find the most suitable answer, knowing here again that nobody knows clearly what should be done “case by case”.
Each member of the team must give his techniques, risks and benefits and association of methods gives the lowest “price” accessible to the patient.
Oncologist: chemo, radio sensitivity, general situation of the patient, foreseeable life expectancy, other metastases with and without clinical significance,
- Radiotherapist: area having already received radiation (classical situation in breast cancer), spinal cord acceptance for more, risk of increased weakness of the vertebrae just after the radiation. - Radiologist: completion of check up, risk for bleeding and possibilities of embolization, vertebroplasty possibilities, on which vertebrae and timing of these compared with surgery and radiotherapy. - General practitioner: he knows ( or should) the patient and his family and will be in charge of the immediate follow up - Anesthetist: responsible for the pain care of the patient and the anesthetical contraindications. - Spine surgeon: he knows the possibilities and risks.
Till now, no score exists to balance the Tokuashi score which is rather a score to foresee life expectancy. We need a score of the “cost” of surgery because a simple anterior cervical corpectomy is possible for any kind of patient and this is of course not the case for a long posterior instrumentation.
To us also, the level of denutrition is a good indicator of risk of complications and the value of surgery in these cases.
The complexity of the haemostatic system also implies individual variance of the effectiveness of haemostasis. Minor haemostatic defects such as mild cases of von Willebrand disease probably occur in several per cent of the population. Furthermore many orthopaedic patients are on medication with ASA, NSAIDs, clopidogrel, antidepressants, warfarin and LMWH, all common drugs which affect haemostasis.
In patients with known haemostatic disorders, substitution of the deficient coagulation factors may improve haemostasis. The same holds true for patients on warfarin medication where substitution with vitamin K, with factors of the vitamin-K dependant complex or with plasma normalizes haemostasis.
Desmopressin stimulates the release of factor VIII and the von Willebrand factor and thus improves platelet function in some subgroups of von Willebrand disease and in platelet dysfunction due to ASA or dextran use. However, the blood-saving effect in patients without these disorders has not been conclusively shown.
In recent years the role of factor VII as a main initiator of coagulation has been stressed. Case reports of effective haemostasis in severe trauma using recombinant factor VII have been published but the experience of its use in orthopaedic surgery is so far limited and the cost is prohibitive for routine use.
During surgery and trauma, the fibrinolytic system is activated with particularly high levels of fibrinolytic markers in the wound. The effect of tranexamic acid, a synthetic fibrinolysis inhibitor has been studied in 17 randomised control trials in knee and hip arthroplasty. The drug significantly reduced blood loss and/or blood transfusion in the majority of these studies. The same findings were reported in 2 studies in spinal surgery.
To exert full effect, tranexamic should be given prophylactically, before the beginning of surgery. In studies at our department, the use of tranexamic acid was highly costeffective as it is significantly cheaper than blood transfusions.
Aprotinin, a protease inhibitor decreasing fibrinolysis has been extensively used in cardiac surgery. It has also been shown to reduce blood loss and blood transfusion in 4 out of 5 RCT:s in major orthopaedic surgery. Neither aprotinin nor tranexamic acid were reported to increase the frequency of postoperative venous thromboembolism.
Fibrin sealant, sprayed onto the wound has also been reported to reduce bleeding in spinal surgery as well as in arthroplasties.
The management of autologous blood aims at reducing the need for allogenic transfusion. Blood requirement (autologous and/or allogenic) will depend on the pre-operative red blood cell stock and on the perioperative blood loss. The red cell stock is related to body weight and preoperative haemoglobin (haematocrit) level; it can be calculated accurately, whereas the perioperative blood loss (external and occult) is variable and unpredictable.
Preoperative donation of autologous blood, as well as intraoperative and/or postoperative recuperation and reinfusion of shed blood decrease the risk for allogenic transfusion in total hip replacement (THR) and total knee replacement (TKR) surgery. However, their efficiency and cost effectiveness are not optimal when applied to unselected patients.
Up to 50% of the predonated units of autologous blood are wasted after THR and THK surgery if patients have not been specifically selected to predonate blood.
In hip surgery the volume reinfused after intraoperative blood recuperation obviously depends on intraoperative bleeding; it averages 500 ml in a hip revision operation.
In TKR (with a tourniquet) the volume reinfused after postoperative recuperation depends on the amount of blood drained in the immediate postoperative period, which reflects both the amount of bleeding and the efficiency of the drainage. On average, 500 ml of shed blood with a haematocrit of 35% is reinfused, which increases the haemoglobin level by 1.0 gr/dl on average. The efficiency of this technique is unpredictable, with a wide dispersion of individual values (standard deviation: 208 ml) for the volumes reinfused. However, in patients with a body weight of 70 kg or less, the increase in haemoglobin level was more predictable and averaged 1.23 gr/dl.
In order to improve the efficiency of these two techniques (preoperative autologous blood donation and recuperation/reinfusion of shed blood), patients need to be targeted, taking into account:
- the calculated preoperative (day before surgery) red blood cell stock and the number of units of predonated blood, - the lowest postoperative haemoglobin and haematocrit level clinically tolerable for that specific patient, - the expected perioperative blood loss, which depends on such factors as duration of surgery, anticoagulant administration, use of a tourniquet,etc)
As a general rule, a haemoglobin level < 13 gr/dl, age > 65 years and weight < 70 kg all increase the risk to require autologous or allogenic blood transfusion, and would justify planning predonation of blood and/or recuperation/reinfusion of shed blood.
Methods: Patients with preoperative intermetatarsal angle of less than 14 degrees were included. Clinical records and radiographs were reviewed. Clinical evaluation done with AOFAS scores and plantar pressures recorded using musgrave system. The foot was divided into 7 regions: first metatarsal head, 2nd & 3rd metatarsal heads, 4th & 5th metatarsal heads, midfoot, heel, hallux and lesser toes. Average pressure, peak pressure distribution and contact time of all seven regions were analysed. A control group of 15 individuals with twenty normal feet were included for comparison. Statistical analysis was done with analysis of variance of the means and Pearson correlation tests.
Results: Seventeen mitchell osteotomy was performed on 13 patients with follow up ranging from 14 to 66 months, a mean of 34 months. Most of our study group were females with an age range of 25 to 71 years, a mean of 53 years. The mean postoperative AOFAS scores were 87 and a median of 90 out of 100. Pedobarograph findings: Statistically significant reduced average pressure, peak pressure and contact time were noted under hallux when compared to the normal control group. The peak pressures were reduced at all forefoot regions but statistically insignificant. Otherwise, the pressure distribution, contact time and center of pressure progression were similar to the normal feet. On analysis of correlation between the parameters observed, reduced pressure distribution under first metatarsal head lead to increased pressures under 4th, 5th metatarsal heads and lesser toes. Significant correlation found between the pressure distribution under hallux and the AOFAS scores, which reveals the outcome of procedure, depends on the load bearing characteristics of hallux and not the first MT head.
Conclusion: Mitchell osteotomy restores the load bearing function of the feet to near normal except hallux, which may affect the outcome of the procedure.
We conducted a prospective clinical study to determine the influence of personality traits on the subjective outcome of operative hallux valgus correction. The surgical technique used in all patients was the chevron osteotomy. Preoperatively, personality traits were evaluated by means of the Freiburg Personality Inventory (FPI-R). 42 patients (38 female, 4 male) could be enrolled in the analysis. The mean age of the patients at the time of operation was 48.3 years (20 to 70). Three months postoperatively 37 patients were satisfied, and 5 patients were not satisfied with the operative procedure. The comparison of the two groups (satisfied and dissatisfied patients) revealed statistically significant differences in the personality traits aggressiveness (p=0.003), extraversion (p=0.001) and health worries (p=0.04). The postoperative hallux valgus angles were 12.2° ± 7.8 and 13.4° ± 8.3 (p=0.74), and the first-second intermetatarsal angles were 7.4° ± 2.5 and 7.6° ± 4 (p=0.89) in the two groups. The results of the current study suggest that the patient’s subjective result after the operative hallux valgus correction is influenced by some individual personality profiles.
In moderate and severe Hallux Valgus metatarsus varus and incongruency of the joints are often important features. Basal osteotomy and distal soft tissue release can often achieve adequate correction of intermetatarsal angle (IMA) and joint alignment.. We retrospectively evaluated the results of Basal Osteotomy in 26 feet in 20 patients between January 1999 and December 2003. American Orthopaedics Foot & Ankle Society Score (AOFAS) was used for assessment. A subjective grading system was used to check patient’s satisfaction. The surgical technique consisted of crescentic basal osteotomy, lateral distal soft tissue release and medial capsular plication according to Roger Mann. Fourteen osteotomies were fixed with K wires that needed second operation to remove them. Barouk Screw was used to fix the osteotomy in 12 feet. Patients were mobilised in High heeled shoe postoperatively. Average age was 55.2 years and average follow-up was 25.8 months. The average preoperative Hallux Valgus Angle (HVA) and IMA were 37.38° and 17.27° respectively. At follow-up the HVA and IMA averaged 13.3° and 6.4° respectively. Sixteen feet had incongruent joint preoperatively that became congruent after surgery. In 25 feet sesamoid position improved after surgery. Average AOFAS score was 88.8. 94% patients were highly satisfied and graded their results as good to excellent. One patient had AOFAS score of < 50 due to her generalised poly-arthralgia and osteoporosis. K wire was broken across the TMT joint in one case and needed removal under GA. This lead to change of our practice as we started using Barouk screw to fix the osteotomy. Other complications consisted of decreased sensations over medial side of toe in three and mild metatarsalgia in one foot. Basal osteotomies with distal soft tissue release in the treatment of Hallux valgus give good correction of the deformity and high patient satisfaction. Barouk screw provides stable fixation.
Material and Methods: The study is made on 10 cadaver first metatarsals. The metatarsals are fixed to a device. The metatarsal inclination and pronation of the metatarsal can be changed by this device. 15-30-45 degrees inclination and 0-10-20 degrees pronation are applied to the metatarsals. After applying radio opaque putty to the medial and lateral articular edges; metatarsal dorsal diaphysial ridge, the x-ray and digital images are taken at different degrees of inclination and pronation. The measurement of PASA is done by graphic software on computer. The statistical analysis is performed by paired sample T-test.
Results: We found that changing the inclination has no effect on PASA (p> 0.1). The pronation of first metatarsal has found to have a positive effect on PASA (p< 0.005). As the degree of pronation increases, the degree of PASA is found to be increased also. No difference was found between the measurements of x-ray and digital photography images.
Discussion: Inclination of the first metatarsal can change depending on the height of the medial longitudinal arch. By this experimental study we tried to simulate the pes cavus and pes planus deformity on the radiologic measurement of the hallux by modifying the inclination and pronation of the first metatarsal. According to the current study, inclination has no effect on measurement of PASA. Pronation of the first metatarsal accompanies some hallux deformities. As pronation influences the measurement of PASA, the current data suggests that the measurement of PASA is not suitable for making clinical and surgical decisions.
Methods: 100 lateral view X-rays were taken. Dimensions assessed were the talar area covered by the tibia, the angle of the distal tibial joint plane to the tibial axis (tilt), the width of the tibia on the joint level, the height of the talus, the joint radius of the ankle joint and the offset of the centre of rotation from the tibial axis.
Results: The tibial coverage of the talus was 88.1 degrees (SD = 0.36), the angle of the distal tibial joint plane to the tibial axis (tilt) was 83 degrees (SD 3.6), the width of the distal tibia 33.6 mm (SD = 2.4), the radius of the ankle joint 18.6 mm (SD = 4.0) with an anterior offset of the centre of rotation of 1.7 mm and the height of the talus was 28.2 mm (SD = 2.1).
Conclusions: In case of symptomatic deformity any reconstruction, i.e. correcting osteotomies, ligament reconstruction, arthrodeses or arthroplasty, should aim to correct the foot in a physiological way; respecting the original dimensions of the hindfoot to achieve maximal benefit. Anterior-posterior translation of the talus may be a source of pain, restriction of motion and a cause of degenerative joint disease because of eccentric joint loading. This is also true for the height of the talus, which may have a significant impact on the hindfoot physiology. To achieve good biomechanical function, the positioning of the talus in relation to the tibia needs to be planned carefully prior to surgery. Poor coverage of the talus by the tibia and too much tilt of the distal tibia lead to higher joint forces and may be the cause of instability. Surgical procedures may fail if this is not recognized preoperatively. Several easily accessible measures on X-rays were found to be reliable to describe the hind-foot, as only small variation was found on the evaluated X-rays. If reconstruction of the hindfoot is required, care should be taken to identify the physiological joint geometry.
To reduce both operative trauma and wound length in plate osteosynthesis of dislocated WEBER type B fractures of the distal fibula we started using 3 hole one-third tubular „anti-glide“ AO plates in 1996 instead of longer implants.
From 1996 to 2001 a total of 72 patients with isolated WEBER type B fractures were treated operatively by using 3 hole one-third „anti-glide“ AO plates. A clinical and radiographic follow-up examination was performed after 38.6 [18–63] months using the original WEBER score. The statistical method to compare our results with previous investigations was Chi-Square-Test according to Pearson (p=0.05).
67 (93.1%) of all patients were without complaints while 3 (4.2%) complained about exercise induced pain and 2 (2.7) reported rest pain. 69 (95.8%) patients showed identical ranges of ankle joint movement, whereas 3 (4.2%) patients had minimal loss of joint function. Radiographically perfect joint configurations were seen in 69 patients while 3 (4.2%)showed grade 1 arthrosis according to BARGON. A total of 68 (94.4%) patients showed very good (n=50) or good (n=18) results according to Weber. In 4 cases the result was not satisfying. This was not significantly different from other investigations with longer implants, but scar length was reduced and duration of after-treatment was signifcantly faster than treatment with longer implants (p< 0.05).
It is concluded that operative stabilisation of isolated Weber type B ankle fractures with 3 hole dorsal „anti-glide“ AO plates can be recommended as a safe, convenient, cost-effective and simple alternative to the use of longer implants.
In conclusion, the fixation done in Group II was found to be biomechanically more stable.
The purpose of this paper is to report on the use of a tendon transfer (anterior tibial to midfoot) to correct dynamic foot and ankle varus deformity. Anterior tibial tendon transfer to mid-foot is useful to consider in planning treatment where there is a need to rebalance a foot in which the unopposed or weakly opposed anterior tibial causes the abnormal varus position of the foot and ankle. 12 patients, 22 feet had anterior tibial tendon transfers performed. 10 were bilateral. 10 patients had neuromuscular disease as the underlying cause for the foot imbalance, 1 patient had idiopathic clubfoot with residual, recalcitrant varus after earlier posteromedial release and 1 patient was hemiplegic secondary to stroke caused by encephalopathy. Age of the patients at the time of their initial procedure(s) ranged from 2 to 34. There was at least 1 year follow-up after each procedure for the patient to be entered into this study. A 1-grade functional loss was encountered following tendon transfer of anterior tibial muscles grading between 4–5. (4=good, 5=being normal). The transferred muscles allowed the dynamic varus deformity to be removed and the foot to become plantigrade. In its transferred position, it functioned to actively contract and contributed to give support of the ankle. After an initial period of cast use post-operatively and bracing for 6 months to support the transfer, continued use of AFO was no longer necessary. Anterior tibial tendon transfer to mid-foot, originally described by Garceau continues to be an useful method for rebalancing a foot in which the abnormal pull of the normal or almost normal functioning anterior tibial muscle. This muscle is unopposed or weakly opposed because of the underlying neuromuscular disorder or previous surgery. Thus, it causes the foot and ankle to turn into varus. The technique used is straightforward and simple. It is a useful procedure to consider when rebalancing a foot may be needed.
Six patients presented a structural derangement localized to the forefoot (Pattern I according to Sanders and Frykberg Classification), one to the ankle (Pattern IV) and 18 to the mid-foot region (Pattern II and III). At first clinical evaluation, 13 patients presented a plantar monolateral ulcer. Their treatment was multifactorial. An offloading regimen was adopted, with the use of a total contact cast and crutches, in order to avoid weight-bearing on the affected foot for the first two months. Patients responsive to the treatment were successively treated with a pneumatic cast (Air cast) and partial weight-bearing for another four months. Four unresponsive patients underwent surgical treatment. 10 patients were also treated with alendronate (70 mg per os once a week). Three patients died during treatment and one during the follow-up, three of them for cardiovascular disease, one for bronchopneumopathy.
We present the results of a multicentre retrospective study of closed fracture dislocations of the Lisfranc joint treated by closed reduction and percutaneous screw fixation (follow-up: almost 5 years).
Forty-two patients that presented between 1994 and 1999 to the authors™ institutions were selected for this study (follow-up AOFAS score 81.0 ± 13.5).
A review of the literature shows that opinions differ as to the most appropriate method of treatment, be it closed or open reduction, screws or K-wires fixation, but most of the authors agree that it is imperative to achieve anatomical reduction.
In our study, no statistically significant differences could be detected when outcome scores of patients with anatomical reduction were compared with outcome scores of patients with nearly anatomical reduction, in both the combined fracture dislocation and pure dislocation subgroups. The conclusion is that even a nearly anatomical reduction is considered acceptable and predictive of a satisfactory outcome.
Furthermore, we found a statistically significant difference in the AOFAS score between patients with combined fracture dislocations and pure dislocations, with the latter having a worse AOFAS score. This suggests that the ligament bone interface cannot heal with sufficient strength to regain stable long-term function.
Methods: The study design was observational and retrospective. Adults, conservatively treated for an acute fracture of the base of the fifth metatarsal included. All patients were given a plaster cast at the emergency department and were instructed not to bare weight (NWB) on the affected limb for at least one week. The further modalities of treatment were decided by individual surgeons according to their current clinical practice. A validated scoring system was used. Additional questions were asked about residual cosmetic and shoe problems and also about intensity of pain and the general feeling of comfort. The respective influences of factors on clinical outcome were examined using multiple linear and logistic regression modeling.
Results: 38 patients (11 men, 27 women) were analysed. The mean age was 48 years. 6 had a Jones fracture, while 32 had a tuberosity avulsion fracture. The mean non-weight bearing period was 2 weeks and 4 days (range 1 to 5 weeks) while the cast was worn for a mean of 5 weeks and 3 days (range 1 to 10 weeks). Three Jones fractures and all the avulsion fractures were healed at the end of treatment. The mean follow-up time was 298 days, ranging from 51 to 603 days. The mean result of the ankle score at follow-up was 77.5 (range 20 to 100). Thirteen of the 38 patients reported problems in wearing shoes. Only 8 patients experienced cosmetic problems. The mean linear analogue score for pain was 2.34, that for general comfort was 8.11. Overall, the most significant predictors of poor functional outcome at final follow-up evaluation were increasing duration of NWB and longer follow-up time. Longer NWB was importantly associated with worse global score, pain, comfort and reported stiffness. Neither gender nor fracture type had any significant influence on the overall clinical outcome.
Conclusions: The most important variable linked to final clinical outcome is the duration of the non-weight bearing period. Neither gender, age, length of casting nor even fracture type, had any significant influence on the overall clinical outcome. Therefore NWB should be kept to a minimum for acute avulsions.
Aim: To highlight the hitherto undescribed arch patterns of Lisfranc injuries.
Methodology: 8 patients with atypical Lisfranc injuries were studied prospectively.
Arch patterns: In 2 patients the arch started at the medial aspect of the ankle with injury to the medial malleolus or the deltoid ligament, passed through the tarsometatarsal region and ended at the cuboid. In one patient the arch started at the tarsometatarsal joints and ended at the lateral malleolus and in another patient the lateral end point resulted in tear of the calcaneofibular ligament. One patient had the medial starting point at the Lisfranc ligament but the arch of injuries went through the forefoot fracturing the midshaft of the 2nd, 3rd and 4th metatarsal shafts without injuring the tarsometatarsal region, thus forming an arch pattern much more distal than usual. Six of the 8 patients had operative management. On follow up, in terms of activities of daily living, 75% had excellent function of the foot. It is not the aim of this paper to highlight the management of these injuries.
Conclusion: In the process of listing the telltale signs of a Lisfranc injury it is mandatory to bear in mind that the arch of injuries may extend to as proximal as the ankle joint or as distal as the forefoot and this will enable us to define the entire spectrum of the Lisfranc injury, however atypical it may be.
Open reduction and internal fixation for displaced intra-articular fractures of the calcaneum has become an established method of treatment. A recent randomised, controlled trial has questioned the benefits of surgery, in particular, pain relief. We reviewed the cases undertaken in our department, complications, which have arisen, and their treatment. We have devised a management plan in conjunction with the department of plastic surgery to minimise the effect of these complications. There were 124 procedures carried out over a 12 years period, 116 unilateral and 4 bilateral in 120 patients (106 males and 14 females, age range [18 to 66]). Two further patients were included who had had surgery in another hospital and had been referred to our plastic surgery unit with significant wound complications. The patients were retrospectively assessed with a case note review and an updated clinical evaluation. The assessment focussed particularly on wound complications including breakdown classified as either major or minor, and association with infection, haematoma and drainage. Neurological symptoms were also noted. There were five major wound complications, three from our unit and two from another hospital. Infection was present in three cases. Four healed uneventfully but one of the infected group subsequently had a below knee amputation for refractory infection. Minor wound breakdown was more common. There was no association with haematoma or drainage but wound breakdown occurred more frequently in patients who smoked. Neurological complications were infrequent and temporary. In conclusion this study confirmed that there is a significant morbidity associated with the surgical management of these fractures, although, the vast majority of patients’ wounds healed uneventfully. With a sensible management plan, which involves working in conjunction with plastic surgeons, even major soft tissue complications may be addressed.
Open operative treatment compared with non-operative treatment was associated with a lower risk of re-rupture (odds ratio (OR) = 0.25, 95% confidence interval (CI) = 0.1–0.6, p=0.003) but a higher risk of other complications including infection, adhesions and disturbed sensibility (OR = 14.1, 95%CI = 6.3–31.7, p< 0.00001).
Open versus percutaneous operative surgical repair was associated with a longer operation duration and higher risk of infection (OR = 12.9, 95%CI = 1.6–105.6, p=0.02).
Patients splinted with a functional brace rather than a cast post-operatively tended to have a shorter in-patient stay, less time off work, quicker return to sporting activities and fewer reported complications (p=0.0003).
Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques and different non-operative regimes.
The increase of ROM in all patients is 17.9 (RA: 18.7 /OA: 16.6). Significant pain relief is described by 92.4% of patients, here all the groups showed no significant differences. An increase in the clinical outcome measured by the Kofoeds Ankle Score is seen from < 70 pts. preoperatively (100% of patients) to > 75 pts. postoperatively (82.3% of patients). The most frequent complication especially in patients with RA is a delayed wound healing (19%), but the revision rate is higher in patients with traumatic and idiopathic osteoarthritis (17% OA /13% RA). A secondary arthrodesis has to be performed only in 2 OA cases.
Radiologically 22 ankles fused, three probably fused whilst 11 (30%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Post operatively the mean AOFAS score was 51, 25 patients were satisfied (of these 20% had radiological non-union) and 19 would undergo the same procedure again.
Sag. Ankle Angle ROM (standard): 14,31 4,72 *(OP); 28,39 4,96(healthy) Sag. Ankle Angle ROM (footmodel): 9,36 2,62 *(OP); 18,68 4,33 Sag. Med Arch ROM: 12,85 4,85 * (OP); 20,11 4,71 Front. Subtalar Inversion ROM: 4,59 1,44 *(OP); 7,56 1,96 Front. Forefoot Ankle Supination ROM: 10,23 3,71 *(OP); 13,91 3,82
(Mean standard deviation; * statistical significance from healthy side p< 0.01)
In order to regain preinjury activities following an Achilles tendon rupture while reducing the potential complications of open surgery and non-operative treatment, we developed a new protocol that involved the use of a modified local anaesthetic technique, percutaneous repair and early function.
We prospectively treated 32 patients with acute Achilles tendon ruptures according to our protocol with a 12 month minimal follow-up. Surgery was performed on an outpatient basis and within 48 hours from rupture for all cases. Our local anaesthetic technique allowed us to have a comprehensive control over sural nerve location by the definition of a “safe area” (video will be shown) and has proved to be effective to avoid sural nerve damage during surgery. The 28 male and 4 female patients had a mean age of 35 years (range, 26 to 47 years). The percutaneous repair was performed with a #2 nonabsorbable monofilament. Patients began range-of-motion exercise at 48 hours, used a posterior splint for 2 weeks, and then began ambulation with crutches and a 2 cm heel wedge incorporated on sport shoes or alternatively country boots. At 5 weeks, the wedge shoe was discontinued, full weight-bearing was allowed, and progressive resistive exercises were initiated.
There were no reruptures, wound infections, sural nerve damage, recurrent pain, or skin necrosis in our group of patients. One patient (with an hemathological disorder) developed a deep venous thrombosis that resolved uneventfully.
Mean AOFAS score was 80 at 6 months and reached 98 at 12 months. High-demand patients (police officer, firemen, athletes, professional soccer player) returned to their activities by 5–6 months. Patients were very satisfied with the procedure and subjetive evaluation turned to be very good or excellent for all cases.
Achilles tendon management using our protocol is an efficacious method demonstrating a low morbidity rate together with a return to preinjury level by 6 months. In addition, this protocol is cost effective (saves on hospital admission, anaesthesia, complications) and athletes in our group were able to obtain their athletics goals with minimal or no deficits.
Percutaneous repair of the ruptured tendo Achillis has a low rate of failure and negligible complications with the wound, but the sural nerve may be damaged.
We reviewed 96 patients who had an acute percutaneous repair done by a single surgeon at district general hospital between January 1998 to April 2004. The mean follow up was 27 months. The repair is carried out using six stab incisions over the posterolateral aspect of the tendon. The procedure can be carried out under local anaesthesia. All patients were put in a below knee cast after the operation. Cast was changed at 4 weeks keeping the foot in plantigrade position. The mean period of immobilization was 8 weeks.
They returned to work at 12 weeks and to sport at 16. One developed a minor wound infection and another complex regional pain syndrome type II. There were 2 injuries to the sural nerve. There were no late reruptures. This technique is simple to undertake and has a low rate of complications. We present one of the largest series reported in literature.
The importance of correctly identifying and treating ankle syndesmosis injuries is paramount to achieving a good functional result. Although it is clear that anatomical correction is essential the practical aspects remain disputed. Controversial issues include diagnosing and determining which injuries need treating, the number and size of screws for fixation, the number of cortices engaged, a screw removal strategy and the use of biodegradable screws or other forms of fixation. We report the results of a survey of 440 orthopaedic surgeons to determine current UK practice, this is then compared to best practice as determined by literature review.
When analysis was performed for the group and by sub-speciality (foot and ankle, trauma and general orthopaedics) we found large differences in practice. Furthermore it appeared that some aspects of treatment varied considerably from published evidence, for instance four out of five screws were removed much earlier than clinical studies have recommended.
Reconstruction of the lateral ligaments of the ankle has been performed for many years, but few reports are available regarding the outcome after 10 years or longer, and there are no such reports on reconstruction with the more recently developed artificial ligaments. I report the clinical outcome and radiological findings.
On stress X-ray taken at the final examination, TTA improved preoperatively 19 degrees to 4 degrees postoperatively, and ADT improved from 12 to 5 mm. There was no marked development or progression of arthropathic changes. No allergic reaction to the artificial ligament material occurred in any patient. postoperatively and no patient had instability that became severe enough for reoperation to be required. As for arthropathic changes, in 3 patients with a TTA of 10 degrees or more postoperatively, progression of mild osteoarthritic changes was observed.
Only 30% of the normal tendon sections showed any positive staining at all
Compared to 36% of ruptured tendon and 43% of the painful tendinopathy sections.
There is a paucity of nerve tissue within these tendons, which may have implications for the neurogenic hypothesis of tendon degeneration
There appear be more nerve fibres in vascular areas of the painful tendinopathy biopsies
There may be more nerve fibres in the peritendinous tissue
Implantation of allograft bone continues to be an integral part of revision hip surgery. One major concern with its use is the risk of transmission of infective agents. There are a number of methods of processing bone in order to reduce that risk. One part of that processing can be carried out immediately prior to implantation using pulsed irrigation.
We report the incidence of deep bacterial infection in a series of 138 patients undergoing 144 revision hip arthroplasty procedures who had undergone allograft bone implantation. The allograft bone used was fresh-frozen non-irradiated. Allograft femoral heads were milled following removal of any residual soft tissue and sclerotic subchondral bone. The bone chips were then placed in a standard metal sieve and irrigated with Normal Saline (pre-warmed to 60 degrees Centigrade) delivered as pulsed lavage at 7 bar pressure. No antibiotics were used in the irrigation solution. The bone chips were washed until all visible blood and marrow products had been removed.
The deep infection rate at a minimum one year follow-up was 0.6%. This method of secondary processing appears to be consistent with a very low risk of allograft related bacterial infection.
Retention of well fixed bone cement at the time of a revision THA is an attractive proposition, as its removal can be difficult, time consuming and may result in extensive bone stock loss or fracture. Previously reported poor results of cemented revision THA, however, have tended to discourage Surgeons from performing “cement in cement” revisions, and this technique is not in widespread use.
Since 1989, we have performed a cement within cement femoral stem revision on 354 occasions. The indications for in cement revision included facilitating acetabular revision, replacement of a monoblock stem with a damaged or incompatible head, revision of hemiarthroplasty to THA, component malposition and broken stem. Cement in cement revision was only performed in the presence of well fixed cement with an intact bone-cement interface. An Exeter polished tapered stem was cemented into the existing cement mantle on each occasion.
Follow up of 5 years or longer is available for 175 cases, and over 8 years in 41. On no occasion has a cement in cement femoral stem had to be re-revised during this time for subsequent aseptic loosening. Advantages include preservation of bone stock, reduced operating time, improved acetabular exposure and early post operative full weight bearing mobilisation. This technique has not been used for 1 stage revision of infection.
This experience has encouraged the refinement of this technique, including the development of a new short stem designed specifically for cement within cement revisions. This stem is designed to fit into an existing well fixed cement mantle of most designs of cemented femoral component or hemi-arthroplasty, with only limited preparation of the proximal mantle required. The new stem greatly simplifies cement in cement revision and minimises the risk of distal shaft perforation or fracture, which is otherwise a potential hazard when reaming out distal cement to accommodate a longer prosthesis.
Early reports on revision total hip arthroplasty (RTHA) suggested that outcomes of this procedure are as good as those of primary total hip arthroplasty (THA). However, RTHA is associated with longer surgery time, greater blood loss and increased risk of complications (thromboembolism, nerve injury, periprosthetic fractures, recurrent hip dislocations and infections). Aseptic loosening after RTHA was reported in 36% of patients aged over 55 years within 4 years after revision. Infections were reported in 32% and complications during surgery in 23% of patients respectively. Unsatisfactory results of RTHA stimulate the search for alternative procedures. Girdlestone excision arthroplasty (GA) seems to be a good solution for older patients with high risk of complications related to a poor general condition.
Infection ceased in 9 cases, 1 patient died because of complications related to chronic infection.
Patellar maltracking after total knee arthroplasy (TKA) introduces complications such as anterior knee pain and patellar subluxation, generally due to prosthetic component malallignment in both tibiofemoral (TF) and patellofemoral joints. It is still debated if it is necessary to resurface the patella, which would better adapt the patellar articular surface to the prosthetic femoral troclea with a prosthesis, but also result in possible bone fractures. In this study, an in-vitro analysis is presented in order to identify differences between intact and TKA patellar tracking with and without patellar resurfacing and to show how much the latter is similar to intact knee patellar tracking.
Three fresh-frozen amputated legs with knees free from anatomical defects and with intact joint capsule, collaterals and quadriceps tendon were analyzed using the Stryker knee navigation system (Kalamazoo, MI-USA). Landmark digitations were used to define anatomical frames for femur, tibia and patella. Manually driven TF flexions, from 0 to 140, were performed under conditions of no load and of 10 kg on the quadriceps, with intact knee and TKA with patella resurfaced and not. TF flex/extension, intra/extra rotation, ad/abduction were calculated according to a standard convention. Patellar flex/extension, medial/lateral tilt, rotation and shift were calculated according to a recently proposed articular convention.
Since more repeatable, results relative to trials under 10 kg are reported. Intact knee: 4 abduction; considerable intra rotation (from 16 to 4), followed by continuous extra rotation starting at 30 TF flexion; linear increase in patellar flexion (from 20 to 110); initial medial patellar rotation (from 12 to 8), followed by medial rotation starting at 60 TF flexion; initial lateral patellar tilt (from 4 lateral to 4 medial), followed by medial tilt starting at 70 TF flexion; initial 6 mm lateral patellar shifts from 0 to 80 TF flexion, followed by 4 mm medial shift. TKA knee: small differences in ad/abduction between intact and TKA knees, both with and without resurfaced patella; slight initial extra rotation, followed by continuous intra rotation starting at 20 TF flexion; linear increase in the flexion of the patella, both resurfaced and not, close to the that of the intact knee; patellar rotation more lateral than in the intact knee; patellar tilt without resurfaced patella closer to the intact knee one; 6 mm lateral patellar shift, likely accounted for the surgical technique.
Slightly more than TKA with resurfaced patella, TKA with non resurfaced patella flexes nearly like the intact knee. The closeness in values of patellar flexion and tilt represents a proof of the closeness in behavior of not resurfaced patella in TKA to the patella in the intact knee.
The average IKS Knee score was 72 (23–97) and the functional score was 68 (0–100) with 74% experiencing none or only mild pain. The SF12 assessment revealed a mean physical score of 55 (14–99). Ninety per cent of patients were satisfied with their knee and 89% would have the operation again if required.
There was one operative death (PE), one deep infection, 3 PE’s, 3 DVT’s and 5 superficial infections. An MUA was required in 9 cases.
Eight knees were revised. Using ‘all revisions’ as an end point. The survival rate was 95.3% at 10 years.
Although conventional thinking and teaching have implicated weight and body mass index (BMI) in premature failure of total knee arthroplasty (TKA) there is scant evidence based confirmation of this belief. Furthermore, there is little knowledge regarding the precise effect of BMI on functional outcomes following TKA. We performed this study to assess the effect of weight on the longevity of TKA and on outcomes following TKA revision (TKAR).
186 consecutive subjects undergoing TKAR in a 17-center prospective cohort study, had data collected on weight (pounds), BMI and time elapsed between primary and revision surgery (T). The Physical Component Score (PCS) of the Short Form-36 (SF-36), the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index, and the Knee Society Score (KSS) were also collected preoperatively and at 6-month follow-up. Univariate, bivariate and multivariate statistical methods were used in the analysis.
The mean BMI and weight were 31.8 (54% of subjects had a BMI > 30) and 200 pounds (range 107–350) respectively. The distribution of both measures of excessive weight was close to normal. Average time between primary and revision procedures (T) was 7.3 years (range 6 months to 27 years). Using linear regression, T significantly decreased as weight (BMI) increased. Mean SF-36 PCS, WOMAC and KSS-Function scores were significantly improved 6 months after revision surgery. However, BMI and, in particular, weight were predictive of worse physical functional outcomes.
This study demonstrates the deleterious effect of weight on both the longevity of primary TKA as assessed at the time of revision and on functional outcomes following TKAR. Although further prospective data regarding this population is indicated, the current findings direct us towards better outcomes prediction for overweight patients and more effective counselling and appropriate management of these patients.
However, previous experiments only analysed the relationship between a single type of stiffness. This approach neglects the multi-dimensional characteristics of bone loading in compression, bending and torsion.
This study investigates how compressive, bending (ap and ml) and torsional stiffness are related to the torsional load bearing capacity of healing callus tissue using a common set of bone regenerate samples of sheep treated with distraction osteogenesis. In addition, this study compares the evolution of the various kinds of stiffness.
This study provides insight into how the various stiffness modes are suited to predict the load bearing capacity by in-vivo stiffness measurement.
The ends of the tibiae were embedded in PMMA and mounted to a sequence of special custom made jigs for compressive testing, 4-point-bending and torsion in a material testing machine.
Stiffness was calculated by regression of the initial linear part of the load-displacement curves.
In a final experiment, the specimens were loaded in torsion until failure to record the ultimate torsional moment.
This study evaluated the effect of a collagen type I /hyaluronate (c/h) implant combined with recombinant human growth and differentiation factor-5 (rhGDF-5) in osteochondral cartilage defects of Göttinger minipigs.
In 20 Göttinger minipigs, critical size defects (6.2mm wide and 10mm deep) were created in the medial condyle of both femora. Defects were treated on one side either with the c/h implant alone (n=10) or the c/h implant + rhGDF-5 (n=10), whereas the other side was left empty as an intra-individual control. After 3 and 12 months, 5 animals from each treatment group were killed. The evaluation included macroscopic investigation, biomechanical exploration by relaxation test and semi-quantitative histological scoring using the O’Driscoll score.
No macroscopic differences were found between the two treatment groups, neither could any differences be found in semi-quantitative histological scoring. Biomechanical measurement after 12 months showed a significant increase in peak stress in the c/h group compared to empty defects, however, rhGDF-5 supplementation was not found to influence the biomechanical properties compared to controls. Bony cysts were seen throughout the three treatment groups, indicating insufficient bone regeneration. In two animals treated with rhGDF-5, pronounced ossifications within the joint capsule were observed. In contrast, no ossifications were detected in the knees with empty defects or single treatment with c/h implant.
In conclusion, the combination of a c/h implant plus rhGDF-5 did not result in better defect regeneration compared to c/h implants alone or even to empty defects in our minipig model.
One major problem seems to be the incomplete regeneration of the bony defect when using this device. In further studies, bilayer matrices should be used to address this problem. Due to the small number of specimens in this study, it cannot be resolved whether the ossifications seen in two knees were due to the usage of rhGDF-5 or can be regarded as an independent event. Further data about growth factor interaction should be acquired in animal studies before clinical introduction can be considered.
Elderly patients with a high mortality risk for revision surgery are severely handicapped by a loosened hip prosthesis. Loosening is mainly caused by particle-induced osteolysis leading to the formation of a synovium-like interface tissue. As an alternative to revision surgery we have investigated the possibility of removing the tissue using a gene therapy approach and thereafter stabilizing the prosthesis with percutaneous cement injection.
First we demonstrated that transduction of interface cells with a gene coding for E.coli nitroreductase (NTR) resulted in a 60-fold increase in sensitivity to the prodrug CB1954 that is converted to a toxic metabolite by NTR. Given these in-vitro data, we explored if intra-articular administration of this adenoviral vector encoding NTR followed by the prodrug was able to kill sufficient tissue in-vivo to allow refixation of the prosthesis by cement.
We report the first three patients from a phase 1 study of 12 patients with a loosened hip who are experiencing debilitating pain and have significant comorbidity. On day 1 the vector is injected into the hip joint and on day 3 the prodrug is injected. On day 10 three holes are drilled in the femur and one in the acetabulum. Biopsies are taken from the periprosthetic space and low viscosity cement (Osteopal, Biomet Merck, Sjöbo, Sweden) is injected under fluoroscopic guidance.
The first three patients have been included in the study and five more are planned for treatment before June 2005. The patients are females of 86, 72, and 79 years old. There were no adverse effects from vector injection (3x10 exp 9 particles). Six hours after prodrug injection the patients experienced nausea, (WHO grade 1) a commonly reported reaction to this prodrug. There was vomiting in two patients. Hip pain increased, but this was anticipated as this therapy will increase prosthesis loosening. 16 ml of cement was subsequently injected into the periprosthetic space in the first patient and 18 ml in the second. The patients were ambulated the day after surgery.
The first two patients have a follow-up of twelve and six weeks. There was no pain in the hip. The maximum walking distance had increased from 5 to 30 meters in the first patient.
The current study is the first to use in vivo intra-articular adenoviral mediated gene transfer in a clinical setting. Our preliminary results suggest that gene therapy and cement injection for hip prosthesis refixation is clinically feasible.
The fluorescent microsphere (FM) method is considered the best technique to determine regional bone blood flow (RBBF) in acute experiments. In this study we verified the accuracy and validitiy of this technique for measurement of RBBF in a long-term experiment and examined RBBF after meniscectomy. 24 anesthetized female New Zealand rabbits (3 groups, each n=8) received consecutive left ventricular injections of FM in defined time intervals after meniscectomy. Group 1 from preoperatively to 3 wks postoperatively, group 2 from 3 wks to 7 wks, and group 3 from 7 wks to 11 wks postoperatively. To test the precision of the FM-method in long-term experiments two FM-species were injected simultaneously at the first and last measurement. After the experiment both humeri, femora, and tibiae and reference organs (kidney, lung, brain) were removed and dissected according to standardized protocol. Fluorescence was determined in each reference blood and tissue sample and blood flow values were calculated. Blood flow in kidney, lung, and brain revealed no significant difference between right and left side and remained unchanged during the observation period excluding errors due to shunting and dislodging of spheres in our experiments. Comparison of relative bone blood flow values obtained by simultaneously injected FM showed an excellent correlation at the first and last injection indicating valid RBBF measurements in long-term experiment. We found a significant increase of RBBF 3 wks after meniscectomy in the right tibial condyles compared to the non-operated left side. Similar changes were found in the femoral condyles. RBBF in other regions of tibia, femur, and humerus revealed no significant difference between right and left bone samples of the same region. Our results demonstrate that the FM method is also valid for measuring regional bone blood flow in long-term experiments. In addition we could demonstrate that meniscectomy leads to an increase of RBBF in the tibial condyles very early. This increase might be caused by stress-induced alterations of the subchondral bone.
Polymethylmethacrylate (PMMA) is the material of choice for vertebroplasty (VP). However, PMMA has several disadvantages such as exothermic curing, uncertain long-term biomechanical effects and biocompatibility. As a result alternative materials are being developed to overcome these problems.
In order to determine the role of PMMA in the generation of cardiovascular changes following vertebroplasty we compared injection of cement with wax in an animal model.
The aim of our study was to evaluate if PTH is able to increase the trabecular density of osteoporotic bone at the site of an implant and whether the anabolic effect of PTH at this side is stronger then the effect of an osteoclast inhibitor like alendronate.
48 cement rod was inserted in the tibia of 48 female rats, of which 36 had been ovariectomized. The cement rods, which served as implants, were made of Palacos R bone cement. After implantation, the 36 ovariectomized rats were divided in 3 groups. One was injected subcutaneusly with PTH (1–34) at a dose of 60 g/kg BW. The second was injected with alendronate at a dose of 205 g/kg BW. The third with vehicle only. The remaining 12 sham operated rats were also injected with vehicle only. All injections were given three times a week and the rats were killed 2 weeks after implantation.
The tibial segments around the hole of the rods were prepared histologically. Thus the surfaces which had been in contact with the rod appeared as straight lines and could be analyzed histomorphometricly. The trabecular density of the bone closest to the implant was measured. One femur of all animals was used for measurement by DEXA.
There was a substantial increase in the trabecular density close to the rods with PTH treatment (Anova p=0.002). PTH lead to a trabecular density of 89%, where as the ovariectomized animals revealed a trabecular density of 58% and the sham operated control of 68%. No significant increase of implant related trabecular density could be found in the alendronate treated group. In this group a density of 72% was established. DEXA showed the expected differences in bone mineral content (Anova p=0.001).
In this study, intermittent PTH treatment increased implant-related trabecular density in osteoporotic bone after 2 weeks. No such positive effect could be found with alendronate treatment at such a short period of time. We think the reason for this phenomenon could be the early onset of the anabolic PTH effect on regenerating bone, whereas alendronate is thought to only inhibit bone resorption, which might lead to a later effect.
The early onset of PTH effects even in osteoporotic bone suggests that intermittent PTH treatment might lead to an increased micro-interlock between implant and bone and might therefore be considered as a possible drug to enhance incorporation of orthopedic implants.
50.8% of released allografts (125 heads) were used in revision arthroplasty. In spine surgery 83 allografts (33.7%) were implanted in spinal fusions and for cage filling during vertebral body replacement. Thirty-two grafts (13.0%) were used in miscellaneous surgeries with minor bone demand.
The costs per donation were 92, with personnel costs the price per head was 140. The price range for commercial alternatives starts at 100 for 1 cm.
Its pathogenesis is based upon the generation of wear debris particles which trigger synovial macrophage activation. Statins, inhibitors of 3-hydroxy-3 methylglutaryl coenzyme A (HMG-Co-A) reductase, have revolutionised the treatment of hypercholesterolaemia and cardiovascular disease. The antiinflammatory properties of HMG-CoA reductase inhihitors or the statin family are well recognised. We investigated the effects of ceriv-astatin in attenuating the activation of human macrophages by polymethylmethacrylate (PMMA) particles.
Western blotting confirmed Raf/MEK/ERK down-regulation by cerivastatin, establishing a mechanism for its anti-inflammatory effects.
Because endothelins (ET) have effects on functions of both osteoblasts and osteoclasts, it is thought that these peptides may be one of the mediators of coupling phenomena that maintain the connection and regulation between bone formation and resorption process in osteogenesis. Along with their demonstrated effects on osteogenic cells they have dual activity on both mineralization and resorption process. So it is also thought that they may have a major role in bone turnover and remodeling processes. We aimed to investigate if ET had a role in the pathophysiology of osteoporosis. Therefore we looked for a difference in ET plasma levels between osteoporotic and normal people.
86 patients (16 men and 70 women) with a mean age of 62.6 (ranges: 51–90) years were included in this study. All patients were examined by dual energy X-ray absorbsiometry evaluation at first. Patients were divided into 3 groups regarding reported T scores. T-scores less than −2.5 on either total lumbar spine or total hip were accepted as osteoporosis, while scores between −1 and −2.5 were accepted as osteopenia and scores above −1 were accepted as normal according to the suggestions of World Health Organization. According to these criteria 19 patients were normal, 43 were osteopenic and 24 were osteoporotic. Then total plasma level of ET was measured in all patients with monoclonal antibody based sandwich immunoassay (EIA) method.
One-way analysis of variance test was used to compare endothelin values between normals, osteopenics and osteoporotics regardless of gender and for each gender. A value of p< 0.05 was considered as significant.
Endothelin total plasma level in patients with osteoporosis was a mean of 98.3663.96 pg/ml, a mean of 100.9247.2 pg/ml in osteopenic group and a mean of 99.5656.6 pg/ml in normal group. The difference between groups was not significant (p> 0.05). In men with osteoporosis endothelin level was a mean of 185.7017.2 pg/ml and this was significantly higher than osteopenic men (124.8059.6 pg/ml) (p< 0.05) and normal men (93.0050.1pg/ml) (p< 0.05). In women there was not any significant difference between groups (normal:102.0060.7pg/ml, osteopenics: 94.7042.7pg/ml, osteoporotics: 79.9053.8pg/ml) (p> 0.05).
We found out that plasma ET levels of osteoporotic men were significantly higher than normal men. But comparison regardless of gender among osteoporotics, osteopenics and normals and comparison of female osteoporotics, osteopenics and normals yielded no significant differences. We think that the reason for differences in our results regarding gender may be the higher estrogen level of the females even if they were in the postmenopausal period and thus estrogens’ possible effect of down regulation in ET-1. Considering these results we think that ET may have a role in the pathophysiology of the men osteoporosis and it can be used as a marker for diagnosis and treatment follow-up of osteoporosis.
Current research efforts aim at enhancing osseointegration of cementless implants to improve early bone fixation.
In tissue engineering, scaffolds are vitalized by cells in vitro. Human mesenchymal stem cells (hMSC) are very interesting because of their ability to differentiate towards the osteogenic lineage and their self renewing capacity. Yet, it is important that implanted cells do not disseminate and exhibit unwanted cell growth outside the implantation site. Therefore the aim of this study was to detect migrated cells in organs of mice after implantation of a composite (cell-scaffold) substitute.
HMSC (Cambrex, USA) were inoculated on a clinically approved 3D scaffold (Tutobone(TM), Tutogen, Germany). One composite and one scaffold without cells were implanted subcutanously, left and right paravertebrally in athymic nude mice (nu/nu). After 2, 4, 8 and 12 weeks constructs were explanted and organs (liver, spleen, lungs, kidney, heart, testicles, brain and blood) were harvested. The entire organs were homogenized and genomic DNA was isolated for qualitative and quantitative PCR.
Human DNA was found in all explanted composites at all examined time points. No human DNA could be detected in control scaffolds. Moreover we did not detect human DNA in all explanted organs at any time point. As internal controls we could detect 1 single hMSC in a pool of 106 mouse cells.
In conclusion, we could proof that cells of implanted composite substitutes do not migrate to other organs. Furthermore, this study showed that implanted hMSC seeded on 3D scaffolds survive over time frames up to 12 weeks.
To tissue-engineer bone suitable cells need to be grown on a scaffold. In this study we grew human marrow cells as they can differentiate into osteoblasts, on porous hydroxyapatite (HA) scaffolds, as this is osteoconductive, allows cell penetration and in growth of capillaries after implantation.
Increased extravascular perfusion through bone increases new bone formation. So we reproduced these physiological conditions in our novel bioreactor by perfusing scaffolds at 6ml/hr.
After 14 days in bioreactor culture the HA was covered with cuboidal cells, consistent with osteoblasts, however in static culture cells remained fibroblastic. TEM results showed that MSCs in the bioreactor produced organised collagen matrix after 21 days and osteoid by 28 days, but no collagen matrix was observed following static culture.
ALP and PICP were significantly greater over 15 days culture when in our bioreactor.
Moreover, MSCs grown on HA in the bioreactor produced significantly more ALP and PICP indicating osteoblastic differentiation. Furthermore, bone osteoid was produced.
Therefore this culture method could be use to convert autologous MSCs from human marrow into tissue-engineered bone which could be used to heal defects after tumor excision.
Arthroscopic procedures may be associated with considerable pain in the first 24 hours. Intra-articular bupi-vacaine provides good analgesia but is short lasting. Intra-articular morphine has been shown to prolong postoperative analgesia in knee and ankle arthroscopy. The aim of this study is to assess the safety and analgesic effect of intra-articular morphine following day case wrist arthroscopy.
Ethical approval was firstly obtained. 31 patients were randomly assigned to one of 2 groups in a double blind clinical study. Group 1 received 5ml of 0.5% bupi-vacaine intra-articularly with 5mg of morphine subcutaneously. Group 2 received 5ml of 0.5% bupivacaine and 5mg of morphine intra-articularly. There were 15 patients (mean age 41.2 years) in group 1, and 16 patients (mean age 38.9 years) in group 2. Postoperatively pain was assessed using a 100mm visual analogue pain scale (VAPS) at 1, 2, 6 and 24 hours. Analgesia requirements were recorded at these times post operatively. The presence of nausea, vomiting, other complications and patient satisfaction were recorded.
Visual analogue pain scores did not show any significant difference between the groups at 1, 2, 6 and 24 hours. Supplementary analgesic consumption over the 24 hour period was slightly greater in group 1 than in group 2. None of the patients who had intra-articular Morphine had vomiting nor any other complications and did not require anti-emetics. Most patients in either group were satisfied with the level of postoperative analgesia.
Intra-articular bupivacaine with or with out morphine provides adequate postoperative pain relief following wrist arthroscopy. There seems to be little difference between the two methods studied.
Disorders of the pisotriquetral joint can cause ulnar sided wrist pain. This joint is not usually seen during routine wrist arthrosopy because it often has a separate joint cavity. The senior author believes that it is more commonly seen from the 6R portal if looked for, than one would expect from the assumed anatomy.
This study assessed the frequency with which the pisotriquetral joint could be observed in 36 consecutive wrist arthroscopies. The connection between the radiocarpal and the pisotriquetral joint were found to vary from a complete membrane separating the two, to no membrane at all, with variations in between. The types of connections are described. The anatomy of the connections was also studied by dissecting the wrist joints of eight fresh frozen cadavers. The findings matched the arthroscopic observations.
In more than 50% of patients, the pisotriquetral joint could be clearly visualised by arthroscopy. The technique and findings have been recorded on video and form part of the presentation.
Most of them used static splintage (45.20%) and only 5.23% used dynamic splintage.11 surgeons stated using both the types of splintage. 267 surgeons did not questionnaire. Majority of the surgeons applied a static splint (pop slab, thermoplastic splint) after the surgery while others applied it after reducing the dressing within 2 weeks of the operation. 264 (46.07%) surgeons did not reply to the question.
In majority of cases the splint was applied by the occupational therapist. The surgeon, physiotherapist, and orthotist in some cases also applied the splint. Individual comments from surgeons made an interesting reading. After an initial period of continuous splintage majority of the surgeons used night splintage only. 265 surgeons did not reply to the question. Mostly the splint-age was used for 4–6 weeks. Although the spectrum of splintage varied from 2 weeks to 24 weeks. Some of the surgeons stated their own clinical practice in their comments.
179 surgeons stated always referring their patient for postoperative physiotherapy.
13 surgeons (2.26%) never referred their patients for physiotherapy.
77 surgeons on very odd occasions had postoperative physiotherapy for their patients.
Majority of surgeons started the physiotherapy between 1 and 2 weeks, after the stitches have been removed. 107 surgeons favoured early commencement of hand exercises within first week of surgery. 224 surgeon did not reply to this question.
Most of the surgeons followed the patients for two to four months. Longer follow up was done for patients with recurrence, severe or bilateral disease. Also those patients, who had proximal interphalangeal joint contracture and other risk factors, were followed for a longer period. Some of the surgeons commented following them for life in their clinical practice.
The purpose of the study was to objectively compare the effects of the scaphoid and Colles’ type casts on hand function. Currently there is no such published study.
Both casts are commonly used to immobilise suspected and radiologically proven undisplaced scaphoid fractures. There is no difference in non-union rates. The scaphoid incorporates the thumb in palmar abduction, whereas the Colles’ type cast leaves the thumb free. Although necessary for bone healing, immobilisation disrupts function and may require intensive corrective physiotherapy. Unnecessary immobilisation of uninvolved joints should be avoided when use does not compromise fracture stability.
We compared the effect of the two casts on hand function in 20 healthy right hand dominant volunteers using the Jebsen-Taylor Hand Function Test, which uses seven subtests designed to test tasks representative of everyday functional activities. Data were obtained through a mixed between and within subject design.
Using the Jebsen-Taylor Hand Function Test, median overall scoring in the Colles’ type cast was 2.5 times that obtained in the scaphoid. In timing individual subtests, the analyses show significant differences (p< 0001) between the presence and absence of a cast. When comparing the two cast types, mean times for all subtests are less in the Colles’ than in the scaphoid, with the difference reaching statistical significance in five out of seven subtests.
Having either type of cast significantly impairs handling and finger dexterity, and so affects activities of daily living. A scaphoid, however, is much more limiting than a Colles’ type cast. This makes it clearly more inconvenient for the patient with socioeconomic implications and occasionally issues of compliance during a long period of immobilisation.
Suture anchors have changed the practice of repair of tendons in modern Orthopaedics. The purpose of the study was to identify the ideal suture anchor length for anchoring flexor digitorum profundus tendon to the distal phalanx.
We dissected 395 distal phalanges from 80 embalmed hands. Phalanges from two little fingers and three thumbs were damaged, hence were excluded from the study. We measured the Anteroposterior and Lateral dimensions at three fixed points on the distal phalanges of all 395 fingers using a Vernier’s Callipers with 0.1mm accuracy.
The mean value of the Anteroposterior width of the distal phalanx at the insertion of the FDP was found to be 3.4mm for the little finger; 3.9mm for the ring finger; 4.3mm for the middle finger; 4.0mm for the index finger and 5.0mm for the thumb respectively. The commonly available anchors and drill bits were found to be too long when used for anchoring the flexor digitorum profundus tendon in certain distal phalanges. Our findings may be a reason for poor outcome of FDP repair to distal phalanx using suture anchors. New designs for tissue anchors for distal phalanges may be necessary.
There is an high incidence of failures of total wrist arthroplasties. We review our experiences in revising total wrist implant arthroplasties to arthrodeses. The most common mode of failure of the arthroplasties in our series was metacarpal loosening with dorsal perforation of the stem. Loosening of the proximal stem, progressive mal-position of the wrist and other causes appeared.
We used for the revision arthrodesis in all our cases tricortical iliac crest bone grafts and additional spongiosa transplants from this donor site region. In one case we used a vascularized iliac crest bone graft to bridge the bone defect because of a bad host quality of the recipient area. Fixation was achieved with plates and screws.
Our average follow-up period was 32 month. 40 patients with 41 failed wrist implants (3 different types) were treated with this technique. 40 wrist undergoing arthrodesis attained a solid painless fusion after a single operation. In one case a non-union with a loosening of the screws due to using a non-rigid plate was seen. In this case a revision was necessary to achieve a bone healing. All patients were satisfied, pain free and achieved an increased pinch and grip strength after bony fusion (measured with Yamar-Vigorimeter). A persisting loss of carpal height was seen in all cases.
Arthrodesis after failed total wrist arthroplasty is a satisfactory salvage procedure even in cases with a bad quality of the recipient area. We recommend a rigid fixation technique to prevent non-unions.
From January 2000 to March 2004 16 thumbs after total avulsion-amputation were replanted in our hospitals. In 15 cases this was successful. In one case the thumb was lost 28 hours after replantation. Mostly the amputation was in the region of the first phalanx or the IP-joint of the thumb.
In all cases our operative procedure for this form of amputation was the reconstruction of the vessels with vein grafts after the osteosynthesis and the reconstruction of the tendons. The donorsite region for the grafts was in 12 cases the dorsal forefoot and in 4 cases the distal forearm. In none of these cases there was the possibility of reconstructing both arteries. Mostly only an anastomosis for one artery and one vein could be done. For none of these patients it was possible to reconstruct the nerves primarily. Until now transphers of neurovascular skinislands of longfingers, free nerve transplantations with coaptations to the proximal stump of the injured nerve, free nerve transplantations with coaptations to the trunk of the median nerve or in one case an end-to-side coaptation have been performed to achieve a resensibility of the thumbs. In one case a patient rejected an operative nervereconstruction, because a sprouting of the proximal stump of the injured nerve lead to a (reduced) sensibility of the thumb. In 4 cases a therapy to achieve a resensibility has so far not been carried out.
After replantations of injured thumbs necroses of the skin in different kinds were noticed. In 4 cases secondary skinreconstructions were necessary. All 15 successful replanted thumbs achieved very good results concerning function, strength and patient’s satisfaction.
Our results don’t agree with the mostly bad results after total avulsionamputations mentioned in literature. We think that the replantation after total avulsionamputation of the thumb has a high chance of being successful and can achieve very good longtime results.