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View my account settingsOutcome measures must be valid, reliable and responsive to change criteria. The most common clinical outcome measures are Knee Society Scores, SF-36 quality of life scores, HAQ and DAS scores. However, performance based measures of functioning may not be dependent on patient report or observer judgment.
Examples of objective pre- and post-operative performance outcome measures are surface Electromyography (EMG) of muscles, kinematics and kinetics (gait analysis). For the evaluation of implant survival after joint arthroplasty, Roentgen Stereophotogrammetric Analysis (RSA) is the golden standard to assess micro-motion of the implants.
Surface EMG can be used to asses the stability of joints before and after intervention. Calibrating of raw EMG data is necessary to compare the data between subjects. It was shown that calibration of EMG data by means of isokinetic contractions on a dynamometer during flexion and extension was more reliable and repeatable than using a Maximum Voluntary Contraction in patients after total knee arthroplasty. After total knee arthroplasty RA patients have a lower net knee joint moment and a higher co-contraction than controls, indicating avoidance of net joint load and an active stabilization of the knee joint.
Fluoroscopy can be used to assess the kinematics of joints. In the pre-operative situation the use of CT models of the involved bones can be matched to the assessed fluoroscopic images. In the post-operative situation CAD models of the implants can be used for this purpose. In this way accurate 3D kinematics of joints can be assessed. During a step-up task of RA patients, the rotating platform of a mobile bearing knee showed no- or far less longitudinal rotation than the femur. Therefore, some of the theoretical advantages of this specific rotating platform knee prosthesis can be questioned. Fluoroscopy has also been used to assess soft tissue artifacts that occur in gait analysis i.e. displacements of skin-mounted markers relative to the underlying bone. The large soft tissue artefacts observed (displacements up to 17 mm and 12 degrees) question the usefulness of parameters found with external movement registration.
In order to assess the micromotion of implants after joint arthroplasty a measurement technique with a much higher accuracy than fluoroscopy is needed. RSA uses tantalum markers as landmarks bony structures and as landmarks on the implant. Recently a new RSA technique has been developed that does not rely on the attachment of artificial markers on the implant but uses CAD models of the implant instead. As an example of RSA as outcome measure, results showed that a calciumphosphate coating improves fixation of tibial components in RA patients, thus preventing mechanical loosening and subsequent long-term revision. In another clinical RSA study, it was found that mobile bearing knees are more predictable and forgiving with respect to micromotion compared to posterior stabilized tibial components in RA patients.
The results obtained by the above described performance outcome measures can be valued since the accuracy and precision of the used outcome measures are all published.
Orthopedic surgeons treat numerous patients in whom osteoporosis (OP) is an important factor: inflammatory arthritides (rheumatoid arthritis); sports medicine (the anorexic, amenorrhoeic female athlete); in consultation to renal, transplant and cardiac units; patients on corticosteroids, as well as others. Orthopedic procedures in patients who have osteoporotic bone require special techniques and precautions. A common example is hip replacement, where, through endosteal resorption, the medullary canal is large, cortices are thin, and the risk of femoral fracture and a poor outcome is higher.
The commonest interface of orthopedic surgery with OP is in the management of fractures. In North America, most orthopedic surgeons manage fractures in hospital and in the fracture clinic, where typically 3%–8% of patient visits are for classic fragility fractures. Traumatic fractures also commonly occur in osteoporotic bone. The yield of screening for OP in orthopedic wards and clinics, targeting fragility fracture patients, is much higher than screening in a general population. Published guidelines based on Level I evidence indicate that fragility fracture patients are at highest risk of future hip fractures, which often occur within one year of index fragility fracture, and that preventive treatment is economical and safe.
Treatment prevents 30–50% of hip fractures in high risk groups. Unfortunately, less than 20% of fragility fracture patients generally receive appropriate OP care, in multiple studies in developed countries. There is a growing international focus on developing care delivery systems that will promote consistent OP investigation and treatment in the inpatient and outpatient orthopedic environment.
In Ontario, Canada, an Osteoporosis Exemplary Care Program was initiated in 2003 to identify, educate, evaluate, refer, and treat female (> 40 years) and male (> 50 years) fragility fracture patients for OP. In the first year of the program, over 95% of inpatients and outpatients were appropriately diagnosed, treated, or referred for OP care. Success resulted from the presence of a dedicated coordinator and cooperation by orthopedic surgeons and residents, technologists, allied health professionals and administrative staff.
Regional, national and international orthopedic associations have developed initiatives designed to improve processes of care for OP in the orthopedic environment.
A better understanding of the pathophysiology of rheumatoid arthritis has led to important and innovative approaches to its treatment In the case of confirmed diagnosis the recommended gold standard is to give methotrexat, possibly in combination with corticosteroids. If disease activity cannot be controlled, other basic therapies, possibly in combination with or as biologic DMARDs (Diseases modifying drugs) are prescribed. The main emphasis here is placed on TNF-Alpha blocker and drugs that inhibit Interleukin-1. New drugs such as anti-CTLA4-Ig and anti-CD20 (Rituximab) aim to influence the activation of T- and B-cells. Management is supplemented by educating the patient, physiotherapy and ergotherapy as well as specific surgical intervention, as required.
Rheumatoid arthritis is a whole body, lifetime incurable disease. The problems engendered by the disease process itself are highly individual, given that each set of problems that a patient has, the assessment and planning of surgery is a crucial aspect of the appropriate management of patients with polyarthritis.
The presence of deformity does not necessarily indicate a problem of function, but one has to accept that certain deformities cause more problems than others and I draw your attention to swan neck deformity being relatively function-impairing and Boutonnière deformities less so. There is always a balance between the risk of surgery and the benefits to be obtained.
The assessment is functional, anatomical, radiological, psychological, medical, financial and, finally, surgical. The functional assessment is intended to identify the problems a patient has in the activities of daily living, the anatomical assessment identifies the structures damaged which need to be prepared or replaced, the x-rays define the bone loss and, therefore, determine the limits of bony surgery, the psychological aspect identifies the patient’s capacity and willingness to be involved in often quite complex therapy programmes over a significant period of time. The medical problems of vasculitis and active disease are less frequent now but are contra-indications to surgery in the acute phases.
The financial aspects are often under-rated. The costs of maintaining someone with significant disabilities is really quite great and, therefore, although surgery may only give some small improvement in function, it often has quite a significant impact on the degree of care and help an individual needs.
Finally, the surgical assessment is to identify which structures and in which order.
In terms of planning, the surgical priorities, described by Nalebuff, are:
1 Nerves 2 Flexor tendons 3 Wrist 4 Thumb 5 MCP joints 6 Extensors 7 PIP joints 8 Distal Interphalangeal joints
Prolonged nerve compressions do not recover well; ruptures of flexor tendons are very difficult to treat; if the wrist is painful and unstable it inhibits any function that the hand might have; the thumb is 50% of hand function; metacarpophalangeal joints need to be stable and to flex approximately to 60° in order to be functional; extensor tendons need to glide and to be able to lift fingers away from the palm; the interphalangeal joints contribute greatly to the closing of grasp.
The role of the therapist is pre-operatively to assess the patient appropriately for surgery, assessing all the aspects defined above and to ensure that the patient is compliant with the treatment post-operatively. The aphorism that 20% of the effort comes from the surgeon, 50% from the therapist and 20% from the patient is probably a fairly accurate representation of the importance of therapy post-operatively. Therapy must be planned, purposeful and progressive.
Destructive processes of osteoligamentous structures and severe osteoporosis may be blamed as the principle cause for pain, deformity and subsequent neurological deficit in the rheumatoid patient’s spine.
The subaxial cervical spine has a tendency to disintegrate in the presence of aggressive course of rheumatoid arthritis. The extent of instability and site of compression has to be carefully analyzed, using MRI and neurophysiological examinations. Due to weak bone structures anterior and posterior interventions are often necessary.
Development of newer finger implant in Japan started with hinged Ceramic implant in early 1980’ and was abandoned its use in early stage (Doi 1984 and Minami 1988). Although silicone finger implant has been most popular, breakage of the implant, particle induced inflammation and implant subsidence continued to be the problems of the silicone implant. In turning to new century, there was another enthusiasm of developing new finger implant in Japan. Surface replacement was chosen for the PIP joints, however, most of design for the MP joint had constrained mechanism, including ball and socket joint with stem allows piston motion and semi-hinged joint with much freedom. Currently available finger implants in Japan will be discussed briefly.
The author developed cement-less surface finger implants (Self Locking Finger Joint, SLFJ) for the MP (including thumb) and PIP. Characteristics of the implant include,(1) the joints anchor(stem) has tapered screw with two long legs which spread intramedullary allows fixation without cement and thus change the position during the operation for optimum collateral tension, (2) joint design that preserve collateral ligament and surface contour, (3) simultaneous replacements of both MP and PIP are possible. Over 500 joins in 200 patients have been operated during last seven years. Of 50 cases operated by author with minimum of 4 years follow up, 34 cases were available for evaluation. There were 98 joints: 72 MP, 12 PIP and 14 MP of the thumbs. Average follow up was 5 years and 5 months (4 years ~ 6 years and 6 months). Fixation of the joints anchor were stable, only three joints showed marked loosening. Breakage of the joint anchors was found in 7 MP and 2 PIP; 5 out of 9 breakage of the legs were occurred during the operation. In x-ray evaluation, about half of the joint anchors were found securely fixed to the bone within 2 years. Dislocations of the joints were found in 4 MP joints in 3 cases (3 were early dislocation and were found to be technical failure and one late dislocation) and 2 PIP joints (one early and one late dislocation). Five MP implants were removed because of progressive flexion contracture and 3 MP and 2 PIP were re-operated. Range of motion of ext/flex averaged −25/70 in MP and −20/65 in PIP.
For many decades ankle fusion has been the only option for treatment of symptomatic osteoarthritis of the ankle joint. From the late 60’s on the crusade of joint replacement for hip and knee led to successful functional restoration for severe destruction of these joints. Because of a lack of understanding the biomechanical principals of the ankle a similar approach in reconstructing the ankle arthritis was doomed to fail. On the other side very good functional outcome after fusion of the ankle seemed to make needless further development. Although first encouraging results with non-constrained designs and cementless fixation were obtained in mid-late 70’s a wider acceptance within the orthopaedic society was found only almost 20 years later whereas today many surgeons wouldn’t give up the ankle arthroplasty for several indications. Despite good and very good midterm results we still need to understand limits and further develop operative techniques especially soft-tissue balancing.
In our institution we have been using TAR since 1995 on a regular basis and by now overlook a total of almost 400 TAR’s. The experience with different designs (Agility, S.T.A.R. and Buechel-Pappas) led to the development of the Mobility-TAR in collaboration with two surgeons from England and the U.S. It is a 3-component TAR, non-constrained. As a unique feature the instrumentation allows an accurate centring of the implants both in the frontal and the saggital plane. In a prospective trial in Wrightington and Zurich we clinically and radiographically evaluate the outcome. The first 42 cases in Zurich with a follow-up of more than 1 year showed a significant pain reduction from av. 8.1 on a visual analogue scale to av. 1.4 after one year. The ROM assessed radiographically could be improved from 26° preoperatively to 33° after one year. We have seen 4 fractures/osteotomies of the medial malleolus and one neuropathy of the tibial nerve as intraoperative complications. Postoperative complications included two superficial wound healing problems, one deep infection and finally two stress fractures of the medial malleolus. One case had to be revised because of aseptic loosening after 6 months. All but one of the first 42 patients would undergo the same procedure again.
The first results are encouraging because of good overall results with significant pain reduction and good ROM combined with only few complications.
With the increasing number of implantation of total ankle arthroplasty a higher rate of pitfalls and failures has to be expected.
Intra- and postoperative complications in total ankle arthroplasty, their sources of failure and revision options are demonstrated.
In the time of 7/97 until 1/06 269 S.T.A.R. total ankle prostheses have been implanted at our hospital.
Intraoperative complications occurred in 7 cases (4 fractures of the malleolus medialis, 2 fractures of distal fibula, 1 fissure of talus).
We observed early complications in form of delayed wound healing (n=31) and 4 deep infections. A higher incidence of secondary wound healing is shown in rheumatoid arthritis patients in comparison to patients with OA.
Late complications included persisting intraarticular synovitis, especially in rheumatoid arthritis, an impingement (11 cases) and osteolysis (4 cases).
Revision surgery was performed in 45 cases (16.7%) 1.5 years after primary implantation (14 operations with problems in secondary wound healing, 9 lengthenings of the Achilles tendon with a dorsal capsulotomy (2 rheumatoid arthritis patients), 11 revisions of the PE gliding core with resection of periarticular hypertrophic bone formation, 4 revisions of singular components, 2 complete revisions of the prosthesis, 4 ankle fusions, 1 amputation. Only in 18 cases (6.7%) these complications and the following surgical procedures influenced the satisfaction of the patients.
Despite the demonstrated complications, total ankle arthroplasty is more than an alternative to open ankle arthrodesis in the progressive phases of arthritic joint destruction, also in RA at a LDE stage ≥ III.
The ankle joint offers adverse conditions to any prosthetic replacement: high loads on small surfaces, only vague landmarks for the insertion, complex and individually very different functional anatomy.
Despite these obstacles many excellent short- and some long-term results have been published, giving little way to a learning curve. This contrasts with our own experiences over at all 29 years now: 24 % failures of cemented two-component EP’s after 14,6 (6,1–21,2) years (n=67) and 8,7 % failures of uncemented tri-component EP’s after 3,7 (0,6–7,6) years (n=92).
We analyze and explain special problems and typical failures by a brief historical review of ankle joint replacement: as a logical sequence of various concepts, each of them basing on the knowledge of preceding insufficiencies. The general concern of the functionally useful, but limited mobility after the implantation will be discussed, also on the basis of own early and medium-term results: ROM ranging on average from 26° for TPR-(n=35) and 29° for New Jersey LCS-(n=30) up to 35° for S. T. A. R.-prostheses (n=12). Possible solutions of problems will be considered, respecting assumed causalities.
Basing on the literature and own earlier investigations, especially the long-term results will be compared critically.
The incertitude of an exact implantation has been partly compensated by the actual „meniscal“ concept of tricomponent prostheses. It should be favourable for their fixation to the bone and moreover reduce polyethylene-wear. But – as before – the discrepancy of high loads on a small area threatens the durability of ankle joint prostheses.
Prosthetic replacement has become indispensable in the treatment of painfully destructed ankle joints, but it demands a careful and critical indication.
Take home message: If ethical aspects allow an RCT, than the RCT is the study set up of choice when a new technique/implant has to be introduced in the market. Once the implant has proved its evidence, the following post market surveillance should be accompanied by registries (introduction of an implant in each country). If an RCT is not indicated (ethical or other contra indications), than registries should be used to prove evidence for an indicated therapy. CCSs are not recommended.
Angiogenesis, the growth of new blood vessels from pre-existing vasculature has an obvious and essential role in soft and hard tissue repair. During the wound healing many potential angiogenic factors are released and may be found in circulating blood. The most important are basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF).
Experimental data confirm the important role of VEGF and bFGF in wounds and bone healing. It was proved that heparin and its low-molecular derivatives may interfere with various steps of angiogenesis process. Enoxaparine (En) is frequently used as anticoagulant for prophylaxis of thromboembolic complications. The aim of this study was to evaluate in vivo angiogenic potency and VEGF and bFGF content of sera collected from 7 patients after hip surgery, treated for 14 days with 40 mg of En (Clexane, Aventis) daily. Evaluation of angiogenic activity was performed twice before surgery (before and 1 day after one En dose) and 14 days after surgery. Sera were injected intra-dermally to anaesthetized Bal/c mice and 72 hours later the number of newly-formed blood vessels was counted in dissecting microscope (SIA test). Cytokines concentration was estimated by ELISA. Results: Sera obtained after one En dose presented increase of angiogenic activity (57,3+/− 2,4, n=112, p< 0.01)in comparison to the value before En (44.6 +/− 2.5, n=113 of newly-formed blood vessels. After 14 En doses, further increase was observed (72 +/− 4.9 blood vessels, n= 112).
BFGF levels increased after the first En dose, VEGF concentration was significantly higher after 14 injections as compare to the results obtained before or after one injection of En.
Since the successful introduction of National arthroplasty registers by the Scandinavian countries, requirements in arthroplasty research have changed from pure implant survival rates to functional results and quality of life aspects. More patient data are required to address these areas. The goal of our international arthroplasty register survey was to determine key factors for an effective database as source for these scientific analyses.
In the first step, we identified and analysed all available arthroplasty registers via extensive literature and web searches. The preliminary data were validated by sending out a standardized questionnaire with questions regarding goals, organization, funding, documentation, data handling and output of the register. The responses were checked and, if necessary, further information requested via phone.
So far we received detailed information from nine arthroplasty registers worldwide. Only two registers collect data from clinical scores or questionnaires in addition to data for the survival rate. The majority of registers are maintained by the national orthopaedic associations, others like Finland by governmental organizations. The legal boundary conditions vary considerably, e.g. in Finland participation is mandatory, while patient tracking via Social security numbers is not possible in all countries. The rate of participating hospitals ranges up to 100%: 510 surgeons in Canada (72%) – 43 hospitals in Denmark (100%). The preferred locations are hip and knee, the preferred documentation method is paper-based, several registers offer online access or other types of electronic data transfer. In return, surgeons receive a regular feedback from the registers, mostly in form of annual reports. Only a few registers allow the surgeons to have online access to their data in the database. Funding is still of major concern. Although the definition of annual total costs varies, they stay far below 500,000 dollars. Examples of funding sources are the government, National Orthopaedic Associations, grants, a levy placed on the sale of implants, and others.
For the completeness of the collected data, a high rate of participating hospitals as well as a high follow-up-rate is crucial. This can only be guaranteed with substantial funding, governmental support for setting up an adequate framework and the compliance of the participating hospitals. New ways of data collection and processing might help to increase patient and hospital compliance.
Silver is a long known local antimicrobial agent. The use of silver coated prostheses is a valuable option in some cases.
Yet there are patients for whom the permanent implantation of large amounts of silver does not seem to be the perfect solution.
From 04/2004 to 01/2006 seventeen patients of slightly less impaired disposition were treated by a comparable two-stage procedure using silver-augmented cemented spacer prostheses or cement fills.
Patients are closely observed regarding toxic side effects.
Concentration of silver in blood and puncture samples are measured using an argon plasma mass spectrometer.
In the second group one patient of seventeen actually shows a persisting infection, but cannot be matched properly as he primarily suffered from a long-term infected knee arthrodesis.
Silver concentrations ranged from a maximum of 1010 to 243 μg/kg (ppb) to a minimum of 84 to 304 μg/kg (ppb) with silver coating, and a maximum of 380 to 22,9 μg/kg (ppb) to a minimum of 76 to 5,02 μg/kg (ppb) with silver spacers.
There are large individual differences in both groups.
We found no signs of argyrosis or recently developed neurological deficits.
Different resurfacing implants offer different kinds of positioning instruments. As it is of outmost importance to position the components within rather narrow limits to diminish the risk of femoral notching or impingement we decided to measure the position achieved in 72 hips resurfaced with the Durom® resurfacing hip and instruments.
There were 38 males and 27 females with 72 hips (7 bilateral). The indication was OA in 51 cases, RA in 12 and ON in 2. We compared 2 groups, 26 hips operated with an antero-lateral approach (A) and 46 with a postero-lateral approach (B).
The acetabular cup anteversion angle was 22±11° in group A and 15±9° in group B. The abduction angle was 38±9 ° in group A and 44±7° in group B. The acetabular gap was 2±1 mm, resp. 2±2 mm. The stem-shaft angle was 140±5° resp. 141±6°. Retroverted cups averaged 7±4°.
The difference between pre- and postoperative acetabular size was 3 mm in group A (mostly RA patients) and 5 mm in group B (mostly OA patients).
The management of a bacterial periprosthetic infection by two-stage re-implantation should be presented using an implanted application spacer for antibiotics to maintain mobility and soft tissue balance and ensure simultaneous local delivery of antibiotics. Indication is an acute periprosthetic infection, acute and chronic course of the infection with unknown spectrum of organism, hardly to treat and with a probable loss of mobility due to protracted immobilization after implant removal. Acute infections with a known spectrum of organisms that can be controlled by synovectomy and antibiotic treatment or by one-stage re-implantation are contraindications for this treatment. Spacers are available for hip and knee replacements including surface replacements of the knee. First a complete synovectomy is performed; the implant bed is then prepared for implantation of the application spacer for antibiotics. Silicone catheters are advanced through two separate drill holes into the intramedullary canal and then inserted into the perforated implant stems. Daily parenteral doses of antibiotics in parenteral doses are delivered through the percutaneous silicone catheters directly into the intramedullary canal. The application spacer for antibiotics allows daily physiotherapy and even mobilization on a CPM device. Partial weight bearing may even be allowed, if there is sufficient stability. Once the CRP values have decreased to normal levels, the definitive implant is placed using antibiotic-impregnated cement according to current resistance studies. 36 patients have been treated with this method since 1993. Two-stage re-implantation of a total knee was performed in 20 cases, and re-implantation of a total hip in 16 cases. The longest postoperative follow-up period is now 10 years. Till now, no revision surgery has been required on a joint treated in this manner, and no periprosthetic re-infections have been observed. In the knee, a range of motion of 0/0 /106 degrees was achieved after an average follow-up period of 6.1 years. In the hip, values of 10/0/110 degrees were achieved after an average of 6.3 years. Revision surgery for infection included cases of fungal and tubercular infection. A postoperative Hospital for Special Surgery rating of 79.5 was achieved in the knee and a rating of 81.3 in the Harris hip score.
The precise implantation of the prosthesis is quite important to have the good long term outcomes. One of the important methods for the implantation is the preoperative templating to determine the selection of implant size, position and alignment. But the preoperative template system sometimes could not give us the reproducibility of the actual size of prostheses which were assessed intra-operatively. One reason for the inaccuracy of the radiograph based templating system is caused by the magnification of the view due to the fixed knee deformity and another is by the rotation view of the prostheses due to tilt shooting radiograph. We are now performing the preoperative CT based 3 dimensional templating system or intra-operative molding template system with virtual bone model, in the addition to the traditional preoperative radiographic templating system. Our aim is to assess the reliability of these templating systems which are traditional radiograph template (2D-template), CT-based template (3D-template) and intra-operative molding template (Free-template), for the selection of correct prosthetic size during operation. We randomly selected 51 patients with 19 osteoarthritis, 30 rheumatoid arthritis, 1 juvenile rheumatoid arthritis and 1 systemic lupus erythematosus, and performed PFC sigma total knee arthroplasty (DePuy). In all 51 knees, the sizes of implants were estimated on the traditional radiograph to get the 2D-template data. The 3D template data were obtained from 25 knees preoperatively by the CT-based navigation system (BrainLab) and Free-template data were collected intra-operatively from 27 knees with the CT-free navigation system (BrainLab). These template data were compared with the actual implanted size of the femur and tibia without any information. The statistical analyses were performed to evaluate the reliability of these templating systems. The precision of 3D-template was not significantly different from that of 2D-template. On the other hand, the reproducibility of Free-template data was significantly higher than the other templating system. In our conclusion, the precise selection of the prostheses could not be achieved with either 2D-template or 3D-template, due to the disappearance of joint space and severe osteophytes. CT-free system could be precisely acquire in-situ bone information of femur and tibia even in the severe deformity knees, and at the same time, CT-free system, which has the kinematics based navigation system, can determine the placement and alignment. Thus CT-free navigation system would be the best assistance during pre- and intra-operation to achieve the long-term good results.
We compared the long-term clinical outcome scores of the Stanmore total hip arthroplasty (THA) in patients with rheumatoid arthritis (RA, n=26 subjects) versus osteoarthritis (OA, n=35 subjects) at a mean of 12 years after THA. Patients with RA were a mean of 11 years younger at review (66 years, P< 0.001) than those with OA. A greater proportion of RA patients had bilateral THA (19/26 versus 12/35, p=0.03), and were of Charnley grade C (23/26 versus 2/35, p< 0.001). The proportion of male versus female subjects and body mass index were similar between groups (p> 0.05 all comparisons). The overall SF-12 score and SF-12 physical component score were 8% and 15% poorer, respectively, in subjects with RA versus those with OA (P< 0.05). The hip-specific Oxford and Harris hip scores, however, were similar between groups (p> 0.05). Within the individual domains of the Harris hip score, patients with RA had poorer scores for walking distance, stair climbing, putting on of socks/shoes, and ability to enter public transport (p< 0.05 all comparisons). The other domains of pain, limp, use of walking aids, sitting, deformity and range of movement were similar between groups (p> 0.05). The observed differences in outcome scores between RA and OA groups were independent of age and whether the patient had bilateral THA (ANOVA, p> 0.05). Clinical outcome scores in the long term after THA are poorer in RA subjects versus OA. The principal differences occur in the ability to walk long distances, and the use of stairs and public transport.
Metal on metal hip resurfacing was introduced in 1992 by Derek McMinn initially using an all cementless device and then an all cemented device. A hybrid resurfacing with a cemented femoral component and a cementless acetabular component was introduced in 1994. The manufacturer of the hybrid hip resurfacing was changed in 1996. Since 1997 the Birmingham hip resurfacing has been in continuous use.
The device is approved by NICE (National Institute for Clinical Excellence) for use within the NHS in patients with Osteoarthritis of the hip. The device is not yet approved for use in patients with Rheumatoid Arthritis and other types of inflammatory arthritis. There are concerns regarding bone quality in rheumatoid patients, which may result in a high incidence of component loosening or femoral neck fracture. Conventional total hip replacement is a successful procedure in inflammatory arthritis however with modern treatments producing increased activity levels there are concerns about polyethylene wear.
The author has performed metal on metal hip resurfacing in patients with inflammatory arthritis over the past 12 years. A total of 170 patients have been operated on with 198 resurfacings. 33% of patients have a diagnosis of some type of inflammatory arthritis. The outcomes have been assessed using Oxford hip scores and long term clinical and radiological review. Our results indicate that there is a minimal risk of femoral neck fracture and a minimal risk of component loosening when the device is used with this approach in patients with inflammatory arthritis.
25 RA patients with their ankles fused with an intramedullary nail were compared to 35 RA patients with their ankles fused with compression screws.
24/25 nailed patients showed radiographic healing at follow-up after 3 (1–8) years, and 26/35 ankles in the compression screw group examined after 6 (1–14) years healed after the first attempt and another 5 after repeat surgery.
In the nailed group 23 patients were satisfied and 2 somewhat satisfied. In the compression screw group 20 were satisfied, 12 somewhat satisfied and 3 dissatisfied.
There were 4 deep infections (3 healed after nail extraction and antibiotics, one unhealed) in the nail group and 1 deep infection (healed after antibiotics) in the compression screw group.
Six patients in the nailed group also had a permanent plantar sensory loss.
RA patients with a normal subtalar joint are of course only managed by compression screws.
Our approach to reconstructing forefoot deformities in patients with rheumatoid arthritis was as follows. In the lateral toes with mild or moderate joint destruction, shortening oblique osteotomy of the metatarsals is performed. With severe joint destruction, metatarsal head is resected. Arthrodesis of the first MTP joint is performed as a rule with resection arthroplasty in the lateral toes. When shortening oblique osteotomy in the lateral toes is indicated, the great toe is managed as follows: in young patients with mild joint destruction in the great toe (Larsen grades I and II) and who are able to ambulate well, Mitchell’s osteotomy is done. In older patients, or in patients with moderate or severe joint destruction (Larsen grades III to V), flexible hinge toe prosthesis is implanted.
Between 1987 and 2000, Mitchell’s osteotomy was performed on 47 feet in 31 patients, whose mean age was 53 years, Larsen grade was 2.5 and hallux valgus angle (HVA) was 35.0 (SD11.9). Arthroplasty with flexible hinge toe prosthesis was performed on 31 feet in 23 patients, 58 years, Larsen grade was 3.7 and HVA was 45.3 (SD12.9). After 1995, grommets were used in 17 feet. In 2002, we studied clinical results of them. 40 feet of Mitchell’s osteotomy had no pain and 7 feet had some pain. 26 feet of arthroplasty with flexible hinge toe prosthesis had no pain and 5 feet had some pain. Radiologically, HVA was 17.2 (SD10.3) in Mitchell’s osteotomy and 12.1 (SD6.3) in arthroplasty with flexible hinge toe prosthesis. Maintenance of correction by arthroplasty with flexible hinge toe prosthesis was better than Mitchell’s osteotomy significantly, especially more than 30 degrees of HVA. Without grommets, grade 0 was 8 feet, grade I was 3, and grade II was 3 feet judged by Granberry’s grade. But no revision surgery was performed by silicone synovitis or fracture of implant. With grommets, there were no fractures.
We added degree of HVA to management of operation after 2002. More than 40 degrees of HVA was considered flexible hinge toe prosthesis. After 2002, Mitchell’s osteotomy was performed on 7 feet in 6 patients, 53.7 years, Larsen grade was 2.4 and HVA was 32.3 (SD6.8). Arthroplasty with flexible hinge toe prosthesis was performed on 14 feet in 10 patients, 60.7 years, Larsen grade was 3.9 and HVA was 42.5 (SD7.5). Radiological result in these patients at 2005, HVA was 14.6 (SD4.9) in Mitchell’s osteotomy and 14.9 (SD2.5) in arthroplasty with flexible hinge toe prosthesis.
In group II (13 hands), the disease was limited to the MP joints, with an average of 30° of ulnar inclination of the fingers, ranging from 10° to 70°. A compensatory radial inclination of 12° was observed at the wrist, ranging from 2° to 26°.
In group III (28 hands), both the wrist and MP joints were affected by the disease. The fingers presented an average ulnar inclination of 17°, ranging from 7° to 40°. The wrist presented an average radial inclination of 4°.
In group IV (34 hands) and V (3 hands), measurements were done before and after the finger deformity was corrected from an average of 45° to 7°, while the wrist corrected itself, without wrist balancing procedures, on an average from 30° to 2° of radial inclination.
Radiographically we observed suspicious radiolucent lines around 17 of 58 implanted components (29%), three of them progressive. Around the tips of three stems an osteolytic area with minimal progression was found. Three stems showed a slight migration. The following intraoperative complications were observed: Two bone fissures and three lacerations of a collateral ligament, which all healed uneventfully. Five endoprostheses were converted into a flexible hinge silicone implant for persistent pain and loosening between 12 and 48 months p.o. One more implant had to be revised due to a late haematogenous infection 4 years p.o.
Between January 1, 1976 and December 31, 1991, 195 total shoulder arthroplasties and 108 hemiarthroplasties were performed by the senior author in patients with rheumatoid arthritis. One hundred eighty-seven total shoulder arthroplasties and 95 hemiarthroplasties with complete preoperative evaluation, operative records, and minimum 2-year follow-up (mean 11.6 years) or follow-up until revision were included in the clinical analysis. Twenty patients died and one was lost to follow-up. All 303 shoulders were included in the survival analysis.
There was significant long term pain relief (P< .0001), improvement in active abduction (P< .0001), and external rotation (P< .0001) with both, hemiarthroplasty and total shoulder arthroplasty. There was not a significant difference in improvement in pain and motion comparing hemiarthroplasty and total shoulder arthroplasty for patients with a thin or torn rotator cuff. However, among patients with an intact rotator cuff, improvement in pain and abduction were significantly greater with total shoulder arthroplasty. Additionally, among patients with an intact rotator cuff, the risk for revision was significantly lower for total shoulder arthroplasty (p=0.04).
Radiographs were available for 152 total shoulder arthroplasties and 63 hemiarthroplasties with a minimum 2 year follow-up. Glenoid erosion was present in 62 of 63 hemiarthroplasties (98%). Glenoid periprosthetic lucency was present in 110 of 152 total shoulder arthroplasties (72%).
The data from this study indicate there is marked long term pain relief and improvement in motion with shoulder arthroplasty. Among patients with an intact rotator cuff, total shoulder arthroplasty appears to be the preferred procedure for pain relief, improvement in abduction, and lower risk of revision surgery.
The recent advance of drug therapy for RA tends to replace preventive surgery, for example synovectomy. A rupture of a dorsal extensor tendon of the hand is an absolute indication for surgery, however. Such tendon ruptures are usually treated by tendon reconstruction and synovectomy of wrist joint. At our department, reconstructive surgery was administered with synovectomy for extensor tendon ruptures of the hand in 97 hands for 86 patients until June 2005. Recently, however, we occasionally encounter ruptures of extensor tendons not associated with severe synovitis. To treat such tendon ruptures, we usually administer tendon transfers in combination with tenosynovectomy through a small skin incision. Because this surgical procedure has achieved excellent results, we report our experience.
This study included 15 patients who received tenosynovectomy in combination with tendon transfers in 14 hands since February 2001. This surgical procedure is indicated for tendon ruptures associated with mild synovitis (swelling) without instability on the ulnar distal end. As a rule, a 2–3 cm transverse skin incision was made on the dorsum of the hand under maxillary nerve block. After exposure of the distal ruptured end of the tendon, tenosynovectomy was administered through the incision. Then, the distal end was transferred to the adjacent normal tendon and fixed to it with sutures. Postoperatively, the repair was immobilized with bandage. The patient was allowed actively to extend and bend the hand on the next day. As a rule, this operation is administered on an outpatient basis. The postoperative course was uneventful, without rupture of the repair. The preoperative ranges of motion of the MP and PIP joints were retained postoperatively without difficulty in ADL.
According to authors investigating problems with the hand in rheumatoid arthritis (RA), up to 95 % of patients suffer due to wrist involvement after 8–12 years from the onset of the disease. In a high activity and a progressive pattern of RA, wrist damage occurs earlier. The question is what to do when pain and instability are dominant factors and at the same time the x-rays show only a mild or moderate degree of destruction of the joint. Trying to find an alternative procedure to a more radical surgery, in 1995 I started surgical stabilization using a pedicled flap of the joint capsule and the extensor retinaculum.
Twenty five years ago, the 1 st paper concerning radiolunate arthrodesis was published by us (Med Hyg 38 1980). Ten years ago a 5 year follow-up radiological evolution of 26 operated rheumatoid wrists by radiolunate arthrodesis compaired with 20 non operated wrists was reported (JHS 20B 1995).
Six critera were retained for XR analysis :
- Evolutive stage classification (Alnot) - Polyarthritis type classification (Simmen) - Frontal desaxation (Thirupathi) - Carpal collapse (Mc Murtry) - Ulnar translation (Chamay) - Carpal instability (Tubiana)
Our results showed that although radiolunate arthrodesis induced a lasting functional improvement, correction of the desaxation and collapse was only temporary.
Details of the radiological analysis will be presented and compaired with the litterature data.
Various radiological classification systems exist for rheumatoid wrist progression but few have been evaluated for reliability and clinical application. In order to research these three sets of wrist radiographs of 35 rheumatoid patients, with an average duration of disease of 11 years, were classified according to four different classification systems (Larsen, Simmen, Wrightington and Modified Wrightington). The inter- and intraobserver reliability of each was calculated. The reliability of the Larsen and both Wrightington systems were good but the Simmen system had poor interobserver and intraobserver reproducibility. None of the classification systems satisfactorily assessed the distal radioulnar joint (DRUJ) and the Modified Wrightington system could not classify DRUJ disease in 6 of the 35 wrists.
Evaluation took place after an average of 5.3 years of follow up (range 1.7–10.6 years) and consisted of a questionnaire, elbow function assessment and anteroposterior and lateral radiographs in a standard way. Pre- and postoperative range of motion was analysed with the paired T-test. Pain scores and EFAS scores postoperatively were analysed using the independent sample T-test. The survival of the prosthesis was calculated from the time of implant to the time of revision or occurrence of radiolucencies.
In group 2 five patients died of an unrelated course and no revisions have taken place, one TEP is loose on X-ray (after two years) with a suspicion of septic loosening The EFAS scores (87 in group 1 and 91 in group 2) and range of motion (84 degrees in group 1 and 90 degrees in group 2) were the same in both groups.
Since the 1970s Swanson implant arthroplasty has become a treatment of choice in metacarpohalangeal (MCP) joint arthroplasty in destructed MCP joints of rheumatoid patients. Sutter (Avanta) implant is also composed of silicone but the centre of rotation is more anatomical, and volar to improve extension moment. Clinical results about these implants have been similar but fracture rates of Sutter implant have been reported to be high. Reason for osteolysis is inflammation reaction to silicone particles released from prostheses due to movement of prosthesis in bone or implant fractures. Reports about osteolysis around Swanson implants present variable result.
There is not grading of osteolysis in the literature before and we created a new radiographic grading for osteolysis around silicone MCP implants. Grading is based on involvement of cortical bone: Grade I: Osteolysis varying from a single clear line adjacent to the stem of the prosthesis to a larger, clear area which did not involve the bone cortex; Grade II: Osteolysis affecting the bone cortex to a maximum of one half of the thickness of the cortex; Grade III: Osteolysis affecting the cortex to more than one half of its thickness but not perforating the cortex; Grade IV: Osteolysis perforating the cortex.
In this study we compare the incidence of radiographic osteolysis following insertion of 89 Swanson and 126 Sutter MCP implants in rheumatoid arthritis patients. Before surgery hands were randomised one by one to Swanson and Sutter implant groups. The mean follow-up time in the two groups of patients was 57 (40–80) and 55 (36–79) months, respectively.
A total of 45 (60%) metacarpal and 40 (53%) proximal phalangeal bones showed no osteolytic changes in the Swanson group. In the Sutter group numbers were 20 (21%) and 26 (27%). In the Swanson group, there was less cortical osteolysis and there were 4 (5%) perforations of a metacarpal and no perforations of a proximal phalanx. In the Sutter group, there were 9 (9%) perforations in a metacarpal and 5 (5%) in a proximal phalanx. (p< 0.001). To create a single independent observation of osteolysis for a hand, the worst osteolysis of a metacarpal or proximal phalanx was recorded. There was only one (5%) perforation in the Swanson group, while there were 8 (30%) perforations in the Sutter group (p=0.011). In all grades of our classification, osteolysis was more frequent in the Sutter than in the Swanson group.
Clinical and radiological assessments were carried out before surgery and at 6 months and one year after surgery and annually thereafter until the death of the patient or the revision of one or both components, the mean follow-up being 8.9 years (S.D. 5.6).
The survival statistics are based on Kaplan-Meier survival curves and Cox regression analysis applied to 3 Groups with differing end-points: 1) Revision of one or both components of the prosthesis 2) Ditto or the development of a complication, seriously threatening the survival of the arthroplasty and 3) As in (2) or definite evidence of progressive radiological loosening.
For Group 1: the survivorship at 5, 10, 15 & 20 years was 95, 89, 82, & 81% respectively; for Group 2: 93, 87, 76 & 69%; and for Group 3: 91, 84, 72, & 68%. In Group 1, indications for revision or removal of one or both components were persistent dislocation (5), fracture (5), aseptic loosening complicated in some cases by fracture (20) and infection (14). In Group 2 the threatening complications included instability (2), un-united fracture of the ulna (4), infection (7), and clinical loosening (2)
The results with the long-stemmed implants showed a very similar trend, the important Zones being 2B, 4B, and 3.
Under the auspices of German AO International (DAOI), the German Society of Orthopeadics and Orthopeadic Surgery (DGOOC), the German Society of Trauma Surgery (DGU) and the German Society of Shoulder and Elbow Surgery (DVSE), and in collaboration with the MEM Institute for Evaluative Research in Orthopaedic Surgery, University of Bern, the nationwide online Shoulder Arthroplasty Register was implemented.
Reconstruction of deficient bone stock during total elbow arthroplasty in rheumatoid arthritis represents a challenge for the surgeon. Fracture and osteolysis of the olecranon process is a very rare condition in rheumatoid arthritis. The consequence of a deficient olecranon is an instable and painful elbow. We report a case of successful olecranon reconstruction with bone graft associated to total elbow arthroplasty with a 8 years follow up and discuss surgical aspects.
This case concerns a 44 years old woman with a very severe rheumatoid arthritis. She complains of pain and instability of her right elbow. X-rays show fracture and major osteolysis of the olecranon process with only some persistent bone at the insertion of the triceps tendon. The humeral condyles were subluxated posteriorly.
We performed a total elbow replacement with a GSB3 implant and reconstruction of the olecranon with two cancellous iliac bone strut fixed by 2.7 diameter screws to the proximal ulna. The triceps tendon with remnant olecranon bone chips was secured to the bone graft by tension band wiring. Postoperatively, the elbow was immobilized for 3 weeks.
With a follow up of more than 8 years the elbow is pain free with excellent function. The active range of motion of flexion – extension is 140° / −20°. The elbow is stable and triceps function is very satisfying authorizing the use of crutches. X-rays show good bony integration of the reconstructed olecranon process and no signs of loosening of the GSB3 implant.
The literature concerning olecranon reconstruction during total elbow arthroplasty in rheumatoid patients is very poor. Kamineni and Morrey reported on one case of olecranon reconstruction with strut allograft in revision total elbow arthroplasty with an unsatisfying result. Their fixation technique was different. We prefer an autograft whenever it is possible and we recommend our fixation technique using screws and tension band wiring.
6 of the elbow replacements had undergone previous surgery, 4 had an interposition arthroplasty and 2 a synovectomy and radial head excision.
No patients were lost to follow up. All were evaluated at a mean follow up of 49 months [6–84 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films.
16 patients had died and 8 patients were lost to follow up. 62 elbow replacements in 46 patients were evaluated at a mean follow up of 79 months [29–137 months] using the Mayo Clinic Performance Index. Postoperative radiographs were also reviewed for loosening using standard anteroposterior and lateral films.
An experimental set up was therefore devised, using a model to determine the actual accuracy of the retroversion obtained under ideal in vitro conditions in two different situations, one in which the proximal humerus was intact such as that encountered in osteoarthritis or P.A.R. and the other where most usual landmarks were missing such as that seen in the four-part fracture situation.
The degree of retroversion of prostheses put is measured according to the angle between the axis passing by the previous face of the condyles of the ulna and the axis passing by the mark taken on the prosthesis (perpendicularly in the axis of the humerus).
The humeral axis, the condylar axis, the prosthesis plane and the cutting plane were determined. 3 barycentres of humeral sections determined the humeral axis. The condylar axis is determined from the 2 barycentres of the digitalized points on the anterior articular condylar surfaces. These 2 axes determine the frontal plane on which a reference mark R(x, y, z) is attached with Z lined up with the humeral shaft and X lined up on the condyles.
This study measures the changes in the lumbar spine in different postures, pre- and after insertion of the device.
All had a positional MRI preoperatively and nine months post-operatively in flexion-extension-lateral bending.
The patients were divided in to two groups:
Group(A) with 8 patients in which Dynesys was used with fusion (disc-height< 40 %)
Group(B) with 12 patients was the Dynesys-only group (disc-height=40–90%).
The changes in the anterior disc height was (mean= −1.18)(p< 0.05) and to the posterior (mean=0.37)(p=0.134). In bending were (mean=−0.87°)(p=0.18) for left and (mean=−0.24°)(p=0.75) for the right
Between 1944 to 2003, eighty nine cases were registered with a diagnosis of Paget’s sarcoma in the Scottish Bone and Soft Tissue Tumour Registry. We found thirteen cases of sarcomatous degeneration of the spine (0.26% of the total bone tumour registry case) which were analysed in this study elaborating clinical, radiological and histopathological features. The mean age was 66.9 years (range 56 to 79 years). There were ten males and three females. There were seven cases involving sacral spine (63.6%), three cases involving lumbar vertebrae and two affecting dorsal spine. One case had diffuse dorso-lumbar involvement from D11 to L3 vertebrae. The mode of presentation was increasing low back pain (in all 13), unilateral sciatica (6, left sided-5, right sided-1), bilateral sciatica (2), lower limb weakness (8) and autonomic dysfunction (4, presented as chronic cauda equina syndrome). The majority of the cases (69.23%) were osteosarcomas. Out of these osteosarcomas, two showed giant cell rich matrix and one revealed predominant telengiectatic areas. Rest of the histological types was shared by chondrosarcoma, fibrosarcoma and malignant fibrous histiocytoma. Decompression laminectomy was performed in three cases. Eight patients had received radiotherapy. The mean survival was 3.93 months (range, 1 week to 7 months), nearly half to the whole Scottish Paget’s sarcoma series with a mean survival of 7.5 months. We found a constellation of symptomatology due to radiculo-medullary compression with a fatal evolution, predominantly lumbosacral involvement, predominantly osteosarcomatous histopathology with a poorest prognosis of all Paget’s sarcoma. Although, decompression laminectomy and adjuvant radiotherapy provided reasonable pain relief and palliation; however, there was no significant influence on the overall prognosis of the patients with Paget’s sarcoma of spine in the last six decades.
Nine (41%) patients underwent surgery and 11 (50%) required rehabilitation in the National Rehabilitation Centre, Dun Laoghaire, with an average length of inpatient stay of 9.22 months (range 5 – 14 months). Eight (36%) patients felt that their injury was preventable. Of those patients without neurology, 60% have returned to playing rugby.
The patients were divided into three groups: those following a standard pathway (group I), patients referred with an MRI scan (group II) and emergency admissions to hospital (group III).
Bilateral decompression of spinal stenosis may induce instability which compromises outcome. In an attempt to overcome this problem, bilateral decompression can be carried out through a unilateral approach. The ipsilateral side is decompressed by hemi-laminectomy with undercutting partial facetectomy and the contra-lateral side is treated by careful excavation beneath the spinous processes and laminae with preservation of the laminae, posterior ligament complexes and paraspinal muscles. This is achieved with the aid of an operating microscope or loupe and headlight. Previous reports contain little information about outcome and complications.
We reviewed 30 patients with bilateral spinal stenosis, but without significant spondylolisthesis who were decompressed bilaterally from a unilateral approach by a single surgeon during a calendar year. They represented a third of our annual operations for spinal stenosis. Thirty patients had 45 levels decompressed. Female to male ratio was 2:1 and average age was 66 years. The average duration of preoperative symptoms was 1.6 years. The mean follow up period was 30 weeks (12 weeks to one year).
Assessment was carried out using the Oswestry Disability Index, pre- and post-operative visual analogue pain scores for leg pain and back pain, walking distance and MacNab criteria of patient outcome.
Whilst the technique is safe, and effective, a longer randomised controlled study is needed to demonstrate any real advantage over traditional approaches.
There are numerous surgical techniques described for cervical decompression for multilevel cervical stenosis. Cervical skip laminectomy is a new technique described by Japanese surgeons in 2000. The advantage of this procedure over the other conventional techniques is it addresses multilevel problem in a least traumatic way without need for instrumentation. It is also described to have lesser incidence of post operative axial symptoms, range of motion and loss of cervical lordosis.
We are presenting our prospective case series of 23 patients who had this procedure in our institution between 2002 and 2004. Of these 16 patients are at least 6 months from their operation. We performed clinical outcome measurements using SF12 questionnaires, pre and postoperative clinical assessment performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression (Done by our musculoskeletal radiologist).
Our study showed a good clinical and radiological outcome with this relatively simple new procedure. This has become our standard operation for our patients with multilevel cervical stenosis with cervical myelopathy.
We report a consecutive series of 352 patients with back pain treated by Dynesys flexible stabilisation between July 2000 and November 2004, to include perceived indications, surgical techniques and complications. A detailed analysis of the first 120 cases with minimum follow up of 2 years is included. Our unit has undertaken 352 operations to date, and this communication reports all cases. Follow up is to 48 months.
All patients were profiled prospectively using the Oswestry Disability Index, Euroquol, SF36, Pain analogue scale, Pain chart and modified Zung. The same measuring instruments were used at review for which follow up was 100%
The procedure involves paired bilateral pedicle screw instrumentation above and below the level of perceived pathology, with each screw pair connected by load relieving carbopolyurethane flexible spacers, in conjunction with a tension band polyethylene cord passed through the spacer. This construct is then held under tension with screws in the main pedicle screws.
All patients are profiled at entry to the hospital service using a proforma which includes the measures outlined above. Conservative treatment is arranged by the centre, and includes physiotherapy to the point of failure. All our cases have failed conservative treatment before enrolling for surgery.
There was significant improvement in symptoms for most of the patients in the series. However clear patterns emerged as to those cases in which Dynesys is contra-indicated.
This is the largest series of cases reviewed so far in the literature.
From the series of 260 cases there were only 3 implant related complications (1.2%).
This study provides preliminary evidence with respect to the safety and efficacy of the Wallis Stabilization System.
Of the 26 patients with a preoperative scoliosis, 10 progressed by a mean of 4.9° (range 2°–15°)
There was correlation between fluoroscopic copies and virtual trajectories.
This image guidance system may not only aid in the placement of pedicle instrumentation but also assist the senior surgeon in trainee supervision.
We analysed the data of 31 patients with SMA (16M:15F) who underwent scoliosis surgery between 1996 and 2004. The data collected included SMA type, age at surgery, percentage predicted forced vital capacity(%PFVC), blood loss, duration of surgery, complications, type of surgery undertaken, pre-operative mean Cobb angle ± SD(including bending film Cobb angle ± SD), post-operative Cobb angle ± SD and length of hospital stay. The decision to do single or two stage surgery was based on the history of recurrent chest infection, %PFVC and the stiffness of the curve. Percentage correction of Cobb angle in patients that had two stage surgery compared with those that had single stage posterior surgery. Comparison of post-operative respiratory complications, estimated blood loss, total hours in theatre and mean length of stay between the two groups.
There were 29 patients with Adolescent Idiopathic Scoliosis and 7 patients with congenital or infantile scoliosis. Z-scores from patients with neuromuscular scoliosis also included, 10 patients with cerebral palsy and 11 with muscular dystrophies (mainly Duchenne MD). There were also 3 patients with Neurofbromatosis and 8 patients with other conditions (miscellaneous). Outcome measures were bone mineral density in patients with different types of scoliosis in form of Z-scores.
We report the results of our continued review of 11 hip arthroplasties using 22.225mm alumina ceramic femoral heads (CCH) on a Charnley flanged stem articulating with a chemically cross-linked polyethylene (XLPE) cup. The initial bedding-in of up to 0.41mm, which was reached within about 2 years, has not progressed further with a follow up to 18.1 years. The mean total penetration of the XLPE cup for this group of patients is 0.31mm (0 – 0.41) and a penetration rate of 0.019 mm/year (mean 0 – 0.026). One patient with CCH/XLPE arthroplasty on the left side and a conventional metal on ultra high molecular weight polyethylene (UHMWPE) on the right side, has a ten fold difference in total penetration: 0.41mm compared with 4.1mm and a year shorter follow-up.
The mean age of the 9 patients (11 hips) attending was 47.2 years (26–58) at the operation and is now 64 years (42–73). Clinical results remain excellent with freedom from pain and normal activity level appropriate to their age and gender.
Radiographically none of the cups or stems show evidence of loosening or osteolysis and there have been no problems that could have been attributed to the materials or the design used.
Triple-tapered cemented polished C-Stem has evolved from the study of long-term results of the Charnley low-frictional torque arthroplasty when the first fractured stem and then proximal strain shielding of the femur and stem loosening were identified as the continuation of the same process: lack or loss of proximal stem support.
The C-Stem, by the concept, design and the surgical technique, caters for a limited slip of the stem within the cement mantle transferring the load more proximally. With a follow-up past 10 years and 3299 primary procedures there have been no revisions for aseptic stem loosening and no stem is radiologically loose.
Four hundred and forty eight patients had 500 LFAs using the C-Stem with the longest follow-up: 256 women and 192 men; 52 patients had bilateral LFAs. The patients’ mean age at surgery was 55.5 years (range 17–89 years) and at a mean follow-up of 5.2 years.
There was an overall improvement in the clinical outcome graded according to d’Aubigne and Postel for pain, function and movement from 3.1, 2.9 and 2.8 to 5.9, 5.7 and 5.5 respectively.
A good quality proximal femur had been maintained in 56.8% and improved in 21.8%.
The results are encouraging and support the concept but place a demand on the understanding of the technique and its execution at surgery.
Total hip replacement using components from different manufactures is common and has been known as cross-breed arthroplasty. The implant industry clearly advises against it for primary arthroplasty, even though this has been the accepted practice in revision hip surgery. The response of the Medicine and Healthcare products Regulatory Agency is to agree with the manufacturers. Thus this advice has been implemented in National Institute of Clinical Excellence guidelines without any supportive clinical data.
A consecutive series of 206 crossbreed total hip arthroplasties were performed in 192 patients by a single surgeon between 1990 and 1993. These were observed for an average 11.5 years (range, 10–13years). There were 126 women and 80 men with an average age of 69 (range, 41–89) at the time of surgery. There were 9 failures defined as reoperation. Of these, 5 were for aseptic loosening of cup, 2 for deep infection, 1 for recurrent dislocation and 1 for revision of stem for Periprosthetic fracture following a fall. There was no aseptic loosening of stem. With survivorship to date of 94% these data suggest that it is safe to continue using at least one of the common combinations in primary hip arthroplasty.
In approximately 73% of NHS trusts D-dimer is a prerequisite test prior to radiological imaging to diagnose DVT.
This study evaluates the effectiveness of D-dimer as a screening tool for DVT in the postoperative period following total hip and knee arthroplasty.
All patients wore pneumatic foot pumps for DVT prophylaxis. Chemical thromboprophylaxis was not used. All patients were under the care of one surgeon with the same postoperative regimen.
Comparing D-dimer levels between hip and knee arthroplasty we found that both groups displayed the same trend in post-operative D-dimer levels (i.e. peaks at days 1 and 7); however levels were significantly higher following knee replacement (At day 7 p< 0.005)
We compared D-dimer levels of these patients with a second group of 43 patients who had a confirmed DVT following hip or knee arthroplasty. The mean D-dimer level in this group was 2.20 (sd=0.98 or range 0.80 – 4.46). This group was subdivided into two groups, those with D-dimer samples before (and including) day 7 and those after. We found a significant difference between the groups (p=0.01). Mean ≤ day 7 = 2.70. Mean > day 7 = 1.97.
The group of patients with Confirmed DVT on or before day 7 were compared with those free of clot. There was no significant difference found between the D-dimer levels of the two groups. (p=0.37)
Here we present the results of functional outcome of 531 patients (aged from 27.6 to 88.7, mean 62.6) who have had the Trilogy (Zimmer; Warsaw IN, USA) acetabular shell implanted for 5 years or longer. All patients operated at our unit between 20/1/1992 and 31/3/2004 were included, looking at both Primary (431) and Revision (100) hip arthroplasties. All surgery was performed by the senior surgeon using the Trilogy shell and liners. The Trilogy acetabular shell was used with either an ultra-high molecular weight polyethylene liner or ceramic liner, along with a wide variety of femoral stems, mainly: Harris Pre-coat stem (183 patients, Zimmer), Versys cemented stem (102 pts, Zimmer), CADCAM (140 pts, Stanmore), and HAC Furlong (96 pts, JRI). There were a variety of other stems, including Exeter and Pro-femur. 48 patients had revision of socket only.
Functional outcome was assessed by three questionnaires: the Oxford Hip Questionnaire (12 best function-60 worst), the Harris Hip Score (100 best to 0 worst), and the WOMAC Hip Score (0 best-96 worst).
Patients filled in these questionnaires at every postoperative follow-up clinic. These were compared with the pre-operative scores obtained from questionnaires which the patients completed retrospectively. Mean follow up questionnaire times were 76.5 months postoperatively for primary arthroplasties, and 70.6 months for the revision arthroplasties.
For primary arthroplasty mean scores improved from 40.8 pre-operatively to 16.4 post-operatively (Oxford), 43.9 to 92.9 (Harris), and 51.8 to 9.4 (WOMAC) (all p< 0.05). For revision arthroplasty mean scores improved from 39.1, 41.7, and 49.3 pre-operatively to 19.6, 88.0, and 12.5 (all p< 0.05).
No patients required re-operation for loosening, one patient dislocated at day 5.
We can conclude that the Trilogy acetabular component is a versatile acetabular implant which can be used with a wide range of femoral components, both in primary and revision Total Hip Arthroplasty, with successful functional outcome scores greater than 5 years after implantation.
Minimum follow-up was 3 years in group 1 and 1.5 years in group 2. There were 3 dislocations in group 1, and none in group 2. There were 2 re-operations in both groups. The relative improvement in WOMAC scores was significantly greater in group 2 at 3 months and 1 year (P< 0.05).
Relatively high rates of fracture of the femoral stem of total hip replacements were seen with early designs manufactured with stainless steel. Improvements in metallurgy, alloy chemistry, materials and stem design have led to a reduction in the incidence of this complication and the occurrence of fracture with modern femoral stems is a now a rare event. However, the implantation of modern stems into heavy patients and the use of higher offset stems leads to considerable testing of the mechanical capabilities of some stem designs.
We present ten cases of fracture of modern stainless steel polished tapered stems. The fractures occur either in the neck, or in the distal half of the stem. Our clinical data suggests that heavy patients with small stems and high offsets are at risk of breaking their implants. Varus positioning of the stem in a number of cases further increases the bending moment of the stems, and the sacrifice of cement mantle thickness for implant size within narrow medullary canals may lead to the loss of proximal support. Failure analysis of the retrieved high nitrogen stainless stems also suggests there may be metallurgical factors that contribute to their failure.
On the basis of our findings, careful consideration is required when using high offset stainless steel stems in large patients.
As part of a user group of a collarless polished tapered stem a database was established in 1993 recording all significant data pre-operatively, intra-operatively and at 1,3,5 and 7 years.
All were primary hip replacements and the study included 38 different surgeons who were free to use the head size, approach and cup of their choosing. All hips had a collarless polished tapered prosthesis (Zimmer inc.).
Data on 2,250 hips were available for analysis and stratification of risk factors for dislocation. Correlation of head size and surgical approach was performed and tested for significance. The patient demographics were standard for a typical arthroplasty study group. Of the surgical approaches used, 13.1% were anterolateral, 27.55% lateral, 23.88% posterior and 35.47% Hardinge. There were no trochanter osteotomies or anterior approaches.
94 (100%) of the hips had a first dislocation occurring in the first two years: 38 during acute stay (40.43%), 45 from acute stay to the first year (47.88%) and 11 during the second year (11.7%). The 22mm head was associated with the greatest risk of dislocation (5.93%, P < 0.001). The risks with the 28mm head (3.05%) and the 26mm head (2.5%) were not significantly different. The lowest risk of dislocation occurred with the lateral approach (2.11%) and the highest with the posterior approach (5.99%). Dislocation rates for the anterolateral and Hardinge approaches (4.1% and 3.28% respectively) were not significantly different. Unfortunately data pertaining to frequency of capsular repair combined with the posterior approach was not available.
The combination of lateral approach and 28mm head was associated with the lowest dislocation risk of 1.56%, while the risk with the posterior approach and 22mm head was the highest at 10.09%.
Cytokine mediated activation of osteoclasts can lead to peri-implant osteolysis and aseptic loosening. The aim of this study was to determine the IL-1β and TNFα mRNA cytokine expression profile of human macrophages when stimulated with polyethylene particles using relative quantitative real-time polymerase chain reaction (rqRT-PCR).
Human peripheral blood monocytes or human monocytes from the cell line THP-1 were used in this study. rqRT-PCR conditions were optimized by stimulating human macrophages with 200ng/ml lipopolysaccharide (LPS). The median CV% value for duplicate measures was 12.6 (range 4.5–54). Stimulation assays were performed using unfractionated endotoxin-free commercial polyethylene particles (median size 7μm); or fractionated particles (size range 0.1–1.2μm). Human macrophages were stimulated with high dose unfractionated polyethylene particles at 0, 3500 or 10500 mm3/cell or with fractionated polyethylene particles at 0 and 100mm3/cell at time points 0 and 3 hours. Low dose unfractionated polyethylene stimulation was performed on THP-1 cells at 0, 50, 100, 1000 and 10000 mm3/cell. In all experiments LPS stimulation was used as a positive control. RNA was extracted and rqRT-PCR was performed using standard techniques
High dose unfractionated polyethylene stimulation did not result in a significant difference in cytokine mRNA levels between groups. Using fractionated polyethylene, a small increase in IL-1β mRNA was identified (21% versus maximal stimulation using LPS). Low dose unfractionated polyethylene stimulation of THP-1 cells demonstrated dose dependent decreases in TNFα and IL-1β mRNA expression that was not due to inhibition of RNA extraction or a decrease of cell viability.
Endotoxin-free polyethylene particles do not appear to be a major stimulus for IL-1β and TNFα mRNA production as measured by rqRT-PCR. We did observe a small positive effect on IL-1β mRNA expression using a fractionated polyethylene stimulus. However it remains unclear whether this effect is due to fractionation of particles into the submicron range or is due to introduction of endotoxin during the filtration process.
The use of sub-lethal doses of cell wall active antibiotics to induce cell wall deficiency in S aureus has been described. Cell Wall Deficient
The adherence of cell wall deficient
The cell wall deficient organisms demonstrated an increased ability to adhere to glass compared to the ‘wild type’. After exposure, there was on average twenty times more cell wall deficient organisms per unit area compared to the ‘wild-type’. The micro-titre plates were similar. After incubation, the absorption of each well was measured. Compared to the ‘wild type’ there was a significantly increased absorption in wells containing the cell wall deficient organisms. Showing an increased ability to adhere to plastic. The third technique quantified the ability to adhere using a centrifugal force. The slides were exposed to ‘wild type’ and cell wall deficient organisms, however before staining they were placed in a centrifuge. On analysis there were five cell wall deficient
An increased ability of cell wall deficient
The longevity of cemented femoral components has been shown to be related to the cement used. The reason for this difference between the available commercial preparations is unclear. One mode of failure of the stem is thought to be cracking within the cement mantle. This may be secondary to residual stress resulting from shrinkage of the cement on curing. It was hypothesised that there was a difference in shrinkage on curing between the different polymethylmethacrylate cements used commonly in hip arthroplasty.
Under standardised conditions, a fixed volume of Palacos-R, Palacos-LV, Simplex, CMW1 Radio-opaque, CMW2 and CMW Endurance was mixed under vacuum and allowed to cure in a measuring cylinder of fixed volume. The cylinder was then split open 24 hours later and the block of cement removed. The final volume of cement was then determined by measuring the volume it occupied in a container filled with water using Archimedes principle.
Our results indicate that, under standardised conditions, the degree of shrinkage for each commercial preparation was Palacos-R 6.9%, CMW1 5.2%, CMW2 5.4%, CMW Endurance 5.3%, Simplex 5.8% and Palacos-LV 7.2%.
There is a difference in the amount of shrinkage on curing between the different types of bone cements in use commercially and this may account for their differences in long term outcome.
There is currently much interest in the wear of metal-on-metal THRs and potential concerns about elevated metal ion levels. Generally, wear of metal-on-metal THR’s has been low in simulator studies. Slightly higher and more variable wear has been found clinically. Variations in surgical approach, technique and fixation method may influence the level of force applied across the prosthesis during gait. It is hypothesised that increased joint tensioning may increase loading of THR’s during the swing-phase; leading to elevated wear and friction due to depleted fluid film lubrication. This study aimed to assess the effect of swing-phase load on the friction, lubrication and wear of metal-on-metal THR’s.
Cobalt-chrome 28mm metal-on-metal THR’s were tested in a physiological hip simulator, loading was modified to provide; (1) ISO swing-phase load (280N, as per ISO 14242-1) and (2) low swing-phase load (< 100N). Friction testing was conducted using a pendulum friction simulator, with 280N and 100N swing-phase loads. Theoretical lubrication modelling was carried out using elastohydrodynamic lubrication theory.
The overall mean volumetric wear rates was 10-times greater in THR’s tested with an ISO swing-phase load in comparison to THR’s tested with low swing-phase loads (0.58±0.49 compared to 0.06±0.039mm3/million cycles). The friction factors were 0.129 and 0.173 respectively under low and ISO swing-phase conditions. A decrease in the predicted lubricant film thickness when the swing-phase load was increased was observed; at the start of stance phase this was 0.12microns and 0.07microns under low and ISO swing-phase conditions respectively.
The results demonstrate that the performance of metal-on-metal THR’s is highly dependent on swing-phase load conditions. It is postulated that fixation method and surgical technique can affect the swing-phase load. This study has demonstrated that over-tensioning of the tissues may also accelerate wear. These observations may explain some of the variations reported clinically.
It has been suggested that minimal incision surgery for hip arthroplasty allows earlier mobilisation and reduces hospital stay. Intensive post-op physiotherapy may also have the same effect. This study aimed to assess which was the more important factor.
The study compared 45 patients (26 NHS and 19 private) undergoing primary total hip arthroplasty using a standard posterior approach to 51 patients (29 NHS and 22 private) with a minimal incision of 10cm or less. Physiotherapy involved once daily weekday sessions with the NHS patients (five sessions per week) versus twice daily with the private patients (14 per week). We compared demographics, incision length, post-operative stay, complication rates and Oxford Hip Scores between the four groups.
Results showed no significant difference in age, sex and BMI between the groups. There was a significant difference (p = 0.0002) in mean scar length between the mini and standard incision groups (15.3 vs. 8.3 cm). There was no significant difference in post-op stay between the mini and standard incision NHS patients or the mini and standard incision private patients. There was a significant difference (p = 0.003) in stay between NHS and private patients (11.4 vs. 7.9 days) regardless of the incision used. There were four (4%) early dislocations, three in the mini incision group. Eleven patients received prophylactic antibiotics compared to five in the standard groups for prolonged wound ooze (> 5 days); only one patient had a proven superficial infection. There was no significant difference in the change in the Oxford Hip Scores between any of the groups.
This study suggests that intensive physiotherapy can significantly reduce in-patient stay but minimal incision surgery itself does not. The higher dislocation rate in the mini incision group demonstrates the learning curve for this technique.
The POMS is the only published method for prospectively describing complications associated with major surgery. It comprises a 9-point survey and provides a generic measure of short term post-operative outcome. Data is simple and quick to collect and easily learnt. No additional tests are required for data collection.
If an arthroplasty patient presents with wound breakdown, sinus formation or a hot, red joint the diagnosis of infection is straightforward. However, most total joint replacement (TJR) infections are difficult to distinguish from aseptic loosening. It is imperative to know if a painful TJR is infected to plan appropriate management.
In this prospective study of 204 patients we analysed the diagnostic accuracy of various tests for infection: Inflammatory Markers (CRP/ESR); Aspiration Microbiology; and the Polymerase Chain Reaction (PCR) – a novel technique in this situation. We used international criteria as the gold standard for infection, applied at the time of revision surgery. Any of – a sinus; frank pus in the wound; positive intra-operative microbiology; positive histology – classified the patient as infected. The sensitivity (Sens), specificity (Spec), positive predictive value (PPV) and negative predictive value (NPV) of each test were calculated.
52 patients with an original diagnosis of inflammatory arthritis were excluded, as histology may be inaccurate. The results for the remaining 152 patients are: CRP > 20mg/l: Sens 77%; Spec 76%; PPV 49%; NPV 92%. ESR > 30 mm/hr: Sens 61%; Spec 86%; PPV 57%; NPV 87%. Aspiration Microbiology: Sens 80%; Spec 83%; PPV 71%; NPV 88%. PCR: Sens 71%; Spec 78%; PPV 43%; NPV 89%.
Few patients with negative CRP/ESR were found to be infected; if positive, there was a 50/50 chance that the joint was infected. Positive aspiration microbiology was associated with underlying infection 3 times out of every 4, and negative results were correct 9 times out of 10. PCR was no more accurate than existing tests.
All patients with painful TJR’s should have inflammatory markers checked – if negative the clinician can be relatively reassured that the implant is not infected. If positive or suspicion remains, further investigation should be undertaken. Joint aspiration for microbiology is currently the best available second line investigation.
Infection is one of the major reasons leading to early revision of total hip joint replacements. Traditionally, samples have been taken for microscopy, culture and sensitivity at the time of surgery. However, this doesn’t always reveal a causative organism. Molecular techniques have now been refined to improve sensitivity in bacterial detection.
In this study, samples were taken from acetabular and femoral components at the time of revision hip surgery for suspected infection. These underwent conventional culturing and also PCR and DNA sequencing. The white cell count, CRP and ESR were also recorded.
Results are available for 6 cases. All of these patients had an elevated CRP level (17–169). Microscopy at the time of surgery showed scanty white cells and no organisms on at least 1 sample from 2 cases. Subsequent culture was negative. When sonication techniques were used to remove bacterial DNA, followed by PCR and sequencing, one of these cases yielded
This study demonstrated that we may be under-diagnosing infection in hip revision patients. These new techniques could prove invaluable in detecting low yet significant levels of bacteria which may lead to a change in current antibiotic policy for joint replacements and subsequently a reduction in the number of revisions required for loosening due to infection.
Peri-prosthetic bone loss may contribute to aseptic loosening after THA. The aims of this randomised controlled trial extension study were to study the effect of pamidronate therapy on Peri-prosthetic bone mineral density (BMD) and Peri-prosthetic osteolysis over 5 years after primary THA.
50 patients were enrolled in the study in 1998. All received a hybrid THA (Ultima-TPS stem, Plasmacup) for osteoarthritis. Subjects were randomised to receive either 90mg of pamidronate or placebo by intravenous infusion on the 5th post-operative day. At 5 years 36 patients (41 Hips: placebo n=21, pamidronate n=20) returned for measurement of BMD and clinical and plain radiographic assessment. Five patients had died and nine had withdrawn from the study.
The effect of pamidronate in maintaining femoral bone mass in the region of the calcar previously reported at 2 years was maintained at 5 years (Gruen zone 6 pamidronate versus placebo ANOVA P=0.038; Gruen zone 7 ANOVA P=0.048). No differences in pelvic BMD were found between treatment groups at 5 years. Harris hip scores used to evaluate clinical outcome did not show any significant difference between the 2 groups over the 5-year period. (Mann Whitney p> 0.05). Isolated expansile osteolytic lesions were identified on AP radiographs of the hip at 5 years in 4 patients (2 placebo, 2 pamidronate; P> 0.05). One patient had a 5x9mm lytic lesion in the region of the femoral calcar, and 3 patients had pelvic lytic lesions in the region of the acetabular dome (largest measuring 20x10mm).
Single-dose peri-operative pamidronate therapy preserves femoral calcar bone mass over a 5 year period after THA. However, although the number of subjects with osteolysis is small, we have seen no difference in the rate of osteolytic lesions between treatment groups. Long term study of this patient group is required to examine the rate of aseptic loosening between the treatment groups.
An ESR and CRP are widely used as the initial screening investigation to differentiate between aseptic and septic loosening of prosthetic joint replacements
Treatment Centres (TCs) specialise in common elective operations with long waiting lists. One of the concerns that has arisen with this enforced new healthcare model is the potential for suboptimal outcomes after joint arthroplasty. In order to decrease this risk we set in place a number of measures and have evaluated the outcome of the fist 100 total hip and total knee replacements undertaken at our TC and compared these to 100 consecutive controls undertaken concurrently by out hip and knee service. •Cases were only to be performed by consultant orthopaedic surgeons appointed to our trust – to the exclusion of visiting / sessional arrangements. •Same implants and care pathways as used within the rest of our department. •Weekly team arthroplasty rounds and planning sessions.
There was no significant difference in baseline demographics with both groups showing a slight female preponderance, and similar age ranges (35–88 av. 62; 42–86 av. 64). The treatment centres patients were heavier (78Kg range 48–111Kg; 72Kg range 43–101Kg). The TC group averaged 2.9 comorbidities per patient compared to 2.2. The average time to discharge was similar at 7.6 days . There was no significant difference in the improvement in Harris Hip or Knee Society Scores at a minimum 6 months follow-up. There were 2 infections in the TC group and one in the control group. There were 3 thromboembolic complications in each group and there was one unrelated death in each group. There was one dislocation and one fracture in the TC group and two fractures in the control group. Radiographic criteria including implant size, position, slope, offset, cementing and alignment were comparable in the two groups.
TC patients are not “fitter more predictable” patients and may have greater comorbidity. Our insistence on a local consultant led service and on identical standards to those of our non TC department have generated similar short term outcomes to those of non TC patients.