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View my account settingsThe optimum design for the femoral component for cementless Total Hip Replacement is not known. We conducted an ethically approved, randomized and prospective trial to compare two radically different designs of fully hydroxyapatite(HA) coated femoral stems. We compared the original JRI Furlong stem with the Wright Anca fit stem which is more anatomical in design. The paper discusses the merits and disadvantages of these two stems. The same acetabular component was used in both samples. The only variable was the stem shape.
All patients placed on the senior authors’ waiting list for primary THR were asked if they would enter the trial. There were no restrictions for selection to the sample. Patients were then randomised for one of the two stems. The surgery was undertaken by one surgeon, in one centre, in matched patients and using the same well-tried CSF acetabular cup and bearings.
335 patients had been entered into the trial, 228 females and 126 males.
191 patients had the JRI furlong hip implanted (57%) and 146 are in the Anca sample (43%).
The number of perioperative fractures in the Furlong group was 13(6.8%)and in the Anca sample 22 (15.3%).
The periprosthetic and perioperative fracture rates for the two stems were found to be significantly different at three years into the study and the trial was stopped. The possible reasons for this difference are discussed.
We present a prospective study focused on radiographic long-term outcomes and bone remodeling at a mean of 17.0 years (range: 15 to 20) in 208 cementless fully HA-coated femoral stems (Corail®, DePuy, Johnson & Johnson). Total hip replacements in this study were performed by three members of the surgeon design team (Artro Group) in France between 1986 and 1991. Radiographic evaluation focused on periprosthetic osteolysis, bone remodeling, osseous integration, subsidence, metaphyseal or diaphyseal load transfer, and femoral stress shielding. The radiographs were digitized and examined with contrast enhancing software (DICOM Anonymizer 1.1.2) for analysis of the trabecular architecture. Radiographic signs of aseptic stem loosening were visible in two cases (1%). Three stems (1.4%) showed metaphyseal periprosthetic osteolysis in two of seven Gruen zones associated with eccentric polyethylene wear awaiting metaphyseal bone grafting and cup liner exchange. One stem (0.5%) was revised due to infection. No stem altered in varus or valgus alignment more than two degrees and mean subsidence was 0.1 mm (range: 0 to 2) after a mean of 17.0 years. Five stems (2.4%) required or are awaiting revision surgery. Trabecular orientation and micro-anatomy suggested proximal load-transfer patterns in all except three cases (98.6%). Combined metaphyseal and diaphyseal osseo-integration and bone remodeling were visible in one hundred stems (48%). Diaphyseal stress shielding and cortical thickening were observed in three stems (1.4%). Other radiographic features are discussed in depth. This long-term study of 208 fully HA-coated Corail stems showed highly satisfactory osseo-integration and fixation in 97.6% after a mean of 17.0 years follow-up.
The JRI cemented total hip replacement consisted of an acetabulum with a gamma irradiated UHMW polyethylene cup encased in a titanium metal shell, a 32 mm titanium head, and forged titanium alloy stem. Revision of this implant for failure, in particular that of the acetabulum, and the lack of published survivorship prompted a retrospective review of the local series. Data was compiled from theatre log books, patient records and X-rays.
During the period 1989–1997 a single surgeon performed 304 total hip replacements using this JRI prosthesis through an anterior lateral approach. The average age was 70 (48–96), with 186 (61%) female and 85% performed for osteoarthritis. Complete data was available in 236 cases to allow further analysis. The average follow up was 9.3 (1–17) years. During this period 37 hips had to be revised: 28 for a loose acetabulum, both components were loose in 5, and 3 had revision for infection. The mean time to revision was 7.4 (1–17) years.
This data provides a revision rate of at least 16% at ten years. This data does not take potential earlier radiographic failure nor patient function into account. This prosthesis therefore fails to comply with modern benchmarks for survivorship of implants. Furthermore this study highlights the importance of ongoing review of patients who have undergone joint replacement, in particular those with implants that have problems with design, as has been demonstrated in other metal backed components.
Bio-active fixation has increasingly gained acceptance over the last two decades. However extent of the coating is still a subject of debate. We introduced in 1986, the concept of total osteointegration of a tapered stem with the hope that we could achieve durable biological fixation while preserving a normal periprosthetic bone trophicity. Patients from our first clinical series using this stem are now eligible for 18-year follow up. Between July of 1986 and December of 1990 we performed 615 total hip arthroplasties using the Corail stem (DePuy). It is a straight tapered stem totally coated with a 150 μ thick layer of HA following an atmospheric plasma-spray process. The mean age at surgery was 64.5 (range 16 to 95 years) 242 patients are now deceased (39%), 62 (10%) patients are lost to follow-up. The mean follow-up for 243 living patients on file is 17.7years. 89 THAs required component revisions. 72 cup revisions were associated with wear and osteolysis. 8 cups and 4 stems have been revised for aseptic loosening. Owing to the high incidence of wear-related revision, Kaplan-Meïer survivorship at 18-year follow-up, using component revision for any reason as an endpoint, was 80.7±3.3 (95% confidence intervals). In contrast, Corail stem survivorship, using stem removal for any reason as an endpoint, was 95.0%±3.0 at 18-year follow-up, and considering aseptic loosening only, the survival probability of the stem is 98.9%±1.1 at 18 years. Therefore, despite wear and proximal osteolysis the fixation achieved with this totally HA-coated stem remained durable through 18-year follow-up. Regarding the periprosthetic remodelling during this period, modifications of the bone pattern have been strictly limited: slight resorption at the calcar level, absence of cortical hypertrophy, anecdotic significant stress-shielding. The radiological silence is one of the paramount facts demonstrated by this prospective study.
Three cross sections were cut from the metaphyseal femur and surrounding bone proximal to Gruen zones 2 and 6 (regions with HA coating). The three sections were A (proximal), B (mid-part) and C (distal). Sections were prepared using the Donath technique and then paragon stained for quantitative histomorphometry using an Axioskop microscope (Carl Zeiss, Germany) with image analysing (SAMBA, France).
For each segment the total implant perimeter, percentage of implant perimeter covered by bone and the total percentage of residual HA coating were measured. Bone implant contact was defined as direct ongrowth of bone to the coating or the titanium surface.
Bone ongrowth ranged between 18%–56% and was independent of the time in-vivo. Bone ongrowth was most strongly correlated to patient age with younger patients having significantly higher bone ongrowth (p=0.001). Bone ongrowth was correlated with HA-resorption only in the most proximal zone A (p=0.001) with lower ongrowth associated with lower levels of residual HA. However, HA resorption was not significantly correlated with patient age.
HA resorption was significantly higher most proximally with less residual HA (13.0%) than mid-stem (22.6%, p=0.05) and distal (28.1%, p=0.05). Metaphyseal stem level and bone ongrowth were not significantly correlated in this manner.
Bone ongrowth but not HA resorption was strongly correlated to patient age indicating that the bone remodelling process is more affected by individual bone health than it can be stimulated by HA coating.
HA resorption increased significantly from the distal to mid-stem and the most proximal coating level in the same way as stress shielding and thus osteoclastic stimulation goes up.
Osteointegration of HA coated devices is well demonstrated. An abundant experimental material exists, allowing to describe the various properties of HA (early osteointegration, sealing effect, gap healing effect, etc…). Various side-effects have been described (third body wear of HA debris, delamination of the proximal coating etc…). Thus controversy still exists, despite a more and more convincing clinical experience. The role of human retrievals is therefore crucial to determine the exact role of all these parameters in the natural life of the implant throughout the years.
49 human well-functioning explants have been retrieved during systemic autopsies in elderly patients previously operated for a displaced fracture of the neck with a Corail® implant. Delays of implantation vary from 5 days to 10 years. All these specimens have been processed for optical microscopy, electronic microscopy with backscattering. This constitutes the longest report on one single implant and the retrievals are evenly distributed over this ten-year period. Several histomorphometric parameters were measured in the different Gruen’s zones: cortical bone density, cortical bone thickness, density of endosteal bone
3 steps are recognized:
Bone formation around the implant appears early after surgery. Multiple units of bone formation go to coalescence as soon as 6 weeks and develop thereafter, leading to osteointegration. Bone remodelling reorganizes the architecture of connecting trabeculae according to the mechanical stresses resulting from the presence of the implant. Compression areas are generally the seat of broad and interconnected trabeculae, whereas tensile stresses areas display the presence of long, thin, unconnected and often parallel trabeculae. Very broad and short trabeculae are often seen at the level of the corners. Coating resorption is seen in every specimen beyond one year of implantation, predominantly in the areas with less bone coverage.
Release of HA particles in the joint cavities was never encountered. Some metallic particles, originating from the femoral ball are commonly seen in the polyethylene. HA particles (presumably scratched off the prosthesis during insertion?...) have never been identified in the heterotopic ossifications.
We conclude that the osteointegration of the Corail stems is a reliable phenomenon with a reproducible sequence of events. It lasts even after the disappearance of the coating in a 5–10 years period. The presence of the stem provokes a remodelling of the cortices but the presence of a total coating and its longer duration at the level of the tip does not induce a disappearance of the proximal bone or a loose of the proximal fixation.
Proximal bone resorption occurred in 27% (R1) or 34% (R7) which is lower than the values reported for the ABG-I stem (R1: 48%, R7: 45%). Bone resorption was significantly higher with tight than non-tight mid-stem fit (69% vs 27%, p=0.04). The same trend was true for tight distal fit (56% vs 37%).
Cancellous densifications were frequent at mid-stem level (R2: 83%, R6:88%) but much less distally (R3: 44%, R5:25%). No influence of fit & fill was measured.
Cortical densifications were noted in 16% (ABG-I 15%) overall with a higher proportion measured for tight distal fit (25%) than loose distal fit (6%, p=0.07). A similar observation was made for cortical thickening (11% overall, tight:non-tight=16%:6%). Pedestal formation (17% overall) was more likely with a non-tight proximal fit (23% vs 12%) and mid-stem fit (20% vs 8%)
A proximal tight fit was achieved more frequently with normal (55%) and stovepipe femora (50%) than champagne flute femora which had the highest proportion of tight distal fit (85%).
As LTP occurred with non-tight fit it seems that elastic mismatch is not the main cause.
Less proximal bone resorption and less distal densifications confirm the design changes from ABG-I to ABG-II.
VAS neck pain: Fusion group/arthroplasty group: Preoperatively 6.2/5.9 n.s., 6 weeks 3.5/3.1 n.s., 12 weeks 2.1/1.9 n.s, 1 year 2/2.1 n.s. VAS arm pain: Fusion group/arthroplasty group: Preoperatively 5.5/5.3 n.s., 6 weeks 2.6/2.4 n.s., 12 weeks 1.7/1.8 n.s, 1 year 2/1.9 n.s. Neck disability index: Fusion group/arthroplasty group: Preoperatively 43/40 n.s., 6 weeks 28/23 p<
0.05., 12 weeks 18/14 p<
0.05, 1 year 20/15 p<
0.05. SF-36 subscore pain: Fusion group/arthroplasty group: Preoperatively 36/37 n.s., 6 weeks 42/44 n.s., 12 weeks 52/58 p<
0.05, 1 year 52/60 p<
0.05. SF-36 subscore function: Fusion group/arthroplasty group: Preoperatively 52/54 n.s., 6 weeks 57/59 n.s., 12 weeks 60/62 n.s, 1 year 64/67 n.s. SF-36 subscore vitality: Fusion group/arthroplasty group: Preoperatively 42/44 n.s., 6 weeks 45/46 n.s., 12 weeks 50/52 n.s, 1 year 54/56 n.s.
In the fusion group we had 1 recurrent radiculopathy and 1 non union without the need of further intervention. In the arthroplasty group we faced 1 recurrent laryngeus recurrens nerve palsy and 3 spontaneus fusions within 1 year postoperatively, which might not be classified as complication.
Graft dislodgement (N=3) and Cage subsidence, both requiring re-operation in the form of ACDF with plate supplementation.
Against this background, the hypothesis is formulated that functional disturbances in the form of pathological activities of the neck muscles occur as a result of a whiplash injury of the cervical spine. These pathological muscle activities can be demonstrated electromyographically and differ from the patterns of activity of healthy subjects.
A subsequent study was conducted to validate the results that had been obtained. For this purpose, the electromyographical activity of the semispinalis capitis muscle was recorded in another subject group (n=20) and patients with acute symptoms as a result of a whiplash injury of the cervical spine (QTF grade II) (n=35).
Subjects in our study, for instance, show a decrease in electrical activity during flexion and the resulting stretching of the semispinalis capitis muscle, while the same movement causes an increase in activity in patients. On the basis of these differences, 93 % of subjects (specificity) and 83 % of patients (sensitivity) could be classified correctly with a discriminance analysis.
In the second study, the specificity was 88 % while a sensitivity of 86 % was determined in the acute patient population.
This paper reports the angle between the EF and the horizontal (the extension facet angle- EFA) in normal knees and in knees with early AMOA.
A sagittal image at the midpoint of the femoral condyle was used to determine the EFA.
There is an association between an increased EFA (ie a steeper EF) and MRI evidence of AMOA. Although a causal link is not proven, we speculate that a steeper angle increases the duration of loading on the EF in stance and tibio-femoral interface shear. This may initiate cartilage breakdown.
We are comparing the above two techniques with 25 patients in each group operated by 3 surgeons. The first group had conventional laminoplasty and the second group underwent the skip laminectomy. The groups were comparable in age, sex, pathology and clinical presentation. Both these group had clinical outcome measurements using SF 12 questionnaires, pre and postoperative clinical assessment with standard tools performed by independent surgeon and a specialist spinal physiotherapist. We also routinely performed pre and postoperative MRI scans to assess the adequacy of decompression.
Frontal collisions (n=13): The median delta-V for frontal collisions is 24 km/h (min=8 km/h; max=50 km/h). 4 individuals reported symptoms. Under delta-V 20, one individual had a fractured cervical vertebra (QTF IV). Side collisions (n=19): The median delta-V for side collisions is 12 km/h (min=4 km/h; max=59,3 km/h). 9 individuals reported symptoms. Under delta-V 10 km/h, two patients had symptoms (QTF II and QTF IV (fracture).
The purpose of this study was to propose a new classification based on the structural, anatomical and biomechanical properties of the odontoid process, to evaluate the outcome and to suggest the adequate treatment in relation to the specific fracture type.
The files of 97 patients with odontoid process fractures admitted to our institution were reviewed. The external and internal anatomy of the axis has been studied. The fractures were classified according to the proposed new classification. The method was tested for reliability and validity. Mean follow-up was 14 years.
Intraobserver and interobserver agreement was excellent with intraclass correlation coefficients at levels of 0.98 and 0.85 respectively. Four types of odontoid process fractures are distinguished; type A fractures are avulsion fractures involving the tip of the odontoid; type B fractures are fractures of the neck between the lower edge of the transverse ligament and the line connecting the medial corners of the upper articular facets of the axis; type C fractures involve the area between the previously mentioned line and the base of the odontoid process (type C1) or extend to the body of the axis (type C2); type D fractures are complex fractures involving more than one level of the odontoid process.
Classification of odontoid process fractures has to be reconsidered as novel imaging technology has shown new patterns of fractures. Computed tomography scan with image reconstruction is mandatory. The analysis of the imaging data in the present study justifies the new classification.
A) Three wound drainages with an autotransfusion system and suction; B) no wound drainage; C) one intraarticular wound drainage without suction.
Haemoglobin values, blood transfusion requirements, blood loss, postoperative range of motion, knee society score and rate of complications were observed and recorded. All patients were operated without tourniques for lower blood loss during total knee replacement.
Total knee arthroplasty had been reported to present similar amount of blood loss in external and hidden form. We studied whether lateral patellar release made any differences on both forms of blood loss.
As there had been no previous studies correlating the two scoring systems, we investigated whether a correlation exists between the two scores at 2, 5 and 10 year periods. A correlation would allow us to determine what OKS value would achieve 90% sensitivity in identifying patients requiring clinical review at the above time points. This strategy would reduce the number of clinical visits required and its associated cost.
We recommend that at 2 years, all patients complete an OKS questionnaire and if this is above 24, a clinical evaluation maybe required. Using this OKS value as a screening technique would allow a reduction of up to 50% in clinic visits and outpatient costs at the 2 year follow-up. This reduction is not as great at the 5 and 10 year periods. At these time periods, we recommend a clinical follow-up.
There is no study assessing orthopaedic journal clubs amongst training programs across the UK. This study had two aims: the first was to determine whether journal clubs still play an important part in orthopaedic training programs, the second was to evaluate the frequency, format and goals of journal clubs conducted in orthopaedic training programs in the UK.
Of the twelve teaching hospitals questioned, five (42%) had journal clubs, and twenty three of the forty five (51%) district general hospitals had journal clubs. The average number of articles critically appraised by trainees who attended journal clubs was 5 (0–15) compared to 3 (0–18) in those not attending a journal club.
When asked whether there was any alternative way in which a trainee might otherwise learn how to critically appraise an article, fourteen suggested online journal forums and eighteen suggested self-directed learning or personal study.
Although only 49% of hospital had journal clubs, 88% of trainees believed that it formed a valuable part of training and 56% thought it should be compulsory.
In contrast, studies from North America show that a regular journal club occurs in 99% of residency programs.
It may therefore be suggested that for those trainees who do not attend a journal club, an alternative method to learning the skills of critical appraisement may have to be sort. One suggested modality is through on-line journal clubs or forums within regions which trainees may be encouraged to undertake from their regional directors.
Experimental studies prove that these different pathological conditions use common enzymatic pathways leading muscle atrophy. In every catabolic conditions where there is proteolyses’s increase, this one happens in association with up-regulation of two specific genes of skeletal muscle atrophy. These genes, MuRf1 (muscle ring finger-1) and MAFbx (muscle atrophy F-box), encode ubiquitin ligases. These ligases bind and mediate ubiquitination of myofibrillar proteins for subsequent degradation during muscle atrophy.
The aim of our study is to obtain a better understanding of human muscle physiopathology in atrophy by use of histochemistry and immunolocalisation of MuRF-1 and MAFbx.
The demonstration that the muscle-specific proteins MAFbx and MuRF1 are upregulated in multiple pathological conditions of skeletal muscle atrophy it is critical to continue studying the cellular pathways to discover promising targets for the development of effective new treatments for skeletal muscle disease.
This study was carried out to evaluate the impact of Socio-Economic Status (SES) and the influence of geographic access to health services on the possible outcomes of total knee replacement (TKR).
Data on 345 patients with one year follow-up were collected from the database of the orthopaedic department. TKR outcomes were assessed according to Knee Society Score (KSS). A postcode was assigned to each patient depending on the residential area and data from the last census was used to calculate Scottish Index of Multiple Deprivation Score (SIMD) and its rating score for geographic access to health services.
The results show that the SES and the geographic access to medical services have significant impact on Function Scores but do not influence Knee Scores.
Patients living in the least deprived regions had a better post-operative Function Scores compared to those living in more deprived regions with differences of up to 13 points between groups (p< 0.001). Similarly the improvement in Function Scores was dependant on deprivation score. (p=0.015). Pre-operative Knee Score, post-operative Knee Score and improvement in Knee Scores were not influenced by deprivation score.
Patients living in rural regions had better post-operative Function Scores and greater improvements in Function Score compared to urban dweller patients (p≤0.011) with differences of up to 17 points. The Knee Score was not influenced by these variables.
These results suggest that SES and the region of residence should be considered when assessing the outcomes of TKR.
As expected, the generated forces at the bike pedal were low (20–25% body-weight) calling for little muscle activity and low compressive joint forces. However, with a mean maximum flexion angle of 131.5°, the observed motion ranges were higher than expected. Prostheses not designed for high flexion activities could lose tibio-femoral contact during cycling with detrimental effects on wear. Still, the measured range of rotation in the transverse plane indicates that despite its posterior-stabilized design rotation is taking place with approximately the same amount as it occurs in normal subjects. This may have detrimental effects on the post at the tibial plateau and could explain the previously observed rotational damage patterns on retrieved posterior stabilized TKA specimens.
Data are suggesting that leisure activities should be considered to determine the appropriate TKA design. This study will provide useful data for future design and wear testing scenarios.
We present an evaluation of basic surgical orthopaedic operative training in the last 15 years, using multiple trauma and elective training procedures in orthopaedics. Identifying the influence of competency training and EWTD on Basic Surgical Training. Whilst trying to identify the area’s the MMC should concentrate on to provide a competent trainng programme.
We assessed clinical exposure using 45 Basic Surgical Trainee Logbooks, from posts in 1990 (n=6), 1995 (n=7), 2000 (n=10), and 2004–5 (n=22); and looked at numbers of carpel tunnel decompression, and emergency hip, wrist, and ankle surgeries conducted. As well as the number of external fixators trainees were exposed to. In the 2004–5 group we prospectively assessed competency and knowledge of fracture neck of femur surgery.
From a peak in operative surgery in 1990 numbers have fallen. Today, BST’s participate in 165 emergency hip cases (mean 4.6 procedures per trainee), today, 4.8% (n=8) as primary surgeon. In 1990, and 2000 trainees were primary surgeon in 43.4% (n = 12/32) and 25.2% (n=33/131) respectively.
Trainees are comfortable with closure of skin, subcutaneous and muscular layers but not access; 91% (n=20) required assistance in positioning, and reduction, and recognition of correct alignment. Only 9.1% (n=2) felt competent without senior supervision (mean Orthopaedic BST experience 15.3 months) in hip surgery; whilst none knew of an intra-operative technique to reduce young adult capsular hip fractures. With regards to wrist and ankle fixation the decline has been dramatic decline by 11.1 and 5.9 procedures per trainee. Whilst, the numbers of forearm manipulations peaked in 1990–1995; it has since dropped to less than 5 per trainee in 2005 from 15–16. In 2005, it was also seen that a in a 6 month period a trainee in a typical district general hospital would be lucky to see an external fixator applied (average 0.6 per trainee in 6 month period).
The decline of elective surgery is shown in carpel tunnel decompressions attended. In 1990 9.8 (6–14) were conducted as a primary operator, in 2005, it was 0.5 (0–3). The greatest decline in procedures of 46.3% occurred between 2000, to 2005. A comparison of total operating showed 88.9 (n=79–125) procedures in 6 months were lost between 1990 and 2005; with a 58.6% loss in trauma.
This study suggests deficiency in operative competence today due to reduced opportunities. Thus emphasis should be placed on rota’s being matched to operative exposure, as trainee case numbers have declined sharply particularly in the last 5 years. The MMC should therefore ensure that trainees in the ST1 to 3 years reach their competencies with adequate time in the operating theatre.
The choice of the treatment of tibial plateau fractures remains a controversial topic in current traumatology practice. The best treatment must have three fundamental requirements: to be less invasive as possible, to result in a good reduction, to have a good stability.
Surgical approach with percutaneous indirect articular reduction by elevating,minimal osteosynthesis and the use of NORIAN Skeletal Repair System lets us reach three fundamental objectives stated before.
NORIAN S.R.S, used to fill the bone gap resulting from the traumatic collapse of the metaphyseal bone, with its mechanical strength allows the stabilization of the joint fragments, the reduction and the relative ostheosyntesis, thus greatly shortening the functional recovery time.
We reviewed 70 patients affected by tibial plateau fractures, treated with this percutaneous technique using the mineral bone substitute Norian:
56 fractures were unicondylar, 21 type 41-B2 and 35 type 41-B3 (according to AO/OTA classificaction); 14 fractures were bicondylar (AO/OTA 41-C3).
The minimum follow-up was 1 year. We used for clinical evaluation the Hohl assessment form, for the radiographs the criteria of Rasmussen. X-rays. The final conclusions, resulting from integrated analysis of the clinical data and X-ray data, can be simplified and represented as follows: 52 cases could be considered excellent-good (74%), 14 fair (20%), and 4 poor (6%).
We can claim that the recostruction of the tibial plateau by minimal invasive surgery such as the percutaneous indirect reduction by elevating minimal osteosyintesis and mechanical stability assured by NORIAN SRS, is a good improvement in order to cutdown the functional recovery time. Mobilization is allowed the day after surgery and weight-bearing within the first week in B2 e B3 fracture type and within four weeks in C3 type reducing to the minimum knee posthraumatic stiffness.
Three identical jigs with hinged metal rods were designed to simulate Colle’s fracture. The bending force was provided by 0.5 kg weight applied at one end of the jig. The resultant displacement was measured to nearest 0.01 mm over the next 48 hours. Each test was repeated 6 times (total 8 groups and 42 tests).
Splitting at 1 hour increased the final deformation of the POP cast and not of the FG cast (p > 0.05). No significant difference was noticed if the casts were split at 24 hours.
The average range of knee motion of the group I and II at the last control were 112.8°, 121.8 respectively. The mean modified HSSs were 73.9 and 79.9 respectively. There was no significant difference for HSS scores and range of knee motion (p> 0.05). Based on the criteria described by Schatzker and Lambert, the outcomes were assessed as excellent in 3 cases, good in 8, fair in 3, and poor in 2 in GI and as excellent in 3, good in 7 and fair in 1 in GII. Poor results of GI were because of osteomyelitis in one case and 15° varus deformity in another. The full weight bearing time was longer in group II depending on the concomitant injuries.
Proximal tibial fractures often are caused from trauma with high energy forces with associated soft tissue lesions. The authors report their experience with 45 cases of proximal tibial fractures treated with less invasive system plates (LISS) with good clinical and radiographic results after 5 years follow-up. There is evidence of good stabilisation of the fractures with this conservative soft tissue method combined with early rehabilitation.
The mechanism of injury was a traffic accident (n=7), a sport trauma (n=8) and slip and fall (n=1). The charts of all patients were analyzed.
The clinical outcome was assessed by personal telephone interview by a modified SSK questionnaire by Insall. Surgery was performed by one team of surgeons 2–89 days after trauma.
Mean and range were reported for continuous variables and relative and absolute frequencies vor categorial variables. Data were analyzed using Stata version 8. The level of significance was defined as p< 0.05.
15 anterior cruciate ligament (ACL) lesions (11x ACL reconstruction), 15 posterior cruciate ligament (PCL) lesions (9x refixation, 3x reconstruction), 13 medial collateral ligament (MCL) lesions (8x reconstruction), 6 medial posterior collateral ligament (MPCL) lesions (4x reconstruction), 4 lateral collateral ligament (LCL) lesions (1x reconstruction), 3 popliteal muscle injuries (2x reconstruction), 5 medial meniscal lesions, 10 lateral meniscal lesions (9x suture, 1x partial meniscectomy), 3 femoral fractures, 1 proximal tibial fracture. One angiography was performed. No vascular lesion was observed. The follow up rate was 93% complete. The mean follow up time was 58 months (range 35–156). 83% of patients were able to return to work without any impairment. 62% of patients returned to the same level of sport activity. 54% of patients were absolutely painfree. Based on a modified SSK score by Insall a mean of 182 points (range 129–200) on a scale with maximum 200 points could be noted.
We are presenting a prospective study of 25 patients with clavicle fracture treated with Rockwood Intramedullary pin fixation. Operative management is required for open fractures, neurovascular injury or compromise, displaced fractures with impending skin compromise and displaced middle third fractures with 20mm or more shortening. Plate osteosynthesis or intramedullary fixation devices are used for operative management.
We evaluated this new implant in our series in a prospective, multicenter setting.
Due to the fact that the treatment of distal femoral fractures is a therapeutic challenge, new specific implants were continuously developed. The techniques should guarantee a reliable bone healing for two different groups. For young patients with high energy trauma and more or less severe collateral injury and for old patients with osteopenic bone, weal soft tissue and a high rate of co-morbidity. Present widespread techniques are reduction and fixation with LISS plate or retrograde nails. In this clinical study from 2003 to 2006 we compared our supracondylar nail (SCN, Stryker) with the LISS plate. We were looking at a series of 77 patients (55 SCN and 23 LISS) with A (36) and C (41) fractures of the distal femur. 43 (78%) of the SCN group healed without complications, 1 malrotation, 1 case of infection, 2 pseudarthrosis and 5 problems with the distal locking screws were observed. In the LISS group only 23 (56%) healed primarily, whereas the complications occured more frequent. Beside radiographic control and clinical examination the success of operation was assessed with a standardised questionare (KOOS). The SCN group showed again a higher rate of satisfaction compared to LISS.
The AP radiograph was evaluated independently by three observers who were blinded to the identity of the patients and their operative diagnosis. The presence of ‘sunset’ sign was recorded. There was 90% inter-observer agreement. In the remaining 10%, a consensus review was performed as to the presence of sign for evaluation purpose. The findings were then correlated with the operative findings to confirm whether they were four-part fractures or not. With 95% confidence interval we calculated the sensitivity, specificity, and positive and negative predictive values for our diagnostic sign.
We present the results of surgical treatment of proximal humeral fractures in a group of 40 patients. The fractures were treated with the angular stable Lockin Proximal Humeral Plate, which is based on the LCP-principle (Locking Compression Plate). The upper part of the plate contains small suture holes for fixation of the tuberosities.
Between january 2002 and december 2005, 40 patients were operated using this technique. There were 24 women and 16 men and the mean age of our population was 56.5 years. Clinical and radiological evolution was followed until fracture fracture healing and functional recovery and a Constant-score was taken on a retrospective basis with a mean follow-up of 23.6 months. During follow-up 2 patients died of unrelated causes with their fractures healed and 2 patients were lost because they were living abroad.
Fracture healing was uncomplicated in 34 patients (89 %). In 4 patients there was secondary displacement of the fracture: varus displacement in 3 cases and complete loosening of the osteosynthesis in a patient who fell again a few weeks after the first intervention. In this patient a new osteosynthesis with the same device was realised and the fracture healed correctly. In the other 3 cases the fracture healed with some varus alignment and in 1 of these the hardware had to be removed because of intra-articular positioning of some screws after varisation of the humeral head. No secondary displacement of the tuberosities was seen. In one case we had an aseptic necrosis of the humeral head 6 months after the osteosynthesis and this patient needed a shoulder arthroplasty. Another patient had severe chondral lesions of the humeral head but symptoms respond well to medical treatment.
Hardware removal was necessary in 8 patients because of subacromial impingement or local tenderness. Reflex sympathetic dystrophy occured in 4 cases. The mean Constant-score was 57.6; when correction was made for age and gender the mean score was 73.0.
We report the short-term results of an alternative treatment for acromioclavicular (AC) dislocation.
36 patients, aged 20 to 58 (mean 36), with Tossy types IV (16) or V (20) AC-injuries were operated on within 1 week after trauma. The majority of patients had sport-related injuries. All patients were engaged in overhead activities, either professionally or for sports. The surgical technique consisted of a double fixation. A processed tendon-graft, either fascia lata or tibialis anterior, was looped around the coracoid process and the distal clavicle in a figure-of-eight and sutured onto itself after reduction of the dislocation. The AC discus was removed if damaged. No attempt at repair of the ligaments was made. The graft was protected for 6 weeks with 2 percutaneously placed acromioclavicular K-wires. In this period pendulum exercises and up to 45° abduction were allowed.
21 patients had an excellent result with painfree function, including full range of motion and strength, at only 3 month postop; another 5 needed 6 months to reach an excellent result. These patients could fully return to their work or sports activities at 3 months postop. 5 developed frozen shoulder syndrome and had a poor result at 3 month postop. These patients recovered well and all had good or excellent results at 8 month postop. 3 patients refused follow up after removal of their K-wires and 2 refused follow up beyond 3 months, at which time their result was good (1/5) or fair (4/5).
Although a good to perfect reduction was obtained perop, X-rays showed perfectly maintained reduction in only 12 shoulders. 15 patients had minimal loss of reduction (< 5mm), 7 had < 100% ascension of the clavicle and 2 had > 100% ascension.
Complications were rare, with 3 patients having early pin migration or removal due to infection which led to loss of reduction. 3 other patients had minor AC wound problems and another 2 pintract infection; all without further consequences.
The use of a processed tendon-graft to reconstruct the coracoclavicular ligaments, protected by 6 weeks of K-wires, appears to be a valuable treatment option for Tossy grades IV and V AC injuries. This technique allows rapid recuperation of full function as well as return to work and sports in the majority of patients.
The goal of this technique is to restore normal anatomy of proximal humerus around a bone bridge inside the head and the metaphysis.
The Authors report the goal of this technique is to restore normal anatomy of proximal humerus around a triangle-shaped bone block positioned inside between the head and the metaphyseal. The fragments are then stabilized with a minimal osteosynthesis by K- wires, screws or bone sutures.
The results of our study show that the technique we propose has good clinical and functional outcomes, with a low percentage of complications.
Especially, no cases of lesions of the axillary nerve or frozen shoulder were seen. The latter we believe is due to the MI procedure and the early functional treatment due to high primary stability of the NCB-PH® plate. Despite good functional outcome, younger patients with higher levels of activity compared to the average patient sustaining proximal humeral fractures tend to feel subjective problems with the plate in situ demanding surgical removal of hardware. The long-term results also prove the NCB-PH® plate to be a safe and effective method of treatment reaching a functional outcome that enables the mostly old patients to regain an acceptable level of activity. Removal of hardware is easy to perform and offers especially in the younger patient a possibility to at least improve patients’ subjective outcome
The aim of our study was to assess the use of the Clavicular Hook Plate in treating acromio–clavicular joint dislocations and fractures of the distal clavicle. The prospective study was carried out at two hospitals- a teaching hospital and a district general hospital.
Between 2001 and 2004 a total of 37 patients with AC joint injuries and distal clavicle fractures were treated surgically with this device. Four of the patients had sustained a Neers Type 2 fracture of the distal clavicle, while 33 patients had acromio-clavicular joint dislocation (Rockwood Type 3 or higher). Mean age of the study group was 35.2 years. Post operatively, shoulder pendulum exercises were commenced on the second day and all patients discharged within 48 hours. During the first few weeks, we restricted shoulder abduction to 90 degrees. At the first postoperative follow up appointment at 2 weeks, average shoulder abduction was 30 degrees and forward elevation −40 degrees. This improved at 6 weeks to 85 degrees and 105 degrees respectively. The plates were removed at an average time interval of 11 weeks for the ACJ dislocations (range 8–12 weeks) and 15 weeks for the clavicle fractures (range 12–16 weeks). At three months after plate removal, we evaluated patients to measure the Visual Analogue Score(VAS) and Constant Score. The mean VAS was 1.4 (range 0–6) and the mean Constant score was 92 (range 72 to 98). Wound healing problems occurred in two patients, while two had a stress riser clavicle fracture. These had to be subsequently fixed with a Dynamic Compression Plate. One patient developed a superficial wound infection. Seven patients had problems due to impingement between the hook and the under surface of the acromion. A 45 year old female patient developed ACJ instability after plate removal. Radiographs revealed widening of the AC joint and some osteophyte formation. She went on to develop frozen shoulder which was treated with intensive physiotherapy.
The AO hook plate represents an improvement over previous implants in treating injuries around the AC Joint. However, the need for a second operation to remove the plate remains a significant problem. Complications resulting from impingement were common in our patients and represent a major drawback of this implant.
In C-type fractures it is not advisable as a standard routine, only for experienced surgeons it might be a possible solution in selected cases.
Proximal humerus fracture treatment remains controversial. If the conservative treatment is widely accepted for Neer I and Neer II fractures, the attitude is not very clear concerning Neer III and Neer IV fractures.
Several methods are proposed in the literature varying from suturing, pinning or plating the proximal humerus. Hemiarthroplasty are even considered.
In our study we present our results of an internal fixation procedure for 3 part or 4 part fractures of the upper part of the humerus.
To review the outcome of compound injury to the shoulder in which traumatic anterior dislocation is associated with concomitant rotator cuff tear and injury to the brachial plexus.
22 patients initially treated at the Peripheral Nerve Injury Unit since 1994 were reviewed from notes, telephone and clinically (n=13) where possible. 19 men and 3 women of average age 53 years were treated with a minimum 3-year follow up. All patients underwent exploration of the brachial plexus and nerve repair where required (graft n=5). Patients had either proven large cuff tear (n=13) or avulsion fracture of greater tuberosity with cuff injury (n=9). 7 of 13 cuff injuries and 7 of 9 tuberosity fractures had been repaired. Nerve injury at exploration was to circumflex (n=20), supra-scapular (n=12), musculocutaneous (n=6), or at the cord level (Posterior n=10, Lateral n=7 Medial n=8). Outcome measures were Berman pain score, sensation, muscle power (MRC grade), abduction, functional scores (Mallett and DASH) and return to work. Statistical analysis used tests for non-parametric data.
22 patients had exploration of the plexus. Most patients did not have an isolated nerve lesion (n=4). Increased depth of nerve lesion correlated with poorer functional outcome. E.g. for circumflex nerve injury (n=18), conduction block (n=8) vs. axonotmesis or neurotmesis (n =10) functional range of movement as assessed by Mallett score was significantly different; Mann Whitney U test p=0.043. Late exploration of nerve tended to correlate with poor outcome, as did late repair of rotator cuff, but not to statistical significance.
Our explorations have shown the nerve injury sustained in these patients to be more widespread than expected. We believe early exploration is vital to give an accurate diagnosis and predict outcome for the nerve lesion. This is particularly important in the presence of associated cuff injury where early repair confers favourable outcome.
Carpal tunnel syndrome is a common condition with a prevalence of 2.7% based on symptoms, clinical signs, and neurophysiology. The procedure to cure these patients, whether it is open or endoscopic, is usually successful in returning sensation, abolishing numbness and paraesthesiae, and improving manual dexterity. However, as many as 14%–32% of patients may have persistent symptoms
The general treatment of patients with recurrent carpal tunnel syndrome is re-exploration of the median nerve and neurolysis. Various procedures have been described to cover the median nerve with muscle or fat tissue. These include–external neurolysis, local muscle flaps, fat grafts and flaps, vein wrapping and synovial flaps. The outcome of secondary carpal tunnel surgery is only fair and many procedures are possible.
In 19 patients presenting with recurrent carpal tunnel syndrome over a period of five years, silicone sheath was used to cover the median nerve following neurolysis. All of these 19 cases were performed by the senior author (ASR).
We audited the results of this procedure using the carpal tunnel outcome instrument (Levine et al., 1993) for subjective assessment and grip strength, thumb key pinch force and two point discrimination sensation for Objective assessment. 17 patients were followed up for the purpose of this study. 2 were lost to follow up. Twelve patients were satisfied with their outcomes and were prepared to undergo the surgery again or recommend it to others (more than 70%). However, two were dissatisfied and three were uncertain of their feelings.
Carpal Tunnel Syndrome is the most common entrapment neuropathy encountered in clinical practice. Previous studies have suggested that the disease has a higher prevalence in the elderly(Stevens JC etal, Neurology 1988;) and that this sub group also tends to have a higher prevalence of severe CTS.(Seror P, Ann Hand Surg 1991; Bland etal, J Neurol Neurosurg Psychiatry). Surgical decompression of the median nerve is the treatment of choice with a reported success rate of between 53 and 97 %.(Katz et al, J Hand Surg 1998).
There has been some controversy regarding the effectiveness of surgery in elderly patients. The aim of our study was to evaluate the results of carpal tunnel release in patients over the age of 75 years at the time of surgery. A literature search revealed few studies carried out in elderly patients–Weber etal-(mean age 75 years), Porter etal (mean age 59.8 years) and Leit et al (mean age 79 years). The average age of our patient group (80.4 years) is the highest reported in literature so far.
We posted questionnaires to all patients who were over 75 years at the time of their surgery. There were a total of 49 patients (65 hands) operated over the last 10 years who belonged to this age group. We used the Brigham And Women’s Hospital Questionnaire devised by Levine et al. (1993). In addition, we added some questions to assess patient satisfaction with the procedure. 65% of the patients were females. The average age was 80.4 years.
The completed questionnaires were used to calculate the Pre and Post operative scores. The mean pre operative score was found to be 3.18, which improved post operatively to 1.8. (Scale of 1 to 5, with 1 being the best and 5 the worst). Importantly, although all symptoms improved, some such as pain and numbness showed a much greater improvement than grasping power. On the Visual Analogue Scale, pain scores improved from 6.4 to 2.3 post surgery. 82 % of patients had no scar tenderness, 12 % had mild to moderate tenderness, while 6 % reported severe scar tenderness. Overall 79% of patients showed improvement, 15 % felt that the surgery had made no difference, while 6% reported worsening of their symptoms after surgery.
Our study showed that 8 out of 10 elderly patients will improve after carpal tunnel release, though all symptoms are unlikely to improve. The symptom least likely to improve is weakness of the hand. The results of this study are important to counsel this sub group of elderly patients, so that they may take an informed decision on whether to proceed with the surgery.
All patients had a repeat of release ading a neurolysis of the median nerve. The adducor digiti quinti flap was dissected up to its neurovascular bundle and flipped over..
The purpose of the study was to evaluate if 2 week Levine score can provide an adequately responsive outcome measure in Carpal Tunnel Decompression by comparing it with 6 month score.
The treatment outcome of 300 patients with Carpal Tunnel Decompression was determined by using Levine score at 2 weeks and 6 months after surgery. The mean age of patients was 55 years and 6 months, 71.3% (214) were female with 55.33% (167) operations being performed on right hand. All patients were scored through Levine questionnaire pre operatively and at 2 weeks and 6 months from date of surgery. The correlation between the scores was evaluated.
Although statistical significance was found between the pre operative score and the scores at both 2 weeks and 6 months, no statistical difference was found between the scores at 2 weeks and 6 months post surgery. Multiple regression analysis with the 2 week–6 month score difference as the dependable variable shows a predictable outcome at 2 weeks.
We conclude that the Levine score at 2 weeks is a reliable, responsive and practical instrument for outcome measure in Carpal Tunnel Surgery. It coincides with suture removal and provides a convenient and predictive assessment of the medium term results in a high percentage of treated patients.
A three dimensional femoral finite element model was constructed and molded with a femoral component constructed from the dimensions of a Birmingham Hip Resurfacing. The model was created with a superior femoral neck notch of increasing depths.
The purpose of this study was to evaluate early results of a new, as yet undescribed, minimally invasive, gluteus maximus splitting posterior approach for metal on metal (MOM) hip resurfacing. Surgical approach is described, backed with a video of the procedure. Results of the first 100 cases are presented.
A new, minimally invasive, gluteus maximus splitting approach is described. The single incision approach allowed MOM hip resurfacing to be carried out through an incision ranging 8.25 ± 2.25cm. Release of gluteus maximus insertion to femur is not necessary. Intra-operative fluoroscopy is not necessary. Special acetabular reamer handle and acetabular impactor had to be used for accurate acetabular component placement. Femoral neck targeting device, suitable for minimally invasive surgery was used for accurate placement of femoral neck centring pin. This allowed for accurate placement of femoral component
Results of 100 patients who had undergone MOM hip resurfacing are presented: Average review was 2 years, range 22–46 months. Average age of patient was 57 years; range 55 ± 22 years. Average BMI was 27; range 29.95 ± 11.85. Average blood loss was 270ml; range 450 ± 350ml. Average incision was 8cm; range 8.25 ± 2.25cm. Operation time was no longer than conventional open posterior approach. Early discharge at day 3, post-op was possible and patients were able to walk without aids at 3 weeks, post-op. There were no cases of infection, nerve damage, dislocation or malposition of implant. There was no case of hypertrophic bone formation. There was one fracture neck of femur at 6 weeks post-op.
Minimally invasive hip resurfacing can be carried out successfully using a new gluteus maximus splitting approach with excellent early results and no complications apart from 1% risk of fracture neck of femur.
Element analysis was performed by EDX (Oxford D. 7060) to identify carbides and the alloy composition. Element distribution maps were taken to separate the single elements.
All implants showed a sphericity deviation less than 10μm. On average the heads tended to have a higher spherical deviation of 4.1μm (SD: 2.3μm) compared to the cups 2.7μm (SD: 1.4μm). Based on the SEM and EDX inspection the manufacturing process, heat treatment and carbide distribution could be clarified.
The characteristically unspheric formations of the heads may be due to the cooling process after manufacturing the implant and there is also a relation between the wall thickness of the implant and the unspheric formations. With decreasing wall thickness the implant cools faster locally. Additionally a cup with a thin wall may deform under loading condition and a very tight clearance could be detrimental.
This study will help to understand clinical observations. It still has to be proven that these biomechanical factors influence the clinical performance of hip resurfacing implants.
Metal-on-metal hip resurfacing is increasingly common. Patients suitable for hip resurfacing are often young, more active, may be in employment and may have bilateral disease. One-stage bilateral total hip replacement has been demonstrated to be as safe as a two-stage procedure and more cost effective. The aim of this study was to compare the in-patient events, outcome and survival in patients undergoing one-stage resurfacing with a two-stage procedure less than one-year apart.
No patients have undergone a revision procedure during the study period and no patient is awaiting revision surgery.
Alignment of the femoral component during hip resurfacing has been implicated in the early failure of this device. Techniques to facilitate a more accurate placement of the femoral component may help prevent these early failures. We aim to establish whether the use of imageless computer navigation can improve the accuracy in alignment of the femoral component during hip resurfacing.
6 pairs of cadaveric limbs were randomized to the use of computer navigation or standard instrumentation. All hips had radiographs taken prior to the procedure to facilitate accurate templating. All femoral components were planned to be implanted with a stem shaft angle of 135 degrees. The initial guide wire was placed using either the standard jig with a pin placed in the lateral cortex or with the use of an imageless computer navigation system. The femoral head was then prepared in the same fashion for both groups. Following the procedure radiographs were taken to assess the alignment of the femoral component.
The mean stem shaft angle in the computer navigation group was 133.3 degrees compared to 127.7 degrees in the standard instrumentation group (p=0.03). The standard instrumentation group had a range of error of 15 degrees with a standard deviation of 4.2 degrees. The computer navigated group had a range of error of only 8 degrees with a standard deviation of 2.9 degrees.
Our results demonstrated that the use of standard alignment instrumentation consistently placed the femoral component in a more varus position when compared to the computer navigation group. The computer navigation was also more consistent in its placement of the femoral component when compared to standard instrumentation. We suggest that imageless computer navigation appears to improve the accuracy of alignment of the femoral component during hip resurfacing.
1) To describe the inter reviewer agreement of a previously designed scoring scheme to rate abstracts submitted for presentation at the Dutch Orthopedic Association. 2) To test if quality of reporting of submitted abstracts increased in the years after the introduction of the scoring scheme. 3) To examine if a review process with a larger workload had lower inter rater agreement.
This research was supported by a grant from the AO Foundation, Clinical Investigation and Documentation, Clavadelerstrasse, 7270 Davos Platz, Switzerland
Impaction allografting is a bone tissue engineering technique currently used in lower limb reconstruction orthopaedic surgery. Our hypothesis was that biological optimisation can be achieved by demineralisation and addition of osteogenic protein-1(OP-1) to the allograft. The objective of our in vitro study was to evaluate human mesenchymal stem cell (MSC) proliferation (Alamar Blue assay, titrated thymidine assay, total DNA Hoechst 33258 and scanning electron microscopy) and osteogenic differentiation (alkaline phosphatase assay) in two types of impacted carrier, namely demineralised bone matrix (DBM) and insoluble collagenous bone matrix (ICBM), with or without OP-1. The objective in vivo was to compare the osteogenic potential of impacted DBM with or without OP-1, with that of impacted fresh frozen allograft (FFA), again with or without OP-1. DBM+OP-1 optimized osteoinduction and significantly improved (p< 0.05) proliferation and differentiation in comparison to the majority of all other graft preparation in vitro. In addition DBM+OP-1 was significantly superior, with regard to osteogenesis, compared to the impacted FFA alone (p< 0.001), FFA+OP-1 (p=0.01) and DBM alone (p=0.02) in vivo. We propose that partial demineralisation and addition of OP-1 provides a good method for improving the osteoinductive properties of fresh allograft currently used in the impaction grafting technique.
1) studies labelled as Level I have high reporting quality and 2) Level I studies have better reporting quality than Level II studies.
One should address methodological safeguards individually.
1) to examine the reporting of outcome measures in orthopaedic trials, 2) to determine the feasibility of blinding in published orthopaedic trials and 3) to examine the association between the magnitude of treatment differences and methodological safeguards such as blinding.
Specifically, we focused on an association between blinding of outcome assessment and the size of the reported treatment effect; in other words: does blinding of outcome assessors matter?
1) the outcome measures used and 2) the use of a methodological safeguard: blinding.
We calculated the magnitude of treatment effect of blinded compared to un-blinded outcome assessors.
Continuous neuraxial or deep peripheral nerve blockade used to provide postoperative analgesia after major orthopaedic surgery is associated with a risk of spinal or perineural haematoma, especially in patients concomitantly receiving anticoagulants. Limited data on the use of fondaparinux in surgical patients in whom this procedure is performed are available. The EXPERT trial was an observational international study in patients undergoing major orthopaedic surgery designed to evaluate the overall efficacy and safety of once-daily 2.5 mg fondaparinux initiated 6 to 12 hours post-operatively and administered for 4±1 weeks after surgery. A 48-hour “therapeutic window” was applied in patients in whom a neuraxial/deep peripheral indwelling catheter was placed: one of the planned doses of fondaparinux was omitted, the catheter was removed 36 hours after the previous fondaparinux dose, and the next fondaparinux dose administered 12 hours after catheter removal. The primary endpoints were symptomatic venous thromboembolism (VTE) and major bleeding 5±1 weeks after surgery. These events were validated by an independent adjudication committee. Overall, 5704 patients (mean age ± SD: 66 ± 12 years) were recruited between July 2003 and October 2004. They underwent surgery for total hip replacement (52%, n=2941), knee replacement (40%, n=2263), hip fracture (6%, n=353), or other indications (3%, n=148). Fondaparinux was given for a median of 35 (range: 1–105) days. Many operations (62%) were performed under regional anaesthesia only. A neuraxial or deep peripheral nerve block catheter was placed in 29% (n=1630) of patients. It was removed between one and two days after surgery in 43% (706/1626), and between three and six days after surgery in 57% (920/1626). Overall, the rate of symptomatic VTE was 1.0% (54/5387); it was 0.8% (13/1535) in patients with catheter and 1.1% (41/3852) in patients without catheter, giving an odds ratio of 0.79 (95% CI: 0.42 to 1.49) in favour of patients with a catheter. The upper limit of the 95% CI being below the predetermined non-inferiority margin of 1.75, the efficacy of fondaparinux in patients with a catheter was therefore not inferior to that observed in patients without a catheter. The rate of major bleeding was 0.8% (42/5382) overall, 0.5% (7/1532) in patients with catheter and 0.9% (35/3850) in patients without catheter. No spinal or perineural hematomas or nerve damage were reported. At 5±1 weeks, 23 (0.4%) patients had died. In conclusion, 2.5 mg fondaparinux given daily for 4±1 weeks after major orthopaedic surgery was both effective and safe in routine practice. This benefit-risk ratio was similar in 1630 patients with a neuraxial/ deep peripheral indwelling catheter in whom a 48-hour “therapeutic window” was applied.
Loss of blood is inevitable during knee replacement surgery, sometimes requiring transfusion. Allogenic blood leads to a risk of disease transmission and immunological reaction. There are various practices used. There is still a risk of bacterial transmission with stored blood and haemolytic transfusion reactions can still occur. Data was collected between 1998 and 2006. There was data on transfusion in 1532 patients undergoing primary knee replacements. There were 1375 unilateral TKRs and 157 bilateral TKRs. After reducing the bilateral cases to one record per patient, it was agreed to restrict the main analysis to 1532 patients. Data was collected prospectively at a pre-admission clinic 3 weeks prior to surgery. Haemoglobin was checked and body demographics including BMI were obtained. Each patient also had a knee score assessed. All patients received a LMWH pre-op until discharge. A tourniquet was used in each case and all patients had a medial para-patellar approach. No drains were used and operation details such as a lateral release were recorded. As per unit protocol, patients with a post-op haemoglobin less than 8.5g/dl were transfused as were symptomatic patients with haemoglobin between 8.5g/dl and 10g/dl. Each of the possible predictive factors was tested for significant association with transfusion using chi-squared or t-tests as appropriate. Multiple logistic regression was used to test for the independent predictive of factors after adjusting for one another. Results show that transfusion was more likely if the patient was older, female, short, light or thin. Among peri-operative factors, the chance of a transfusion was increased for bilateral patients, those with low knee scores and those with high ASA scores. Also patients undergoing a lateral release, those with low pre-op haemoglobin and those with a large post-op drop were more likely to be transfused. All the significant variables were entered into a forward stepwise multiple logistic regression. Transfusion was significantly more likely in those undergoing a bilateral procedure, with a low BMI, low pre-op haemoglobin and those with a large post-op drop (> 3g/dl). Allogenic transfusion is associated with immune-related reactions, from pyrexia to urticaria to haemolytic transfusion reactions, which can be life threatening. There is also the risk of viral pathogen transmission. Women were shown to be almost twice as likely to need transfusion. This has been shown in previous studies and is thought to be due to women having a lower weight and pre-op haemoglobin, both of which were shown to be significant independent factors in increasing the risk of transfusion. A pre-operative haemoglobin of less than 13g/dl, a BMI less than 25, and undergoing a bilateral procedure were shown to have an increased risk of transfusion. For patients falling into these categories, measures can be planned to try and reduce this risk.
The authors offer their personal experience with long term results on 71 patients (72 allografts) operated between 1961 and 1990. 23 were large osteoarticular grafts, 28 intercalary grafts and 20 fibular grafts. We used one composite hip endoprosthesis in 1988 after 16cm proximal femur resection due to Ewing sarcoma in a 10 year old girl. From the 23 osteoarticular grafts 14 (60%) are long term survivals including one after fracture salvage. Six had to be removed due to infection. From the 28 intercalary grafts 16 (57%) are surviving over 15 years. Infection occurred in 6 patients with chemotherapy. Two of them had intra-arterial CDDP and one additional radiation. All of the proximal humerus allograft had complete resorption of the proximal head within 3 years. The diaphyseal reconstructions with additional cancellous autografts incorporated within 3 years. The patient with the composite stem had two cup revisions, but the stem is doing well and we observed only a mild osteolysis at the proximal part of the graft between the 2nd and 5th year that remains stable. Fractures of the graft can be salvaged in most cases.
Infection leads to the removal of the graft in almost all cases. Factors influencing the survival, remodeling and complications of the grafts are discussed. The regime of cryopreservation, fixation and loading of the graft influence these factors together with the use of autologous bone chips around the allograft-host junction as well as the application of chemotherapy or radiation. Fracture of the graft can be salvaged in most cases in contrary to infection that remains the most severe complication that can occur at any time period. Even with the improvement of tumor endoprostheses the use of allografts remains an optional solution especially in young patients.
The osteochondral defect in the knee and ankle joint is a difficult and common problem in young population. The bone-cartilage autologous grafting represents a recently introduced treatment option for osteochondral lesions of the weight bearing articular surfaces of femoral condyles and talus.
The aim of our study was to evaluate the MRI findings, and in particular to find out about the fate and the time needed for the graft incorporation, to assess the continuity, homogeneity and smoothness of the cartilage layer of the transplant compare to the remaining cartilage, to estimate the viability of the graft and to determine the correlation between the MRI findings and the functional outcome.
We performed a prospective study and followed up 33 patients, who underwent osteochondral autografting for defects in both medial and lateral femoral condyles as well as in the talus. The grafts were harvested from the anterolateral region of the ipsilateral knee using an insider rinsing diamond bone-cutting instrument (DBCS). The grafts were implanted using press fit technique.
16(48%) women and 17 men were included in our followup with an average age of 38.4 years (age range-16to58 yrs). There were 20(60%) osteochondral defects in the femoral condyles and 13 in the talus. 13(40%) patients gave a history of trauma. All the patients were followed up with MRI scans between 1 to 4 years postoperatively.
The MRI study illustrated a cartilage contour interruption by 16(48%) patients and 19(58%) had uneven joint surface. 9(27%) of the patients were shown to have homogeneity between the graft and the surrounding bone and cartilage tissues. A subchondral oedema was observed in 2(6%) of the cases. Only 1 patient had a subchondral bone-oedema in the graft-donor site. All the autologous grafts were incorporated by 4 years as proven by MRI scans
The MRI evaluation revealed regular incorporation of the osseous part of the graft in the subchondral bone. On the contrary, cartilage layer integration was less common. The MRI findings did not show any correlation to the clinical outcome. Hangody (2003) reports all grafts to incorporate into the recipient bed and most articular surfaces to have congruency and similar appearance to the surrounding articular cartilage and bone in 6 years.
Despite using very accurate harvested autologous osteochondral cylinders, which fit exactly the defects, match precisely the corresponding chondral and osseous layers and cause no immune reactions, it was shown in this short term MRI followup that the height and the shape of the original articular surface cannot be fully restored. However the relief of symptoms and improved functional outcome are promising findings and define bone cartilage autografting as a currently efficient treatment of osteochondral lesions of knee and talus.
A major challenge to be faced in order to introduce cell-based therapies for bone repair into wide-spread surgical practice is to translate a research-scale production model into a manufacturing design that is reproducible, clinically effective, and economically viable. One possible means by which to achieve this goal is via a bioreactor system capable of controlling, automating, and streamlining all of the individual phases of the bone-tissue engineering process. In a first step to meeting this challenge, in this work we aimed at developing and validating a closed bioreactor system for
the efficient seeding of cells into 3-dimensional scaffolds and the generation of osteoinductive constructs starting from human bone marrow-derived cells.
Our patented bioreactor technology essentially consists of scaffolds arranged in a circular plate, which is moved in alternating directions by a linear drive unit through a cell suspension/culture medium, thus resulting in the perfusion of the cell suspension/culture medium directly through the pores of the scaffolds in alternate directions. The cultivation chamber is fully isolated from the external environment, with liquid/gas exchange achieved through aseptic interfaces.
Human bone marrow nucleated cells from 3 donors were perfused through porous ceramic discs (8 mm diameter, 4 mm thick), resulting in adhesion of the osteoprogenitor cell fraction in the ceramic scaffolds. Efficiency of cell seeding was consistently greater than 80%. Cell seeded constructs were further cultivated under perfusion for a total of 20 days, resulting in the expansion of the osteoprogenitor cells directly within the scaffold pores and maintenance of greater than 90% cell viability. Ectopic implantation of the cultivated constructs yielded abundant and reproducible formation of bone tissue, distributed throughout the scaffold pores.
The developed bioreactor provides a simple and efficient approach
to establish and maintain 3D cultures of cells into scaffolds under perfusion, and to generate osteoinductive grafts starting from minimally processed bone marrow aspirates and bypassing typical cell expansion in monolayers.
Incorporating the bioreactor unit into a system for automated medium change and monitoring/control of culture parameters is likely to lead to the development of a closed system for the standardized production of autologous cell-based bone substitutes.
The outer diameter of the spacer ranges from 20–25–30 mm and the length from 40 to 70 mm. Two or three spacers can be combined via a special connector. Nails in the length 60 to 200 mm and the Ø 7 to 18 mm with the possibility of static or dynamic interlocking complete the modular system entirely made from Ti-6Al-4V.
The indication: Tumor: Humerus 8, Femur 16, Tibia 2, Postinfectious: Tibia 4, Posttramatic Femur 4, Tibia 2.
Biomechanical testing: the clamp connection spacer/ nail can neutralize axial loads which can not be expected in human beings. The clamp connection spacer/nail Ø 10 mm resisted an average axial load of 8,5 kN. This can be compared to a force of 850 kN (equivalent to 10 multiples of 85 kg body weight). The bending test with a nail Ø 10 mm shows that the spacer can resist long term loads from an occurring stress of 400 N/mm2 in the nail. Clinical evaluation: All spacers are still in place and all are full functioning, except 2; one spacer in the femur had to be replaced by a second spacer due to bone cement incorporated during first operation.
One spacer was removed during amputation for recurrency of osteosarcoma. No infection, no loosing were reported.
Ankle arthrodesis is considered a valid reconstructive option after bone tumor resection of the distal tibia, distal fibula and of the talus. The purpose of the present study was the review of author’s experience in ankle arthrodesis for bone tumors with the employ of bone grafts.
Over the last 15 years, 17 ankle arthrodesis were performed in author’s Institution for oncological pathologies. Average age at the time of surgery was 41 years (4–75). Twelve patients had a malignant tumor (3 osteosarcoma, 2 fibrosarcomas, 1 Ewing sarcoma, 1 emangioendotelioma, 1 condrosarcoma, 1 pleomorphic sarcoma, 1 adamantinoma and 2 metastases from renal carcinoma) and 5 patients had a benign tumor (4 giant cell tumors, 1 condroblastoma). In 13 cases the tumor involved the distal tibia, in 2 cases the distal fibula and in 2 cases the talus. In 15 patients we performed a tibiotalar arthrodesis and in 2 patients (tumors of the talus) a tibiocalcaneal arthrodesis.
The bone defect after resection was reconstructed with: cortical structural autografts from controlateral tibia and autologous bone chips from iliac crest in 5 patients; cortical structural autografts from controlateral tibia + cortical structural allografts + autologous bone chips from iliac crest in 2 patients; cortical structural allografts + autologous bone chips from iliac crest in 2 patients; structural autografts in 4 patients; autogenous vascolarized fibula in 4 patient with cortical allograft in 3 cases and autograft in 1 case. Stabilization was obtained by intramedullary anterograde nailing in 8 patients, plate in 2, two or multiple screws in 7 (including two tibiocalcaneal arthrodesis).
Three patients died before this review (1, 1.5, 7 years after surgery: 1 Ewing sarcoma, 2 patients with metastases from kidney cancer). Follow-up for alive patients ranged from 14 to 146 months (average 53). Two local recurrences were observed, in a Ewing sarcoma in 1 case and in a giant cell tumor in 1 case. One patient is alive with lung metastases but no signs of local recurrence. In all patients but one the arthrodesis healed successfully. In one case a deep infection occurred (with wound dehiscence) and the arthrodesis did not heal. Complications included 1 deep infection, 1 superficial infection of the donor site (controlateral leg) and 1 fracture of the controlateral tibia (donor site of cortical autograft) treated with plaster cast. Three patients underwent a secondary surgical procedure: two partial hardware removals and one myocutaneous sural flap.
The low rate of local recurrence (1/5 in benign tumors and 1/12 in malignant tumors) and the high percentage of bone union (16 out of 17) together with the satisfactory functional outcome showed that ankle arthrodesis with bone grafts can be an oncologically safe and a meccanically successful procedure in bone tumor surgery.
Data were prospectively collected from the tumour register and patient records. Functional scores of the affected limbs were assessed according to the Musculo-Skeletal Tumour Society scoring system.
The minimal follow up was two years, and the average follow up 50 months (range 24–119 months).
At follow up three recurrences had occurred in patients treated for enchondroma. One residual tumour was diagnosed in a patient with chondrosarcoma grade Ib. All patients were treated again with curettage and cryosurgery and disease free at the latest follow-up.
Of the 37 complications the most common were a fracture at the surgical site (18), fracture of osteosynthesis (6), 3 wound infection (3), delayed soft tissue healing (3), and transient nerve palsy (3).
Functional MSTS scores increased in time to an average of 28 points (94%) at two year follow up. No significant difference in scores were found regarding to localisation of the lesion, age or gender. A significant discrepancy in functional scores was observed between patients who did suffer from one or more complications and patients who did not.
The authors present their experience of acetabular fractures, as examined according to Harris’ recent (2004) CT based classification into four separate groups and relative sub-groups.
Each group is here represented as a completely documented clinical case, with pre and post-op roent-grams as well as axial and volume rendering CT imagery.
The Harris classification differs from the classic and 40 year old Letournel classification, basically ignoring the fracture complexity and focusing on the pattern of the fracture itself, with respect to column walls and extension beyond the acetabulum. It’s also possible to include some commonly seen fractures otherwise not classified by Letournel. Fracture comminution therefore is not a defining characteristic.
This topographic approach is easier for the surgeon to comprehend and memorize, thus facilitating pre-operative planning and the possibility of interdepartmental assessment of the fracture types.
Obviously, computerized tomography is the defining technique of this classification. The axial CT display of acetabular fracture patterns within the pelvis is furthermore confirmed by the 3D reformatted images.
This classification is loosely based on that of Tile and Helfet ; with the advantage of further simplifying the sub-groups from 27 to 16.
The Harris classification is simple and unambiguous, providing clear indications for both diagnosis and surgical treatment planning of this most complex chapter of Traumatology.
All patients were assessed postoperatively with a CT scan and annually for up to 5 years for a clinical and radiological assessment. Clinically patients were graded according to the Epstein modification of Merle D’Aubigne/ Postel Hip Score. The radiographs were graded using the Roentographic Grade criteria used by Matta.
At the time of operation 40% of fractures were reduced anatomically. There were 12 post operative complications.
Clinically excellent or good results were seen in 70% and radiologically in 68%. There were 11 revisions for osteonecrosis, infection and osteoarthritis.
There was a high correlation between the accuracy of the reduction and the subsequent prognosis.
Anatomical reduction of the joint is the primary aim in the treatment of acetabular fractures as any other articular fracture. The current standard approach provides open reduction and internal fixation (O.R.I.F.) through a variety of surgical approaches which have been associated with relatively high complications rate such as haematomas, deep infection, and neuro-vascular lesions. These procedures need long operative times with significant blood loss.
Many authors have demonstrated the feasibility of closed reduction and percutaneous fixation (C.R.P.F.) for minimally or non displaced acetabular fractures; this technique can be considered a valid alternative to O.RI. F. in order to decrease the morbidity related to surgical approaches.
Between 2001 and 2006 we performed C.R.P.F. for acetabular fractures in 15 patients; the reduction has been controlled with fluoroscopy during the operation and with CT scan after the operative procedure. The osteosinthesis has been performed with cannulated screws and In more complex cases the reduction has been achieved and maintained with ileo-femoral external fixation (ligamentotaxis technique).
Fractures were classified according to AO classification. Clinical and functional results have been evaluated according to Harris Hip Score on the base of post-operative CT scan and on x-ray films at last follow-up.
According to our experience the use of external fixation in the treatment of acetabular fractures must be reserved for very selected cases in which for general or local condition the joint the distraction associated with minimal internal fixation can guarantee good reduction and fracture stability avoiding the poor results of conservative treatment or the risk of major complications related to ORIF. The best reduction can be achieved when the treatment is carried out early while the best stability is achieved with the association of percutaneous cannulated screws. The use of external fixation has never compromised the range of movement of the hip.
Injuries to the spinal cord are rarely isolated problems. Multiple trauma patients with spinal injuries can face significant long-term disability. In this retrospective, descriptive study we investigated the relationship between the level of spinal trauma and the injuries associated with this. We aimed to define the populations at risk and highlight trends identified.
LC II- 11 excellent, 6 good, 8 fair, 5 poor; LC III- 0 excellent, 2 good, 0 fair, 0 poor; APC I- 5 excellent, 2 good, 1 fair, 0 poor; APC II- 14 excellent, 5 good, 3 fair, 0 poor; APC III- 3 excellent, 0 good, 4 fair, 1 poor; VS- 5 excellent, 2 good, 3 fair, 0 poor; CMI- 9 excellent, 7 good, 7 satisfactory, 4 poor,
From the appearing of the first works of R. Judet, E. Letournel, M. Tile up to this day, the methods of pelvic surgery changed cardinally. These operations are technically complicated and accompanied by blood loss. That’s why the low-invasive surgical methods including endoscopic approach are perspective.
The endoscopic methods of reposition and osteosynthesis offer advantages which are expressed in increasing of injury visualization, reduction of surgical incisions and fast postoperative restoration. A surgeon using the method of osteosynthesis needs endoscopic skills and thorough knowledge of standard surgical approaches.
We have the experience of the treatment of 12 patients. We consider that the indications for these operations are not only a type of pelvic injury, but also anatomico-technical moment: an opportunity of creating of workspace.
We have 2 techniques:
endoscopic osteosynthesis with using of pelvioscope; optical endoscopic osteosynthesis.
In any case, it is necessary to create the workspace from a small incision above the injury region by the method of tissue pneumotization. Fracture reposition is realized using a fracture table and reducing attachments. Osteosynthesis is immediately carried out with both standard and original steel constructions using the special tools that we developed and produced (ports, drill, screwdrivers etc.). The intraoperative blood loss was not more than 150 ml in all cases and in the postoperative period in drains–not more than 100 ml. The promotion of the patients was realized by the standard methods. There were no complications. The good functional result was in all cases.
We think that further development of such techniques will allow to activate pelvic surgery on the new qualitative level.
The treatment of the patients with severe injuries of pelvis in polytrauma must be realized in special clinics, with necessary equipment and specially prepared nursing. Treatment tactics depends on the severity of common state and on the severity of pelvic injuries.
Without thromboprophalaxis, the recorded incidence of deep venous thrombosis (DVT) in pelvic fracture varies between 35% and 61%. The incidence of pulmonary embolism (PE) is reported to be 2–10% and death subsequently occurs in 0.5–4% of patients. With preventative measures the incidence of clinically significant DVT has been reported as low as 0.5%. The primary aim of this study is to look into the efficacy of Enoxaparin in preventing clinically significant DVT and PE in patients with pelvic and acetabular fracture. The secondary aim is to investigate the effect of prolonged pre-operative exposure to Enoxaparin on operative and post-operative bleeding. Sixty-four patients with pelvic and acetabular fractures were reviewed retrospectively between 2000–2005. Patients with coagulopathies were excluded. 40mg Enoxaparin was administered daily following haemodynamic evaluation and continued thereafter until discharge. Blood loss was measured using 3 indicators: volume of blood transfused, difference in pre and post operative Hb, and amount of blood collected in surgical drains. The incidence of clinically significant DVT was 2.9% (2 cases). There was no confirmed incidence of PE. 47% of patients were operated on within a week of admission (Group A), 40% within 1–2 weeks (Group B) and 13% in over 2 weeks (Group C). The group with the most prolonged pre-operative exposure to Enoxaparin: Group C, required the least transfused blood (A: 4.8units, B: 2.0units C: 1.3units), bled the least into drains (A:310ml, B:253ml and C:212ml) and had the smallest post-operative fall in Hb (A:2.2, B:2.0, C:1.9). The low incidence of clinically detectable DVT in the study confirms that Enoxaparin is an effective method for reducing the incidence of significant thrombotic events. Prolonged pre-operative administration of Enoxaparin does not pre-dispose patients to an increased risk of operative and post-operative bleeding.
We identified femoro-acetabular impingement as a source of pain, which promptly disappeared after surgical off-set restoration.
In 6 patients the clinical examination and the rx could demonstrate femoro-acetabular impingement. In four cases this was due to anterior osteophytes of the femoral neck, in two cases it was due to retroversion of the femoral implant. These 6 patients were revised.
The idea of resurfacing the femoral head instead of removing it has been attractive for a long time.
Unfortunately the results have been invariably poor if compared with contemporary available conventional hip prosthesis. In the last decade metal on metal technology with very accurate manufacturing made hip resurfacing a viable option. The main complication of this operation is early failure due to femoral neck fracture. This event is still incompletely understood and probably multi-factorial. Accurate placement of the femoral component to avoid notching the femoral neck, cementing technique to avoid over-penetration of the cement, small implantation forces and careful soft tissue handling to minimize the damage to the bone vascularity are thought to be the main issues. The ideal candidates for this operation are young and active patients because they have good bone quality and will take advantage of the improved performances that hip resurfacing can offer.
Unfortunately young men are also the group of patients at higher risk for the formation of heterotopic ossifications.). To prevent this complication radiotherapy was administered in a single dose of 6 Gy with two opposite fields of 18 MV generally the first post operative day. When we started to perform hip resurfacing we did not consider changing our protocol. Between March 2004 and May 2005, 55 hip resurfacings were performed using the ASR implant (DePuy) by a single surgeon (LM). Most males under the age of 60 received radiotherapy. There were 4 femoral neck fractures in the 23 male patients who received radiotherapy (17.3 %) and 1 fracture in the 32 patients who did not receive radiotherapy (3.1 %, Chi-square test: p= 0.07). All the fractures occurred between the 90th and the 120th postoperative day. No fractures were reported in the 12 women included in this study. What arouse our attention was the unacceptably high number of femoral neck fractures. The learning curve alone could not explain what was happening. At first the radiotherapy was not considered at all as factor but errors in the surgical technique were looked for. The clue came from the observation that there were no women in the fracture group in spite of the fact that the surgical technique was the same and also in spite of the fact that women should be at higher risk due to poorer bone quality as shown in the literature. This led us to check the incidence of fractures in the radiotherapy and in the non radiotherapy group. At this stage things became quite clear. Subsequently the histology of the specimen was re-examined with regard to this factor. Bone necrosis of the femoral head in the patients who underwent radiotherapy was much more pronounced then in other failures which show different degrees of necrosis. In conclusion there are strong indications that radiotherapy of the femoral head should not be performed in combination with hip resurfacing.
At more than 15 years follow-up, the mean PMA hip functional score was 17.1. 66% of the hips was A, 4% were B and 30% were C according to the Charnley’s score. Of the 164 hips in the patients who had survived at least 15 years, 28 had femoral osteolysis in zone 7, and 31 had femoral osteolysis in one (or more) of the other 13 zones. 6 hips had an impingement sign on the neck of the femoral component, without aseptic loosening.
According to Kaplan-Meier analysis, the fifteen year survival rate, was 84.36% with revision for any reason (infection, dislocation, osteolysis…) for end point. The young age of the patients at the time of the index surgery is correlated with loosening.
The topic of this study was to research the survival rate of ATLAS hip prosthesis (acetabular cup) performed by one operating surgeon only and with a minimum of 10 years follow up.
Each patient was contacted by phone to find out if the prosthesis was still in place or whether a new operation had been performed. For the deceased patients, the family or the usual doctor were contacted by phone to answer the question with a maximum of details.
The non-parametric survival rates were performed using the actuarial method according to Kaplan-Meier. The results were given with a reliability rate of 95%. The PRISM program was used.
32 patients had undergone a revision: 23 due to the cup: there were 15 cases of wear of the polyethylene, 4 osteolysis, 3 cases of recurring dislocation and a secondary tilt of the cup, 5 cases of acetabular and femoral revision for 4 femoral loosening (change of cup by principal) and 4 cases of revision of the femoral components only.
The survival rate of the global series of 297 ATLAS (coated and non coated with hydroxyapatite) taking into consideration only the revisions due to the acetabular cup (wear of polyethylene, wrong position) was evaluated at 90% after 10 years and 85,5% after 15 years.
The results were better for the ATLAS III coated in hydroxyapatite: 92,3% after 10 years and 88,4% after 14 years, which confirms the advantages of this surface treatment. In this series, the revision rate for wear of the polyethylene was less important (3%)
With a maximum of 17 years follow up no mobilisation of the insert in the cup had been observed and no metallosis.
The rate was higher for the ATLAS III coated with hydroxyapatite: 92,3% after 10 years and 88,4 % after 14 years, which confirmed the advantages of this surface treatment.
The short stem titanium prothesis preserves the femoral neck. No reamer and no rasp is used for the implantation. Two times compression of the bone with a compressor and with the prothesis it self continues the principle of bone retention.
Preserving the femoral neck and compression of the bone lead to an high anchorage and the best primary stability. This is mandatory for safe osseo integration.
Except metal on metal all combinations are suitable. Deltaceramic-Deltaceramic is the most modern possibility.
The high anchored short-stemp leaves enough virgin-bone for any standard prothesis in case of later revision. In 1999 implantation of CFP Prothesis was started in the Endoklinik-Hamburg. Until 2005 2500 prothesis were implanted. A five year follow up of the first hundert cases does not show system corellated failures. An overview of 2400 implants shows a revision rate of 1%. Total exchange procedure was necessary in 8 cases because of deep infection (0,33%). Only very few none fixed stems and cups had to be reviced.
Minimal invasive surgery is well suitable. In our clinic we prefer the posterior aproach.
With six sizes left and right nearly all tipe of bone shape is covered.
Extreme varus or valgus hips are not indicated as well as severe deformaties.
The CFP Prothesis is an good alternative to the CUP Prothesis especially for the young patients with femoral head necrosis which we see in about 10%.
A five year follow up is only really interessting if it has bad results, with goog results it gives us confidence to wait for the ten year results.
The initial diagnosis was primary coxarthrosis in 63, rheumatoid arthritis in 10, congenital dislocation of the hip in 5 and necrosis of the femoral hed in 3.
In all cases the cementless Alloclassic stem was used, as bearing material metasul was implanted in 73 and ceramic-polyethylene in 8 cases.
The preoperative Harris hip score was 53,13 pts (23–73), the postoperative score after 10 years 96,5 (78–100).
Radiographic evaluation after 10 years showed no lucencies in 78 of 81 jpints. 3 hips had a lucent line of 1mm in zone III. We detected no signs of osteolysis, loosening or migration.
No reoperations for any reason exept 2 septic cases have been performed yet.
362 revision and 920 primary THA were performed with a minimal of 5 years follow-up in the Orthopaedic Department of Amiens University Hospital with modular necks.
The hips operated before 1985 were 14. The patients were 10, in 4 cases the operation was bilateral. There were 9 females and 1 male. The average age of the patients at the time of the operation was 19.3 years. All the patients had a DDH without X-ray signs of osteoarthritis and had a mild or absent pain. In 9 cases the isolated periacetabular osteotomy was performed and in 5 cases a femoral varus osteotomy was associated at the same time. The osteotomies were Wagner type I in 12 cases and Wagner type III in 2 cases.
We always used a Smith-Petersen approach. The periacetabular osteotomy was made by special spherical chisels of different diameter under X-rays control. The fixation of the osteotomy was made in 8 cases according to the original technique with a special double horn plate fixed by screws to the ileum and in 6 cases only with the help of Kirsches wires, as actually we prefer.
10 cases with a clinical and X-ray follow-up longer than 20 years have been controlled. 4 cases are lost to follow-up. Occurrence and type of pain, walking, limp, range of motion were evaluated. Wiberg CE angle, signs of osteoarthritis and centre of rotation of the head are observed on the X-rays.
We developed fast and easy-to-use computer software to perform three-dimensional (3D) analysis of the individual hip joint morphology using two-dimensional (2D) AP pelvic radiographs. Landmarks extracted from the radiograph were combined with a cone beam x-ray projection model and a strong lateral pelvic radiograph to reconstruct 3D hip joints. Twenty-five parameters including quantification of femoral head coverage can be calculated for a neutral orientation. The aim of the study was to evaluate the validity of this method for tilt and rotation correction of the acetabular rim and associated radiographic parameters.
External validation; internal validation; and intra-/interobserver analysis.
A series of x-rays of 30 cadaver pelves mounted on a flexible holding device were available for step 1 and 2. External validation comprised the comparison of radiographical parameters of the cadaver hips when determined with our software in comparison with CT-based measurements or actual radiographs in a neutral pelvic orientation as gold standard. Internal validation evaluated the consistency of the parameters when each single pelvis was calculated back from different random orientations to the same neutral pelvic position. The intra-/interobserver analysis investigated the reliability and reproducibility of all parameters with the help of 100 randomized, blinded AP pelvic radiographs of a consecutive patient series.
All but one parameter (acetabular index) showed a substantial to almost perfect correlation with the CT-measurements. Internal validity was substantial to almost perfect for all parameters. There was a substantial to almost perfect reliability and reproducibility of all parameters except the acetabular index.
Improvement in coverage achieved by double or triple osteotomies is limited by the size of the acetabular fragment and the ligaments connected with the sacrum. Correction is achieved with the notable asymmetry of the pelvis. In periacetabular Ganz osteotomy (PAO) the acetabular fragment has no connection with the sacrum, which creates enormous possibilities for correction, leaving the pelvic ring untouched.
The aim of the study is to present our experience and early results of using PAO in the treatment of hip dysplasia in adolescents and young adults who were previously treated operatively in childhood, and to find the technical and clinical impact of previous operations on our Results: In the years 1998–2005 262 periacetaubular osteotomies were performed in our hospital. All the patients were operated by one surgeon (JC). From this group 41 patients (43 hips) had previously been operated in childhood for the treatment of hip dysplasia. The previous treatment consisted of: open reduction in 10 hips, DVO in 14 hips, pelvic osteotomy (Salter, Dega, Chiari) in 8 hips, combined: open reduction+DVO+pelvic osteotomy in 10 hips, greater trochanter transfer in 3 hips, bone lengthening in 4 hips, acetabular cyst removal in 1 hip. The age at the primary operation ranged from 1–20.. The follow-up period ranged from 1–7,5 ys av. 2 ys.
In 31 hips the Smith-Petersen, and in 12 hips ilioinguinal approach were performed.
We find the technique of PAO as a safe, and effective tool for treating hip joint pathology increasing treatment possibilities for hip joint preservation.
Periacetabular osteotomy (PAO) is a well established method to treat hip dysplasia in the adult. There are, however, a number of complications associated with this procedure as well as a time related deterioration in the grade of osteoarthritis that can influence the long term result. It is essential that patients are fully informed as to the effectiveness of PAO, the likelihood of complications and their influence on the subjective outcome prior to giving consent for surgery. Generic outcome measures offer the opportunity to determine treatment efficacy and the influence on the outcome by complications.
60 PAOs on 50 patients were investigated retrospectively after a mean follow up of 7.4 years. The patients’ self reported assessment of health and function was evaluated by the SF-36 and the WOMAC questionnaires at last follow-up. 40 healthy persons served as a control group.
The centre-edge angle improved from a mean of 8.7° to 31.5°. The weight bearing surface improved from a mean lateral opening of 8.7° to 4.2°. The degree of osteoarthritis improved in one case, remained unchanged in 20 and deteriorated in 17. There was a tendency of higher CE-angles towards a higher rate of deterioration, indicating that overcorrection may increase osteo-arthritic degeneration. 13 of the 60 interventions had no complications. Minor complications occurred in 25 (41%) interventions and in 22 (37%) at least one major complication occurred. SF-36 summary measure was 76.4 for PAO patients and 90.3 for the control group. Mean WOMAC score was 25.1. The severity of ectopic bone formation, incidence of postoperative peroneal nerve dysfunction and delayed wound closure did not influence the subjective result. Patients with major complications had a similar subjective outcome as patients with minor or no complications, but persistent dysesthesia due to lateral femoral cutaneous nerve dysfunction led to a worse subjective function as assessed with the WOMAC score.
For the prevention of premature osteoarthritis of the hip, the periacetabular osteotomy (PAO) of Ganz has become a common procedure. Though being a powerful method for obtaining large correction angles its drawback is the need for a broad exposure, resulting in more or less disfiguring scars. We modified the surgical approach to PAO by using two small skin incisions and reduced the extent of deep exposure by leaving the rectus femoris tendon in place and avoiding larger peri-articular deep soft tissue release.
The aim of this study is, to compare the early clinical and radiographic results of this less invasive approach with the conventional Smith-Peterson approach.
Finite element (FE) analysis is widely used to calculate stresses and strains within human bone in order to improve implant designs. Although validated FE models of the human femur have been created (Lengsfeld et al., 1998), no equivalent yet exists for the tibia. The aim of this study was to create such an FE model, both with and without the tibial component of a knee replacement, and to validate it against experimental Results: A set of reference axes was marked on a cleaned, fresh frozen cadaveric human tibia. Seventeen triaxial stacked strain rosettes were attached along the bone, which was then subjected to nine axial loading conditions, two four-point bending loading conditions, and a torsional loading condition using a materials testing machine (MTS 858). Deflections and strain readings were recorded. Axial loading was repeated after implantation of a knee replacement (medial tibial component, Biomet Oxford Unicompartmental Phase 3). The intact tibia was CT scanned (GE HiSpeed CT/i) and the images used to create a 3D FE mesh. The CT data was also used to map 600 transversely isotropic material properties (Rho, 1996) to individual elements. All experiments were simulated on the FE model. Measured principal strains and displacements were compared to their corresponding FE values using regression analysis.
Experimental results were repeatable (mean coefficients of variation for intact and implanted tibia, 5.3% and 3.9%). They correlated well with those of the FE analysis (R squared = 0.98, 0.97, 0.97, and 0.99 for axial (intact), axial (implanted), bending, torsional loading). For each of the load cases the intersects of the regression lines were small in comparison to the maximum measured strains (< 1.5%). While the model was more rigid than the bone under torsional loading (slope =0.92), the opposite was true for axial (slope = 1.14 (intact) 1.24 (implanted)) and bending (slope = 1.06) loads. This is probably due to a discrepancy in the material properties of the model.
The aim of this study is to identify the incidence of mal-rotation of TKR components in a group of patients with unexplained knee pain identified from the University of Dundee joint replacement database and compare that group with a group of painless TKRs
38 of 45 NexGen LPS Total Knee Replacements identified with unexplained pain at a minimum of 1 year following surgery underwent CT scanning to determine rotational alignment. All patients had a Knee Society Pain score of 20 points or less and a mean Visual Analogue Pain Score of greater than 4.0. This group was compared with a control group of 26 TKRs all of which had never reported pain from 1 year post surgery.
In the painful group mean femoral component rotation was 2.2° of internal rotation (range 8.8°IR to 3.9°ER, sd 3.6, SEm 0.59) compared to 0.9°IR (range 6.9°IR to 6.8°ER, sd 3.39, SEm 0.67) in the painless group (p= 0.15). In the painful group 21.6% of femoral components were more than 6° internally rotated compared with 7.7% in the painless group however this was not statistically significant (p=0.18). No femoral components in either group were in excessive (over 8 degrees) ER.
Tibial component rotation was much more variable than femoral component rotation in both groups particularly in the painful group. Mean tibial component rotation was 4.1°IR (range 37.9°IR to 31.1°ER, sd 14.6, SEm 2.4) in the painful group compared to 2.2°ER (range 8.5°IR to 18.2°ER, sd 6.95, SEm 1.36) in the painless group (p=0.024). 15 tibial components (39.5%) were greater than 10° internally rotated in the painful group whilst no tibial components were more than 10° internally rotated in the pain free group (p< 0.001). In the painful group 7 tibial components (18.4%) were more than 10° externally rotated whilst 4 (15.4%) were in more than 10° ER in the painless group (p=1.00). Overall 22 tibial components (57.9%) were in more than 10° of malrotation in the painful group compared with 4 (15.4%) in the pain free group (p=0.05).
Mean rotational mismatch between femoral and tibial components was 1.9° tibial IR (range 39.7° tibial IR to 35.1° tibial ER, sd 16.1, SEm 2.7) in the painful group whilst in the painless group mean rotational mismatch was 3.1 degrees tibial ER (range 10.3° tibial IR to 22.1° tibial ER, sd 8.4, SEm 1.65). This difference was not significant (p=0.12). 16 TKRs (55.3%) had rotational mismatch of more than 10° in the painful group compared to 7 (26.9%) in the control group (p=0.02).
We conclude that rotational malalignment is frequent in painful total knee replacements and may be a major cause of pain after TKR. In particular tibial internal rotation is the most frequent alignment error in the painful TKR and appears to play a major role in the aetiology of pain after TKR.
In addition, we measured ankle and brachial pressures in a separate group of 39 patients with the limb in three different positions: flat with the knee in extension (ABPI 1), raised with the knee in extension (ABPI 2), and finally with the knee flexed to 90° (ABPI 3).
ABPI measurements were calculated in the standard fashion, the mean ABPI in each limb position being 1.17 (ABPI 1), 0.87 (ABPI 2) and 0.83 (ABPI 3) respectively.
In this prospectively randomized study, we compared the changes in the range of motion (ROM) in posterior cruciate ligament-retaining (PCLR) (n=50) and -sacrificing (PCLS) (n=50) total knee arthroplasties during the perioperative period. The median ROM in PCLR prostheses was 122.5° preoperatively, 120.0° intraoperatively, and 100.0° at discharge, and 115.0°, 120.0°, and 95.0°, respectively, in PCLS. The designs did not differ statistically in each period (p> 0.05). Both designs showed significant correlations between the preoperative and intraoperative ROM, and between the preoperative and discharge ROM. Only the PCLS showed a significant correlation between the intraoperative and discharge ROM. Since the PCL tenses with flexion, the degree of preoperative degeneration, intraoperative recession, and postoperative tension of the PCL may have played a major role in the results. The PCLS design has an advantage in rehabilitation planning because of the predictable changes in the ROM during the perioperative period, although the acquired average ROM at discharge did not differ statistically.
In the clinical trial, 58 consecutive patients undergoing total knee arthroplasty were included. After a routine exposure the AP axis was marked on each distal femur. The AFCL was then identified and the anterior femoral cortical cut was made parallel to this line. The angle between this cortical cut and the perpendicular to the AP axis was measured using a sterile goniometer.
In the MRI study, 50 axial knee images were assessed and the most appropriate slice/s determined in order to identify the AFCL and the other 3 reference axes and then their relationship was measured by an on-screen goniometer.
By MRI and with respect to the epicondylar axis, the AFCL was a mean 5° externally rotated (SD= 3), White-side’s Line was 1° externally rotated (SD = 2) and the posterior condylar axis was 3° internally rotated (SD = 2).
In the clinical study in 8 patients it was impossible to draw the AP axis because of dysplasia or destruction of the trochlea by osteoarthrosis. In the remainder the mean difference between the anterior femoral cortical line and Whiteside’s AP axis was 4.1 degrees internally rotated (SD = 3.8°). The lateral release rate for this cohort was 4%.
Conclusion: The anterior femoral cortical line provides an additional reference point, completing the ‘compass points’ around the knee. It has been shown in this study to be reliable in the laboratory, on MRI and in a clinical setting for assessing rotation of the femoral component. It may prove particularly useful when one or all of the other reference axes are disturbed such as in revision TKR, lateral condylar hypoplasia or where there has been previous epicondylar trauma.
No release–MFT angle not less than −12° with varus stress, greater than 2° with valgus stress, and/or if extension deficit was not greater than 5°. Moderate release–MFT angle less than −12° with varus stress, between −5° and 2° with valgus stress, and/or extension deficit not greater than 5°. Proximal release–MFT angle less than −12° with varus stress, less than −5° with valgus stress, and/or extension deficit greater than 5°.
Results: Pre-operatively, the mean MFT angle was −9.6°varus (−3° to −22°) with varus stress and −0.8°varus (4° to −11°) with valgus stress. Post-operatively, the mean MFT angle was −3.5° varus (0° to −5°) with varus stress, and 2.1° valgus (4° to −1°) with valgus stress.
Using regressional analysis, there was a strong linear correlation between both varus (r=0.871, p< 0.0001) and valgus (r=0.894, p< 0.0001) stresses and the MFT angle.
Post-operatively, the mean MFT angle was maintained within a narrow range (0° to −5° with varus stress, 4° to −1° with valgus stress), with no outliers. There were no extension deficits.
Templating of preoperative radiographs is routinely recommended prior to knee arthroplasty. We performed this study to assess the reproducibility and accuracy of the templates for three commonly used knee implants (PFC, Kinemax, Scorpio). Six lower limb surgeons templated 10 patients for each of the three designs. The inter and intra-observer reliability and accuracy was calculated. There was marked variation in the reliability of the templating with the tibial insert scoring better than the femoral and the Kinemax being the most reproducible of the three. In general, the intra-observer scores (κ= 0.57–0.81) were better than the inter-observer ones (κ= 0.21–0.60). The Scorpio was the most accurately templated of the three implants, with the percentage correlating with what was actually implanted ranging from 55–62% for the femur and 72–75% for the tibia, with no templated sizes more than 1 size different from the actual implant. The other implants ranged from 38–42% for the femur and 53–58% for the tibia with both having up to 3% more than 1 size difference from the actual implant. We believe that the use of templating in total knee arthroplasty should be interpreted with caution and we urge the development of more accurate prosthesis sizing techniques.
A subvastus approach was used with a less than 10 cm incision. Femoral component alignment is established with an intramedullary, and the tibial component, with an extramedullary alignment guide. The navigation system was used for fine adjustment and verification of cutting block position. The navigation system used for the study was the VectorVision® CT-Free Knee 1.5.1.
Range of movement was correlated with extent of soft tissue release, to see if release had any impact on increase in range of movement.
Patients requiring extensive releases tended to have less preoperative ROM, but the gain was independent of medial release. Those requiring extensive posterior release had poorer preoperative movement, and significantly less improvement.
In those requiring an extensive medial release, a posterior release improved gain in ROM.
There is interest to provide total knee arthroplasty (TKA) patients large ranges of functional knee flexion. Factors contributing to flexion include a posterior femoral position on the tibia, posterior condylar offset, and posterior tibial slope. These factors can be incorporated into implant designs and surgical techniques. It is useful to assess the robustness of the resulting design, that is, the consistency of kinematic or functional results when patient and surgical factors vary widely. This study evaluates in vivo flexion performance of a single implant design in patients whose posterior cruciate ligament (PCL) was either retained or sacrificed.
28 knees in 20 patients were imaged using fluoroscopy during maximum flexion kneeling and lunge activities. 20 knees (12 patients) received TKA with the PCL retained by a bone block (PCL+ group). Eight knees (7 patients) received TKA with complete PCL resection (PCL- group). All knees received a fixed-bearing TKA (3D Knee™, Encore Medical, Austin, TX) with an asymmetric tibial bearing having a sagittally curved medial compartment and a lateral compartment fully congruous with the lateral condyle in extension (approximating anterior cruciate ligament substitution). Three-dimensional knee kinematics were determined using model-based shape registration techniques.
For the kneeling activity, mean implant flexion was 124°±11° for PCL+ knees and 121°±17° for PCL- knees (p> 0.05), mean tibial internal rotation was 10°±4° for PCL+ knees and 9°±3° for PCL- knees (p> 0.05) and tibial valgus was −1°±1° for PCL+ knees and 2°±4° for PCL- knees (p=0.003). Medial contact location averaged −2±4mm and for PCL+ knees and −1±2mm for PCL- knees (p> 0.05). Lateral contact location averaged −10±4mm for PCL+ knees and −7±1mm for PCL- knees (p> 0.05). For the lunge activity, mean implant flexion was 120°±11° for PCL+ knees and 121°±21° for PCL- knees (p> 0.05), mean tibial internal rotation was 11°±4° for PCL+ knees and 8°±3° for PCL- knees (p> 0.05) and tibial valgus was −1°±1° for PCL+ knees and 2°±2° for PCL- knees (p=0.0002). Medial contact location averaged 0±4mm for PCL+ knees and −4±3mm for PCL- knees (p=0.04). Lateral contact location averaged −8±4mm for PCL+ knees and −9±4mm for PCL- knees (p> 0.05).
There was no difference in implant flexion between PCL retaining and sacrificing TKA. Both groups had knees with more than 145° implant flexion (~155° skeletal flexion). There were no significant differences in tibial rotation or lateral condylar contact locations. There were differences in tibial valgus for both activities. PCL- knees exhibited a tendency for the medial compartment to ‘book open’ with flexion beyond 130°, consistent with loss of PCL function. Based on this small cohort comparison, it appears that robust flexion performance and knee kinematics can be obtained with a fixed-bearing TKA design.
Femoral intramedullary canal referencing is utilized by most of the total knee arthroplasty (TKA) systems. Violation of the canal is performed in order to engage rod instruments in the femoral diaphysis and to refer of the anatomical axis of the femur. Fat embolism, activation of the coagulation cascade, and bleeding may occur from the reamed femoral canal. The purpose of our study was to validate a new set of _minimally-invasive friendly_ instruments which allow to prepare the femur without violating the intramedullary canal. Twenty-five consecutive patients undergoing primary TKA through a mini-subvastus approach were enrolled in the study after informed consent had been obtained. Results of this cohort (group 1) were compared to another contemporary group (group 2) of 25 TKAs operated by the same surgeon using intramedullary instruments. The two groups were matched for gender, deformity, degree of arthritis, and surgical approach. Reliability of the new extramedullary set of instruments was first tested in ten cadaveric limbs. Preoperative long weight-bearing AP and lateral view of the knee were obtained taking care of neutral limb positioning. Template of the mechanical and anatomical axis were performed. Distal femoral resection was planned according to the template, and considering a bone cut perpendicular to the mechanical axis of the femur. Measurement from the template were reproduced on the distal femoral cutting jig. Flexion-extension control of the distal femoral resection was obtained using the anterior meta-diaphyseal cortex reference. Depth of resection, and varus-valgus angulation were selected according to the previous measurements and referring over the most prominent distal femoral condyle. A double check was performed using an extra-medullary rod referring two and a half finger-breaths medially to the antero-superior iliac spine. Postoperative blood loss, pain, swelling, functional recovery, and complications were recorded. Radiographic alignment was measured with long film. Mechanical axis was within 0±2° in 88% of group 1 and 84% of group 2 (p> 0.05). There were no difference between the two groups regarding the operative time. In group 1, postoperative blood loss (740 vs 820 mL) was reduced but this difference did not reach the statistical significance (p=0.07). No difference was found in terms of postoperative pain, knee swelling, and functional recovery. Extramedullary reference with careful preoperative templating can be safely utilized during total knee arthroplasty. Avoiding the violation of the femoral canal may enhance the benefits of a less invasive approach.
Soft tissue balancing is an important factor in the success outcome of TKA, but if extensive can necessitate the use of thicker tibial inserts. This may alter the position of the patella in relation to the tibia and increases the risk of creating a pseudo-patella baja.
TKA surgery creates a Pseudo-Patella Baja. Excluding patients with a pre-operative patella baja, pseudo patella baja was introduced into 25.6% of patients. (p=0.00). Extensive soft tissue releases during TKA are associated with a 100% increased in the incidence of pseudo patella baja compared to more moderate soft tissue releases. (p=0.002). The use of large tibial inserts is associated with a significant increase in the incidence of pseudo-patella-baja, compared to smaller inserts. Three groups were identified: Small Inserts 8 mm, Medium inserts 10–12mm, and Large inserts 15, 18 &
22 mm. (p=0.042). There was no correlation between the incidence of a pseudo-patella baja and changes in clinical or functional outcome, including range of motion, as measured using the OKS and AKSCRS.
Since 1996 over 400 isolated patellofemoral replacements using the Avon prosthesis have been undertaken in Bristol. As a result of the usually gratifying outcomes seen in patients over 55 years old, the indications for this surgery were soon extended to include the many younger patients who have severely disabling patellofemoral disease. We present results from a prospective cohort study of patients under 55 years of age at the time of surgery.
110 knees in 86 patients (median age 47 years, range 24–54) have been treated with Avon patellofemoral replacement (88 in females and 22 in males). Diagnoses included lateral facet OA (59 knees), patella dislocation (25 knees), trochlear dysplasia (41 knees) and post patellectomy instability (7 knees). 79 knees had undergone previous surgery. 17 knees required additional intra-operative procedures including 11 lateral releases and 2 patella realignments. All patients were assessed pre-operatively and at regular intervals using the Oxford, Bristol and WOMAC scores.
All knees were scored preoperative and only one knee has been lost to follow-up due to the patient’s death, which was unrelated to surgery. Post-operative Oxford knee scores have been obtained for 106 knees with follow-up between 8 months and 8 years (mean follow-up 24 months). The mean Oxford score improved from 18 preoperatively to 31 at latest review. Bristol and WOMAC scores showed similar improvements. 16 knees required post-operative additional procedures including 6 lateral releases, 3 patella realignments and 11 revisions. Of the revisions 5 were for progression of tibiofemoral OA but none of these were knees with trochlear dysplasia. Equally good mean scores were seen when comparing patients with the 3 main underlying pathologies (trochlear dysplasia, patellar dislocation and lateral facet OA). At least 37% of the patients studied had pre-existing trochlear dysplasia and the majority of these patients report onset of symptoms, often patellar dislocation, in the first three decades of life. More than 90% of patients were overweight or obese according to their BMI at the time of surgery.
Many of this type of patient, with disabling symptoms, wish to “live now”. The short-term improvements are frequently dramatic. As yet there is no suggestion of prosthetic failure. Revision presents little difficulty since minimal bone is resected in the primary proceedure. Radiological deterioration of the tibio femoral joint is seen in some cases of primary OA but not with trochlear dysplasia.
Patients were clinically assessed for 2 years using the Knee Society Score (KSS). At final follow-up patients were assessed once using two accelerometer based motion tests (Dynaport Knee Test and Minimod Gait Test; McRoberts, Netherlands). The knee score is composed of four sub scores (Locomotion, Rise & Descend, Transfers, Lift & Move). The gait test records walking parameters such as step frequency, length and speed plus various parameters of step asymmetry, irregularity and efficiency. Statistical analysis was performed using the van Elteren’s test (KSS data) and a stratified regression analysis (Dynaport and Minimod data)
The Dynaport knee test showed a significant functional advantage for patella resurfacing (RS=44.1+/−12.1, NR=39.7+/−19.2, p=0.04). The sub score Rise & Descend showed the largest advantage for patella resurfacing (RS=44.7, NR=39.7, p=0.04). The other sub scores also favored resurfacing but were not significant. The Minimod Gait test favoured RS in most parameters but at non-significant levels.
The advantage of patella resurfacing may be less due to pain relief but due to a functional benefit during demanding motion tasks for which standard clinical scores and low demanding tests do not account for sufficiently and objectively enough. We recommend complementing the classic evaluation tools with demanding functional tests.
There is an increased early postoperative mortality (operation risk) after joint replacement surgery. This mortality is normally associated with cardiovascular events, such as deep venous thrombosis, pulmonary embolism, and ischemic heart diseases.
Our objective was to quantify the magnitude of the increased mortality and how long the mortality after an operation persists.
We focused on the early postoperative mortality after surgery for total knee and total hip replacements from the national registries in Australia and Norway, which cover more than 95% of all operations in the two nations. Only osteoarthritis patients between 50 and 80 years of age were included. A total of 244.275 patients remained for analyses.
Smoothed intensity curves were calculated for the early postoperative period. Effects of risk factors were studied using a non-parametric proportional hazards model.
The mortality was highest immediately after the operation (~1 deaths per 10.000 patients per day), and it decreased until the 3rd postoperative week. The mortality was virtually the same for both nations and both joints. Mortality increased with age and was higher for males than for females.
A possible reduction of early postoperative mortality is plausible for the immediate postoperative period, and no longer than the 3rd postoperative week.
Radiologically, the humeral offset, the lateral gleno-humeral offset (coracoid base to the greater tuberosity) as well as the acromiohumeral distance were significantly increased. No intra-or postoperative complications encountered.
- patients below the age of 70, in order to avoid complications of the reverse prosthesis - patients with still a goof active range of motion
Starting in the 1970s, long-term survivorship of total hip and knee arthroplasty has been under investigation for the Scandinavian population with the aid of implants registries. In the United States, no national arthroplasty registry currently exists. Nationwide inpatient discharge databases in the United States have proven useful when comparing the revision burden in the United States and Scandinavia. For this study, we compared the implant survivorship in the Medicare population with contemporaneous registry-based data from well-established and validated Scandinavian arthroplasty registries. The 5% systematic sample of Medicare claims from 1997 to 2004 were examined for primary and revision THA and TKA claims. The Medicare beneficiary ID was used to follow patients longitudinally between primary and revision surgery. De-identified data from the Norwegian and Swedish national hip and knee registry were also obtained for the same time period. During the 8-year study period, 30,583 and 62,878 elective primary total hip or knee replacements, respectively, were extracted from the Medicare data. In the same time period, 41,823 and 15,927 primary total hips or knees replacements were identified from the Norwegian registry. 82,037 primary total hips were identified from the Swedish registry. Survivorship was assessed by the Kaplan-Meier method, and Cox regression was used to evaluate the effect of patient attributes and cross-country comparisons. The K-M estimate showed that 8 years post-primary surgery, 93.6% of THA and 96.2% of TKA remained revision-free among the elderly Medicare population. By comparison, among Norwegians aged 65 and above, 96.0% of THA and 93.6% of TKA remained revision-free. In the US, men had a significantly higher risk of knee revision than women, but no significant gender difference among hip revision. In Norway, men had a significantly higher risk of hip revision, but no differences in knee revisions. In Sweden, men had a significantly higher risk of hip revision (5.4% vs. 3.3%). Older patients had a reduced risk of revision as compared with younger patients, in both the US and in Norway. The survival of THA is significantly better in Norway than in the US with a hazard ratio of 1.64 (p< 0.05). On the other hand, TKA had a better survival experience in the US than in Norway, with a hazard ratio of 0.55 (p< 0.05). This is the first study to evaluate the utility of Medicare as a source of THA and TKA survivorship data and to compare prosthesis outcomes in Medicare with those from Scandinavian arthroplasty registries. Unlike the Norwegian and Swedish registry data, the reasons for revision (e.g., femoral loosening) are not captured and thus greatly limited the value of the Medicare data as a tool to understand the need for revision, thereby helping to improve implant longevity and to reduce the associated cost and burden to the patient and care provider.
In OA patients, satisfaction was highest, but function was poor. Patients with out cuff tear pre-operatively did not develop it later. They may thus benefit from a TSR compared to HHR. RA patients had the least pain, best function and high satisfaction. Most had evidence of either primary or secondary cuff dysfunction. In them patients HHR may be the preferred option. Trauma patients did poorly in all respects. More anatomical reconstruction and greater emphasis on salvage of the humeral head is required in this group.
Cyclic loading was performed, as it was considered the best way to simulate the postoperative conditions. The maximum tensile strength, the failure mode, and the displacement of the fixation device (system displacement) under load at the first cycle of 75 N and at the maximum tensile strength were recorded.
The absorbable Spiralok 5 mm screw anchor showed the highest failure load with a mean of 223 N. The failure loads of the remaining anchors were similar and ranged from a mean of 169 N for the Super Revo 5 mm, over a mean of 173 N for the Ultrasorb RC anchor to a mean of 188 N for the Bioknotless anchor. Among these anchors the differences were not significant. Only the Spiralok 5 mm screw showed a significantly higher failure load when compared with the Super Revo 5 mm screw.
The displacement of the various systems showed significant differences. The displacement of the Bioknotless anchor showed after the cycle with a tensile strength of 75 N a mean displacement of 13.8 mm, which was significant when compared with the remaining anchors.
Positioning the inferior screw fully inside the lateral border of the scapula correlates with lower bony coverture of superior screw.
The purpose of this study is to present our experience with numerous reamed femoral nails and to report the results and the complications.
The 415 fractures according to AO classification were divided as follows: Type A: 105 (25.4%), Type B: 179 (43.1 %), Type C: 131 (31.5 %) There were 341closed fractures and 74 open. Those 74 were classified according Gustilo to 33 Grade I, 24 Grade II, 14 Grade III A, 2 Grade III B and 1 Grade III C.
The fractures were treated with 308 AIM titanium nails and 107 Gross-Kempf nails. Dynamic stabilization was performed in the majority of the type A fractures, and static to those classified as B and C. We encourage our patients to walk with partial weight bearing, from the second post op day, except those with type C fractures who started their weight bearing after a month.
The patients were evaluated 3,6,12,36 weeks and 1 years post surgery clinically and with standing X-Rays.
Our complications were: 9 non unions (aseptic pseudarthrosis) (2.2%), 14 delayed unions (3.4 %), torsional malunion (more of 5°) in 4 patients (0.96 %). In 6 patients (1.44 %) we had limb shortening of 15 mm. Neurological complications were observed postoperatively in 30 patients, 25 with paresis of the pudendal nerve, due to traction (all recovered in a month), and 5 with paresis of peroneal nerve which were recovered in 3 months. There was found 28 broken screws but no broken nail. We had 3 pulmonary and 2 fat embolisms, but none of them was fatal. In 4 patients was observed clinically vein thrombosis below knee. Also we noticed one superficial and one deep infection, but we didn’t have a case of compartment syndrome.
Patients returned to their previous activities in a mean time of 10 months.
Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin.
We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution.
All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks.
The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening.
Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%.
We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.
10 open, 9 pathological fractures and 8 non-unions. Accordingly, from a total of 247 tibial fractures, 190 were closed, 27 were open and there were also 30 non-unions. The average age was 37 years. The patients were assessed clinically and radiologically according to a specific protocol. Follow-up 1–9 years (average of 4, 4 years).
At least three of the following four fluoroscopically positioned, postoperative AP radiographs were analyzed: immediate postoperative, between the 3rd and 6th postoperative months, at one year postoperative and at two years postoperative. The immediate and the two year radiograph were required for study inclusion. The radiolucent line score (RLLS) was calculated using the technique of Molé, involving the summation of radiolucencies in each of six specified zones. The RLLS was compared between the two groups.
Conclusions:
- low kappa index of reproducibility (0,3274–0,5269) of humeral component radiolucent lines evaluation for component-cement interface as well as for cement-bone interface. - low kappa index of concordance (0,1242–0,2478) of humeral component radiolucent lines evaluation for component-cement interface as well as for cement-bone interface. - High number of plausible observations when the same prostheses was evaluated immediately after surgery and at 1 year follow-up.
The use of a Shoulder Hemiarthroplasty for the treatment of Proximal Humerus Fractures (Neer 3 and 4 Parts) is the subject of this study.
71 patients with 71 Proximal Humerus Fractures were treated with this method. Four were exluded from the study (they did not match the follow-up criteria). From the remaining 67, 60 were women and 7 men, aging from 38 to 96 years (average 67.13 year, S.D. 14,769s). Of these patients 22 were Neer 3 (1 with a dislocation) and 45 were Neer 4 (17 with a dislocation). There were 4 cases of a failed ORIF and in 8 cases the operation followed failed conservative treatment (2 non-unions and 6 AVN). Time between fracture and surgery ranged from 1 to 5 days in 54 cases, while in the rest it exceeded 8 weeks. The fracture classification was performed with the use of 3 plain X-rays (AP, Lateral and Axillary views) and the results were evaluated using the Constant Score. The mean follow-up was 55.75 months (range 36 to 105). The average Constant Score was 67.4 (S.D. 14.3). There were no significant statistical differences regarding sex and age in respect to the Constant Score (t 65 =.243, p =.81), range of motion (t 65 =.048, p =.96), strength (t 65 =.741, p =.46), activities of daily living (t 65 =.030, p =.97) and pain relief (χ2 [1] =.001, p =.98). On the other hand the group of patients with the higher pain relief scores presented higher Constant Score values and better shoulder joint function in respect to the group which presented lower pain relief scores.
In conclusion the treatment of Proximal Humerus Fractures (Neer 3 and 4 Parts) with the use of a Shoulder Hemiarthroplasty is a good treatment method offering substantial pain relief, functional improvement of the joint leading to a faster rehabilitation in the majority of patients, regardless age and sex.
Methods: 100 shoulders (98 patients/60y/21–88) with intracapsular fractures of the proximal humerus were included in a prospective surgical evaluation protocol (Binary [LEGO] description system: 48/100 4-, 46/100 3-, 6/100 2-fragment fractures). Humeral head perfusion was assessed intraoperatively by means of laser-Doppler flowmetry and borehole judgement. 51/100 fractures were treated with osteosynthesis (group A). 49/100 were treated with hemiarthroplasty (group B). In group A 41/51 heads were perfused at the index procedure (A1) and 10/51 were ischemic (A2). The patients were re-evaluated at a mean follow-up of 5.0 years (3.3–7.3) using the Constant-Murley-Score (CMS), the Subjective Shoulder Value (SSV) and conventional x-ray imaging.
Results: The median total CMS was 76 (37–98) in group A, 70 (39–84) (group B) (p=0.02). The median SSV was 92 (40–100) (group A) and 90 (40–100) in group B (p=0.93). In group A1 6/30 heads were structurally alterated but not collapsed; 4/30 were collapsed. In group A2 6/10 were structurally alterated but not collapsed; 3/10 were collapsed. The median CMS for patients without structural alterations was 80 (37–98), for those with structural alterations 84 (53–93) and for those with collapsed heads 63 (48–74). The median SSV was 95 (50–100), 92 (50–100) and 60 (40–80), respectively.
Conclusions: Revascularization of the humeral head after initial ischemia is possible and occured in 7/10 patients. Their functional results were comparable to those of patients with initially perfused heads. When feasible, osteosynthesis is a viable option even for ischemic heads. The indication for osteosynthesis should be weighed against the fact that Osteosynthesis and Arthroplasty showed comparable long-term results.
This prospective follow-up study investigates the correlation between healing of the tuberosities and the functional outcome after arthroplasty with a trauma shoulder prosthesis in elderly patients with non-reconstructable humeral head fractures.
Surgery was performed on 65 patients (66 cases). Patients underwent clinical and radiological evaluation.
A total of 56 patients (57 cases) were examined after a mean time to follow-up of 16 months (range 4–62 months). Mean Constant Score was 50 and the age- and gender-corrected value was 73%.
The Constant Score was significantly higher (62 points, p=0.015) if the tuberosities healed. Mean ASES index was 68 and correlated significantly to the Constant Score (r=0.77).
Healing of the tuberosities is crucial to achieve good functionality in patients treated with a humeral head prosthesis. For elderly patients, the main objectives are to recover the ability to perform activities of daily living, to become pain free, and to reach a high level of satisfaction. All these criteria are largely achieved by the procedure described in this paper.
Inverted shoulder arthroplasty has been initially proposed for the treatment of omarthrosis secondary to deficient rotatory cuffs, however its use in acute traumatology has not been yet investigated.
The mean ASES score was 9 points (0–19) out of 24. The mean DASH score was 44 points (0–92) out of 100.
Post-operative complications included 3 reflex sympathetic dystrophies, 5 regressive neurological complications, 1 loosening of the deltoid suture, 1 anterior dislocation and 1 acromion fracture. There was no infection.
Radiographs at last follow-up showed peri-prosthetic calcifications in 36 cases, displacements of the tuberosities in 19 cases and scapular notches in 10 cases (1 type III, 3 type II and 6 type I notches). No migration of the prosthetic components was observed.
The PHILOS plate attempts to improve on previously designed implants by preserving the biological integrity of the humeral head articular fragment. The minimally invasive technique minimises soft tissue damage whilst at the same time securing the reduction using multiple locking screws with angular stability, thus allowing early mobilisation.
We also present a cost analysis relating to the use of the PHILOS plate in practice.
Mean OSS and DASH at follow up were 24.8 (S.D 11.6) and 28.0 (S.D 26.9) respectively. Worse scores were seen in those patients who had complications (OSS 39.4 Vs 22.6, DASH 58.2 Vs 23.4) although this difference was not statistically significant. There was also a trend for poorer scores with increasing fracture complexity and better scores in those patients operated upon by surgeons with a specific interest in the upper limb and in patients whose surgeon had performed more than 5 fixations.
The aim of this study was analyse the results of locking plates used for fractures of the proximal humerus and to look for specific complications.
Our study has shown that PHILOS plates are reliable implants for internal fixation of proximal humerus fractures. An inverse correlation was seen between oxford shoulder scores and DASH scores. Patients with higher oxford scores indicating a good outcome had lesser disability scores. Comminuted fractures (four part fractures) had less than satisfactory shoulder scores and higher disability scores. In general, younger patients did better than older patients. This study demonstrates that PHILOS plates provide stable internal fixation for proximal humerus fractures. Age and fracture configuration play a significant role in the clinical outcome of these fractures after internal fixation.
The objective of this study was to ascertain knowledge of the normal anatomy and appreciation of components of an “adequate” or “acceptable“ reduction by the medical staff responsible for management of distal radius fractures in the emergency departments (A& E) in UK. A nation wide structured questionnaire survey based on literature review was performed on 138 doctors. Of the 100 (72%) respondents, only 40% could cite the correct values for volar tilt, radial inclination, and ulnar variance, there being a significant difference between orthopaedic n=16(64%) and A& E staff n=24(32%); p=0.031; c2 = 12.17. Only 18% respondents were aware of the acceptable ranges of adequate reduction; with orthopaedic staff n=12 (48%) being more aware than A& E staff, n=6 (8%); p=0.002; c2 = 6.38. Only 19% formally measure the key parameters before decision making [52% Orthopaedic versus 8% A& E staff; p=0.018; c2 = 7.31]. Only 14% of respondents from hospitals equipped with picture archive navigation system (PACS) stated that they used the angle measurement function.
A lack of knowledge of the normal anatomical values and implementation of generally accepted measurement criteria predictive of fractures unlikely to benefit from repeat manipulations is evident. It is important to emphasize the influence of factors reported to affect stability such as age, functional demands of the patient and extent of initial fracture displacement in decision making. The introduction of a set of guidelines and further education of the medical staff could reduce the number of inappropriately treated distal radial fractures in the A& E setting with significant economic implications.
The humerus neck fractures (HNF) are a frequent pathology in the 6th decade of life. Until now the manipulation and the most of the traditional surgeries (including prosthesis) haven’t shoed satisfactory results. By using the TGF system, a minimal invasive technique, we have the advantage of immediate mobility of the articulation. The TGF system is a mixed fixator that creats a new concept in osteotaxis. This new concept, using tension-guides, allows us to look at HNF as a non invasive and effective way of treatment.
We use the Neer classification, accepted worldwide in HNF. We have operated successfully 5 HNF Neer II, 16 HNF Neer III and 9 HNF Neer IV, between 26 years and 83 years old in 6 males and 24 females. The cinetical lesion’s energy was divided in: Hight energy–4 cases, Medial energy–5 cases, Low energy–21 cases.
Because of the complexity of this type of fractures, the conservative or the osteosynthesis have a low rate of sucess. With TGF system the results are good, with 100% of consolidation and a good final alignement. The funcional results are: Very good, with 100% of mobilization and no pain–4 cases; Good, with 80% to 100% of mobilization and some times pain–23 cases; Regular, with 80% to 50% of mobilization and pain with effort–3 cases; Bad, with less than 50% of mobilization and constant pain–0 cases. As complications we reported 4 pin superficial infection.
The TGF system has proved, as we can show, attending it’s safety ness and efficacy, to be the best method for the treatment of HNF.
51 male and 49 female. Average age of 48.0 (25.3–63.8IQR) 45 Simple, 46 comminuted and 9 pathological fractures. 70 were isolated and 10 were part of multiple trauma fractures. 91 closed and 9 open fractures. 52 fractures due to simple falls, 30 road traffic accident,9 pathological fracture,8 work related and 1 unknow cause.
Out of 100 nails, 90 were statically locked while 9 were locked proximally and 1 was locked only distally.
The outcomes were assessed clinically, radiologically and using the Disability of Arm Shoulder and Hand (DASH) function scoring system.
Statistically Cronbach’s alphas were calculated for the three scales of the DASH instrument. These scales were the function/symptom scale consisting of 30 items, sports/music module containing 4 items, and work module comprising 4 items.
Medians (interquartile ranges) and ranges are presented for numerical variables.
Mann-Whitney U tests (two-tailed) and Univariate and multivariate regression analysis were used.
The DASH function scale scores was categorised into good 71 patients 85.5% (Score 0-< 25),
Medium 4 patients 4.8% (Score 25-< 40) and Poor 8 patients 9.6% (Score 40+).
Univariate and multivariate regression analysis showed, Increasing age (adjusted OR=0.96,95%CI 0.93–0.99,P< 0.01) and communited compared to simple fractures (adjusted OR=0.12,95%CI 0.03–0.45,P< 0.01) were associated with reduced likelihood of attaining full range of motion.
Male patients (unadjusted OR=2.37,95%CI 0.90–6.25,P=0.08) and patients involved in RTA compared to falls (unadjusted OR=4.5,95%CI 0.96–21.07,P=0.06) were associated with higher likelihood of attaining full range of motion.
85 % had no complication, while 15 % had complications.
One nerve palsy and one case of infection.
Seven patients required nail removal and 3 required removal of proximal locking screw.
Distal radius fractures are commonest injury managed by junior doctors in accident and emergency department. Technique of manipulation is very well described and doctors are prepared from the days of medical school. Though manipulation is done in good position at initial management many patients require re-manipulation and surgical stabilisation due to loss of position on subsequent examination. Many Senior surgeon thinks this is due to inadequate plastering and moulding technique.
Fractures of the distal radius are common skeletal injuries. In most practices patients are discharged within few weeks to few months. The aim of this study is to investigate whether there is a difference in outcome between 6 months and 1 year with different treatment methods with special focus on conservative management.
A one-year prospective cohort study of patients with fractures of the distal radius was set in York Hospital. From 204 patients included, 200 (98%), 182 (89%) and 164 (82%) patients were evaluated at 6 weeks, 6 months and 1 year, respectively. Two patients had bilateral fractures. In total 162 fractures were treated conservatively, and 8 fractures were treated operatively following failure of conservative immobilization.
Outcome assessment included Gartland and Werley, DASH and SF-36 scoring systems. Between 6 months and 1 year there was statistically significant improvement in the over-all Gartland and Werley score (p< 0.001) and most of its components such as the subjective evaluation, grip strength, arthritis change, finger function, and the range of motion. There was no significant improvement in pain and deformity.
In the conservatively treated patients a good or excellent result was found after 6 months in 77%, after 1 year in 92%. In the failed conservative group it was 61% (5/7) and 83 % (5/6).
In order to eliminate the “conflict” that can occur with physiological roll back of the femur on the tibia, most modern knee arthroplasty prostheses are designed to have little conformity between the femoral and tibial surfaces. However, a consequence of this design is paradoxical anterior sliding of the femur on tibia, which can result in clinically significant gait abnormalities. Recent studies show that during movement of the knee, the medial side remains very nearly stable like a ball-in-socket joint, whilst the lateral side moves front to back, rotating around the centre of the medial side. A total knee joint prosthesis designed with these same kinematics may therefore be advantageous. The objective of this study was to investigate the hypothesis that the increased constraint of a medial pivot knee promotes earlier loosening of the prosthesis.
We aimed to identify whether patients in lower socioeconomic groups had worse function prior to total knee arthroplasty and to establish whether these patients had worse post-operative outcome following total knee arthroplasty. Data was obtained from the Kinemax outcome study, this was a prospective observational study of 974 patients undergoing primary total knee arthroplasty for osteoarthritis. The study was undertaken in thirteen centers, four in the United States, six in the United Kingdom, two in Australia and one in Canada. Pre-operative data was collected within six weeks of surgery and patients were followed for two years post-operatively. Pre-operative details of the patient’s demographics, socioeconomic status (education and income), height, weight and co-morbid conditions were obtained. The WOMAC and SF-36 scores were also obtained. Multivariate regression was utilised to analyse the association between socioeconomic status and the patient’s pre-operative scores and post-operative outcome. During the analysis, we were able to control for variables that have previously been shown to effect pre-operative scores and post-operative outcome. Patients with a lower income had a significantly worse pre-operative WOMAC pain (p=0.021) and function score (p=0.039) than those with higher incomes. However, income did not have a significant impact on outcome except for WOMAC Pain at 12-months (p=0.014). At all the other post-operative assessment times, there was no correlation between income and WOMAC Pain and WOMAC Function. Level of education did not correlate with pre-operative scores or with outcome at any time during follow-up. This study demonstrates that across all four countries, patients with lower incomes appear to have a greater need for total knee arthroplasty. However, level of income and educational status did not appear to effect the final outcome following total knee arthroplasty. Patients with lower incomes appear able to compensate for their worse pre-operative score and obtain similar outcomes post-operatively.
Average range of motion was the same in both groups.
Knee score was similar in both groups.
Canamathic assessment confirmed in both group excessive exteneraltation of the femur over the tibia and in fixed bearing group it confirms the spelling of the lateral femoral condoral from the tibial Plato which wrist concern about the safety Fix bearing in deep flexion.
The objective of the study was to verify a positive effect of an additional oblique cancellous screw on the primary rotational stability of complete and incomplete high tibial closed-wedge osteotomies (8°) in ovine tibiae. Of 51 specimen 48 were employed for final results. The osteotomy site was stabilized with L-shaped plates (Allopro, Sulzer Orthopedics GmbH, Freiburg, Germany). The specimen were subdivided in 4 groups: complete (1/2) and incomplete (4/5 of the mediolateral tibial diameter in height of the horizontal sawing-jig) (3/4) osteotomies each with (1/3)) and without (2/4) an additional oblique cancellous screw. Constant axial load of 200 Newton and rotational velocity of 0,496°/sec. was applied during testing. 8 ovine specimen were tested without osteotomy or rigid fixation as a control group (5). Statistical significance (p< 0,05) was determined via the nonparametric Mann-Whitney U-test. The results were charted with SPSS (version 11.0). Correlation between objective measurement parameters and primary rotational stability of the specimen was displayed according to Pearson. The primary rotational stabilty in group 1 (intact medial cortical bone, incomplete osteotomy with additional oblique cancellous screw) was significantly higher than in groups 2, 3 and 4. In this group the resulting torsional moments in the initial part of the charted graphs were even higher than in the control group. Group 2 (incomplete osteotomy without a oblique cancellous screw) showed a significantly higher primary rotational stability compared to the groups with complete osteotomy (group 3/4). Between the groups with complete osteotomy (3/4) no significant differences in rotational stability occured. No significant correlation could be found between the objective measurement parameters of the specimen (length, weight, maximal width of the tibial plateau) and the primary rotational stability of the rigidly fixated ovine tibiae. This biomechanical in-vitro assessment showed that an intact medial cortical bone bridge has a statistically significant impact on the primary rotational stability of lateral closed-wedge osteotomies in proximal tibiae. An oblique cancellous screw through the osteotomy gap has an additional effect concerning rotational stability. In case of complete osteotomy of the proximal tibiae or due to inadequate operative technique the stabilizing effect of the medial cortical bone bridge gets lost. This results in a deterioration of rotational stability at the osteotomy site and in a sufficicantly rigid fixation is no longer guaranteed. In this case an additionally inserted oblique cancellous bone screw leads to higher resistance against rotational forces. A rigid osteosynthetic stabilization of corrective osteotomies in proximal tibiae seems a condition precedent to obtain the desired correction angle.
Opening wedge high tibial osteotomy (HTO) for varus knee osteoarthritis has shown several advantages over the classic closing wedge technique. The aim of the current prospective study was to evaluate mid-term clinical and radiographic results, as well as complications, of medial opening wedge osteotomy using the hemicallotasis technique. Forty-nine high tibial oste-otomies were performed for unilateral varus primary osteoarthritis from 1999 to 2002. A medial incomplete osteotomy was performed after elevating the superficial collateral ligament. Four pins were inserted, two hydroxyapatite-coated in the metaphyseal bone, and two standard conical pins in the diaphyseal bone. The correction started 4–5 days postoperatively. The patient managed the correction by adjusting half of a turn twice each day. When the desired correction was achieved, the device was locked. Eight-to-nine weeks after surgery, the radiographic healing was evaluated, and if adequate, the device was removed on a outpatient basis. The mean age of the patients was 57 years (range, 32–70 years). The mean follow-up was 5 years (range, 4–7 years). The mean hip-knee-ankle angle (HKA) was 167 (range 164–171) deg preoperatively and 182 (range, 176–186) deg at follow up. We did not observe any early or late collapse of the new bone wedge. Union was achieved in all patients, and the mean time to fixation was 69 (range 60–85) days. Knee Society score improved from 52 points preoperatively to 93 at follow up. Eighty-five percent of the patients showed excellent-to-good clinical outcome. None of the knees had required revision surgery at follow-up. No meta-diaphyseal mismatch was noted on both the sagittal and coronal plain at radiographic analysis. Patellar height (IS ratio) reduced, on average, from 1.1 (±0.4) to 0.9 (±0.4), but no patella was found to be baja. Complications included a number of superficial infection uneventfully healed such as two cellulitis with erysipelas-like rushes, and five minor (grade I-II) pin tract infections. There were two technical problems. One obese patient developed an undisplaced inter-condylar fracture of the proximal tibial osteotomized fragment, which subsequently healed and the patient achieved a good clinical outcome. In another patient the anterior pin on the metaphyseal fragment was positioned too anteriorly, and was thereafter repositioned. There were no neurologic or vascular complications. Using the hemicallotasis technique for HTO the authors obtained a precise correction with a relatively low complication rate. The use of an external fixator allowed quick surgery, early weight-bearing, immediate knee motion, avoiding permanent hardware on bone. Conversion to a total knee arthroplasty seems to be easy when this technique has been employed, but the influence of pin tract infection on possible septic failures remains to be determined.
The maximal rotation recorded for the inlay centers was 1.6 ± 1.2 mm at 1.2° knee flexion and 4.3 ± 3.3 mm at 1.3° for the MPS design.
No funds were received in support of this study.
We measured patellar height, VMO length on the axial views of the scans. The VMO insertion was calculated from the data and we divided the patients into proximal and distal groups in relation to the VMO termination on the patella. The proximal group included patients with VMO termination proximal to the mid-point of the patella and distal group included patients with VMO termination at or distal to the mid-point of the patella.
On either end of this line, the articular surface of the trochlea can be fitted to spheres of radius 30mm (stdev 6mm) laterally and 27mm (stdev 5mm) and an rms of 0.4mm medially. The centres of the circle and the two spheres fall on a line with an rms of 1.1mm.
The anterior and proximal patellar planes could be described as flat surfaces (rms of 0.4 and 0.3mm). The median ridge could be described as a straight line (rms of 0.2mm). The angle between planes was 112° (stdev 5°); the average angle between the proximal plane and the line on the medial ridge was 62° (stdev4°).
The functional centre of the patella was defined as a point in the centre of 2 planes orthogonal to the sagital plane from the midpoint between the most proximal and most distal points on the median ridge. The length, width and thickness of the patellae were measured at 22mm +/−4mm, 47mm +/− 3mm and 24 mm+/− 2 mm.
This paper describes a simple new MRI measurement of the axial patellar tendon angle (APTA), and compares this angle in patients with and without patello-femoral instability.
In PFI, the patella is commonly tilted laterally. This is matched by the orientation of the patellar tendon. The increased tilt of the tendon is only partially corrected at its distal insertion with an abnormal angle of tibial attachment. When performing distal realignment procedures, angular correction as well as displacement may be appropriate.
Pre-op oxford knee score was recorded in all the patients. Post-op scores were recorded annually and at final follow up. X-rays were analyzed for implant positioning and loosening. Data were analyzed using SPSS version 12.
This study reports a clinical comparison of new and old establishing whether this modified implant has maintained the established normal kinematic profile of the Oxford UKR.
Knee kinematics were assessed by analysing the movement of the femur relative to the tibia using the PTA.
Functional outcome in Total Knee Arthroplasty (TKA), as measured by means of gait analysis for kinematics, kinetics, and muscular activity around the knee shows abnormalities even in patients with excellent clinical outcome. Knee flexion during loading response phase is reduced, accompanied by co-contraction of knee extensors and flexors. Such subtle failure in knee performance during loading absorption was claimed to depend on several factors: quadriceps weakness, prosthetic design, pre-surgical pattern, proprioception disruption. It was supposed to damage the implant in time. The lack of the anterior cruciate legament seems to play a major role in the loss of control of the roll back pattern of the condyles on the tibial plateau in TKA patients. Previous works on unicondylar knee artrhoplasty (UKA) demonstrated better gait performance when anterior cruciate ligament was preserved allowing the patients to maintain normal quadriceps mechanics. The aim of the present work is to evaluate UKA patients knee function during gait compared to TKA with the hypothesis that UKA ensures more physiological knee loading response pattern of movement and a more phasic muscular activation, thus reducing the risk of failure. Twenty patients with Oxford/Exactech UKA (mean age 70 (SD 7.9), mean follow-up 2 years) were evaluated by means of a Vicon 612-8 cameras system, two Kistler forceplates and Telemg respectively for knee 3D kinematics, kinetics and muscular activity. Data of UKA were compared to those of a control population of ten healthy subjects and ten patients with TKA matched for age and follow up. Mean UKA-IKS score at the time of gait analysis was 90. Time-distance parameters evidenced a slight slow gait with reduced stride length and cadence and a symmetric longer stance phase with respect to TKA and controls. Knee kinematics on the sagittal plane showed knee flex-ion during loading response very close to controls and a reduced but phasic pattern of joint moments on the sagittal plane. Adduction moment at the knee was normal. EMG showed controversy results as some patients had a regular pattern of activation of rectus femoris and hamstrings without co-contraction whereas other patients had co-contraction. These preliminary results indicate that UKA allows in most patients a quite normal knee kinematics and kinetics, although some abnormalities persist in quadriceps activation. Further research is required to understand these findings assessing other factors which could influence quadriceps activity such as age, proprioception, and muscular strength.
Radiolucent lines (RL) are a common radiographic finding following Oxford Uni knee arthroplastv. These RL are commonly seen at the bone-cement interface under the tibial tray and can only be evaluated using screened radiographs. These lines occur during the first year, are well defined and remain constant for years. The clinical relevance of this phenomenon is unclear. Pulse lavage has the potential to thoroughly clean the trabecular bone by clearing the bone from bone marrow and debris and can thereby facilitate cement penetration and interdigitation into trabecular bone.
Pulse lavage can reduce the occurrence of radiolucent lines under the tibial tray by improving cement penetration and interdigitation.
Since 2001 we routinely use pulse lavage before cementing the Oxford uni implants at the Orthopä-dische Universitätsklinik Heidelberg (group A). At Nuffield Orthopeadic Center, Oxford conventional irrigation has been used before cementing (group B). At a minimum follow-up of 1 year 56 screened AP radiographs of the knee after Oxford UCA have been blinded and evaluated for radiolucency and cement penetration by an independent observer. For standardized evaluation the cement bone interface has been devided into 4 zones and a specific algorithm for evaluation of the radiographs has been developed.
Complete radiolucencies were detected in 2 cases (4%) in group A and in 13 cases (23%) in group B (p=0,001). Partial radiolucent lines were seen in 32 knees of group A (57%) and in 40 knees (71%) in group B. In zone 1 RLs were found in 31 tibias (55%) in group A, in 32 tibias (57%) in group B. In zone 2 17 (30%) group A, 29 (52%) group B. In Zone 3 4 (7%) in Gruppe A, 20 (36%) in group B. In Zone 4 6 (11%) group A, 30 (54%) group B. The differences between group A and B were significant (P=0.001) in zones 2, 3 and 4.
In group A in 14 cases (25%) RL were limited to one zone, in group B in 5 cases (9%), respectively. In 12 cases (21%) 2 zones were affected in group A (12 cases (21%) group B). RLs in 3 zones were found in 4 cases (7%) in group A and in 10 cases (18%) in group B.
Mean cement penetration (mm) was 2,3mm in group A and in 1,4mm in group B. The use of pulsed lavage led to an increase in cement penetration by a factor of 1,6 (cement penetration in group A/B zone 1: 1,4mm/0,8mm; zone 2: 2,4mm/1,5mm; zone 3: 1,4mm/0,7mm; zone 4: 4,0mm/2,4mm).
The use of pulsed lavage significantly decreases the appearance of RLs at a minimum of 1 year follow-up by increasing cement penetration into cancellous bone. Even though the clinical relevance of tibial RLs in unclear we recommend the use of pulse lavage to improve cement penetration and interdigitation with cancellous bone. Unnecessary revisions due to misinterpretation of RLs may be prevented.
Lateralisation of the tuberosity tibia causes distal malalignment of the extensor mechanism of the knee and can lead to lateral tracking patella (LTP), resulting in anterior knee pain, or objective patellar instability (OPI), resulting in recurrent luxations. For a precise preoperative diagnosis the tuberositas tibia (TT) trochlear groove (TG) distance was measured on a CT scan. A distance of more than 15 mm was considered to be pathological.
In a prospective study, the clinical results of a subtle, CT-guided medial tuberosity transfer for LTP and OPI were evaluated. 30 Consecutive patients with LTP and 30 patients with OPI and an increased TT TG were included. Outcomes were documented at 3, 12 and 24 months follow-up using the Lysholm scale, the Kujala score, and a visual analogue pain score. Postoperatively all but one patient reported good improvement in stability (no persistent subluxations or luxations). All patients had a marked improvement in pain and functional scores at follow up. Complications seem to be related to the peroperative technique. CT-guided TT transfer appears to be satisfactory and safe method for treating patients with an increased TT TG leading to either LTP or OPI.
Survivorship of unicondylar knee replacement (UKR) exceeds 85% at 10 years. During long term follow-up, progressive osteoarthritis (OA) and loosening are typical of UKR failure. The decision to revise UKR is complex as radiographic findings are not always consistent with clinical symptoms. This study of revised UKR compares intraoperative assessment of component fixation and progressive OA with prerevision radiographic evaluations.
Twenty-seven UKR were retrieved from 22 female and 5 male patients. Patient age and time in situ averaged 76 (68–87) years and 79 (25–156) months, respectively. At index arthroplasty, all knees received a fixed-bearing medial UKR with cement fixation. Prior to revision, radiolucent lines and component alignment were assessed on radiographs according to Knee Society guidelines. Suspected revision reasons based on clinical and radiographic evaluation included aseptic loosening (63%), progressive OA (22%), and wear (15%). During revision surgery, component fixation was manually assessed and graded as well-fixed or loose, and progressive OA was graded using Outerbridge classification. Intraoperative and radiographic assessments were completed independently.
Average Knee Society Scores declined > 30 points to 53+18 (pain) and 43+11 (function) before revision. During revision surgery, femoral and tibial component fixation were graded as loose in 19 (70%) and 9 (33%) knees, respectively. There was Grade III or IV progressive OA in the lateral or patellofemoral compartment of 15 (56%) and 16 (59%) knees, respectively. Radiolucent lines were evident in 8 of 19 loose femoral components and 5 of 9 loose tibial components. In contrast, 3 of 8 well-fixed femoral components and 6 of 18 well-fixed tibial components had radiolucent lines. There were 11 loose femoral components and 4 loose tibial components without radiolucent lines. Radiographic limb alignment averaged 3°+3° valgus immediately after index UKR. Change in limb alignment ranged from 0° to 17° at revision. Tibial or femoral component alignment changed 5° to 9° in 12 (44%) knees and > 10° in 5 (19%) knees. Eight of these 17 knees (47%) had malaligned components graded as loose.
The prevalence of progressive OA at revision UKR was more than double occurrence suspected from radiographs. Interpreting radiographic indications for loosening was difficult. Radiolucent lines predicted loosening in 46% (13/28) of the components graded as loose and falsely predicted loosening in 35% (9/26) of the components graded as well-fixed. Radiolucent lines were absent in 15/28 (54%) of the loose components and changes in component alignment > 5° were associated with component loosening in < 50% of the knees. Rigorous attention to clinical symptoms and careful interpretation of radiographic phenomena are needed to determine indications for revision in UKR patients.
99 knees were followed for 15 years, 21 knees for 20 years and four for 25 or more years. The average Bristol knee score of the surviving knees fell from 86 to 79 during the second decade, largely as a result of aging.
A previous study of the St Georg. Fixed bearing UKR showed an 89% 10 year survivorship and this is now extended to 82% at 15 years and 76.5% at 20 years.
The aim of this prospective study was to compare UKAs to HTOs, in terms of clinical and functional Results: Materials and Methods:
In all UKAs we implanted an Accuris prosthesis (Smith& Nephew, Memphis TN), in all HTOs we performed a medial opening wedge osteotomy, according to the surgical technique and syntesized with a Puddu Plate (Arthrex, Naples FL).
We evaluated all patients preoperatively and at 6 months postoperatively, at 1 year, 2 years and at the last follow-up visit (mean 3,5 years for UKAs and 2,5 years for HTOs), using the Knee Society Score (KSS) and the WOMAC (Western Ontario and McMaster Universities) Score.
Postoperative program for the HTO group was: 4 weeks of CPM (continuous passive movement), partial weight-bearing al 4 weeks (30–50% of body weight) and then full weight-bearing at 8 weeks postoperatively.
In the UKA group, full weight bearing was allowed immediately after operation.
We observed only one significant complication postoperatively: an early infection in an HTO patient. We thought this complication was not related to the treatment chosen, but to external factors, so we decided to exclude this patient from our study.
In the HTOs group, the KSS knee score (KS) and function score (FS) improved from respectively 38 and 55 preopertively to 76 and 91 at the final follow-up evaluation, while in the UKA group KS increased from 43 to 93 and FS increased from 50 to 84.
The WOMAC Score improved from respectively 48 (HTO Group) and 45 (UKA Group) preoperatively to 15 (HTO Group) and 14 (UKA Group) at the final follow-up evaluation.
Comparison of study groups shows good outcome at early and mid-term follow-up. All patients had scores rated good to excellent (both KSS and WOMAC).
However, we found a little difference in KSS between the two groups: UKAs have a higher Knee Score (better knee assessment), while HTOs have a significantly higher Functional Score (better performances, maybe due to a more “anatomic saving” procedure).
This data suggests that the UKAs have better knee assessment, meanwhile the HTOs have better function. Given that, both treatments lead to a good to excellent outcome at early followup.
Between 29th May 2001 and 15th May 2003, 233 consecutive Preservation unicompartmental knee replacements (UKR) were performed. Of these, 30 were lateral UKRs (13%) performed in 12 men and 16 women (2 bilateral cases) with a mean age of 67 years (range 36 to 93 years). A metal-backed mobile bearing tibial component was used in 13 knees and an all-polyethylene fixed bearing tibial component in 17 knees. The patients were reviewed prospectively at 1 and 2 years. The 2 year results show no difference in range of motion or function between the mobile and fixed bearing versions of the Preservation knee when used on the lateral side. This is similar to the reported results on the medial side. There were 3 early revisions, all in the mobile bearing group. The incidence of revision has been reduced by the introduction of an improved cementing technique.
In cementless Total Hip Arthroplasty (THA), some discussion persist in different continents, weather straight double tapered stems providing proximal metaphyseal fixation are preferable to more diaphyseal cylindrical fixation designs.
With the objective of studying the grade of loosening of a straight double tapered stem and its survival rate, the authors analysed 257 THA with implanted Spotorno stems, followed up for a maximum of over 18 years (221 months), with an average of 110±57 months. The age of patients was 62±10 years in average, ranging from 18 to 86. Demographic data is analysed including, sex, height, weight and BMI.
Main diagnosis was Primary Degenerative Osteoarthritis in 56% and Avascular Necrosis in 13% of all patients. Other diagnosis occurrence is presented, as well as the affected side, type of cup, head and stem size distributions.
Clinical and functional evaluation of the THA showed Very Good and Good patient satisfaction grading in 78% of the cases and the average Harris Hip Score was 87, ranging from 49 to 98. In the Radiological evaluation, stem positioning, migration, osteolysis and distribution of radiolucent lines are quantified and described.
79 patients included in this study with 84 THA, died or were lost after a minimum of five years of complete clinical and radiological follow up. The most significant early and late complications of THA are presented and commented. THA requiring revision of the cup or stem for any cause, were 1 severe deep infection (0.4%), 4 cups loosened and migrated but not requiring revision of the stems (1.6%), 1 femoral osteolysis and loosening (0.4%) and 2 late traumatic femoral fractures (0.8%). From these, considering stem survival alone, a total of four stems (1.6%) underwent femoral revision as previously described, one due to infection, one due to loosening and two due to femoral fractures. Kaplan-Meyer cumulative survival analyses of the THA show a Spotorno stem survival rate of 98.4% at 18 years, with a confidence interval of 95%.
In the experience of the authors, the Spotorno double tapered straight stem provides excellent clinical results, with high survival rate at longterm evaluation. The design of the stem allows for immediate progressive weight bearing without significant migration or thigh pain. Femoral proximal osteolysis or radiolucent lines are almost always associated with wear or loosening of the cup, that very often allow for revision of the cup without the need for revision of the stem.
Of the 339 patients, 218 were available for follow-up, 72 had died, 38 without revision surgery were contacted by phone and 11 were lost to follow-up.
The underlying pathology was idiopathic degenerative joint disease (153 pts.), dysplastic OA (37 pts.), femoral head necrosis (12 pts.), posttraumatic OA (6 pts.) and OA of other origins (5 pts.). To evaluate changes in stem position, radiolucent lines, osseointegration and revision, clinical and monitor-controlled radiographic follow-ups were conducted at 10 years plus.
At the 10 year follow-ups (10,0 to 11,1, mean 10,2 years) the stem position was unchanged in all of the 213 patients. The stems had been implanted in proper anatomical alignment in 196 patients, in varus in 16 and in valgus in one patient. 93 patients showed no changes of the peri-implant bone. In 96 peri-implant bone apposition was recorded in one or more zones (Gruen). 20 patients presented with radiologic evidence of both peri-implant bone apposition and some atrophy. None of these patients showed abnormalities clinically (HHS: 95.2; 76–100). At the 10-year follow-ups 2 stems had worked loose. Another 2 patients presented with intertrochan-teric osteolyses with definite progression versus the 5-year follow-up. On analysis, radiolucent lines (RLs) were seen in zone 1 in 28.6% of cases, in zones 2 and 6 in 3.3%, in zones 3, 4 and 5 in 0.5% and in zone 7 in 22.1%.
The Kaplan-Meier survival rate was 98.2% (CI 95.3 to 99.2) with revision of the stem for any reason as the end point (N = 339).
Using software adapted for the specific purpose, femoral cortical volume was measured at three different levels at a fixed distance from the lower border of the lesser trochanter on both sides: 6mm distal to the tip of the prosthesis (z), At the top of the cylindrical portion(x) Midway between x and z (y).
Accuracy and precision of the of the method was also assessed.
No significant trend was noted with change of volume of bone with time.
In the three cases who had cemented hips on their other side, the cemented hips exhibited substantially more stress shielding than their cementless controls (ratios of 0.82, 0.74 and 0.85).
A high correlation between the test and standard measurements was noted. The interobserver agreement between two observers was also good.
There have been no femoral revisions for loosening and no complete radiolucencies involving the cancellous structured titanium (CSTi). 85% of x-rays show proximal bone condensation with maintenance of a strong calcar. Distal radiodense lines (halo) are present in 20% around the split smooth tip, with 30% showing an asymptomatic midstem cortical buildup.
Average Harris Hip scores at 10 years (including all Charnley classes) was 85. 90% of patients reported either no pain (65%) or slight (requiring no medication). 100% were satisfied with their outcomes. Anterior thigh pain was conspicuously absent occurring in one patient but disappearing the first year.
Clinical and radiological follow-up was planned at 4 months 1, 2, 5, 10, 15 and 20 years. Clinical follow-up included a standardised examination and the completion of an IDES form. Cumulative survival rates were calculated by Kaplan-Meier analysis. Radiographs were analysed for osteolysis according to Gruen et al. (zones 1–7) and radiolucent lines.
The median HHS at the last follow-up was 80 points (range 30–98 points).
31% of the non-revised 41 stems showed osteolysis, most of them in zone 7 (21.9%). Two stems with isolated cup revision had a continuous radiolucent line. Incomplete radiolucent lines appeared most frequently in zone 1. Cup revision was associated with increased radiological changes on the femoral side (p=0.094, Mann-Whitney U-test).
We aimed to determine whether proximal femoral bone remodelling, as measured by DEXA scan for each Gruen Zone, differed for 3 different femoral stem designs. These were:
Group 1 – Triple taper polished (C-stem J&
J DePuy) Group 2 – Double taper polished (TPS J&
J DePuy) Group 3 – Collared satin finish stem (Stanmore Biomet)
Ethical Committee approval was obtained and all patients gave informed consent. All operations were performed by 3 surgeons using a standard lateral approach, third generation cementing technique and a standard post-operative regime.
Seventy-five patients were randomised prospectively using a stratified randomisation programme for known risk factors in bone density. The randomisation was stratified by age, sex, Charnley Group (A or B), BMI and femoral neck bone mineral density. There were 25 patients in each Group, 5 patients did not have complete data sets and were therefore withdrawn from evaluation.
The Groups were similar with regard to age, sex, BMI, BMD and Charnley Group. Patients were followed up at 3, 6, 12 and 24 months by Nurse Practitioners for clinical and radiological evaluation and DEXA scan at each time of follow-up. There were no catastrophic failures of sepsis or dislocation. All patients functioned well at 24 months by Harris Hip Score.
The bone remodelling pattern will be described for each stem design. Findings are summarised thus. In the lateral Gruen Zones the triple taper and collared stem design faired better and both behaved differently to the double taper design. In Gruen Zone 7, all stems demonstrated reduced bone density as compared to pre-operative scans but this was less with the triple taper design.
Intraoperatively, the ARR was placed with its medial border adjacent to the tear drop figure. The weight bearing area was fixed with 3–4 cancellous screws in the acetabular bone stock. Regular clinical and radiological follow-up 3months, 1, 2, 5, 10,15 and 20 years was planned. The radiographs were assessed for osteolysis, radiolucent lines and screw breakage after 15 years. Survival for revision due to aseptic loosening was calculated by Kaplan Meier.
Of the 96 patients (104 rings) operated at least 15 years ago, one was lost for follow-up. Three rings were revised due to aseptic loosening (11, 12, 16 years after implantation) and one was removed due to infection (1,8 years after implantation). 54 patients (with 56 rings) died before they reached the 15 years control. None of them was revised for aseptic loosening of the ring. 37 patients (43 hips) remained for 15-years control, six of them refused to come and were contacted by questionnaire or phone. Two cups were radiologically loose with broken screws but not symptomatic. The mean HHS after 15 years was 80.1.
All patients where followed up prospectively and evaluated clinically and radiologicaly at three, six months at one year and yearly thereafter. The clinical outcome was assessed with the Harris Hip score (HHS) and Oxford Score (OS).
There were four dislocations in this group. One required open reduction and head replacement while another one needed cup revision due to mal orientation. There were five femoral fractures treated intraoperatively with wires, two patients developed transient sciatic nerve palsy and two non fatal PE.
Harris Hip Score was 91 (range 69 to 97) compared with 48 (range 24 to 58) before surgery. The outcome was excellent in 59 hips, very good in 8, good in two and fair in one. Leg length discrepancy more than 2 cm was evident in five unilateral cases (range 2 to 4.5). Trendelebourgh sign was evident in four patients.
The procedure was always performed with the patient in lateral position through a lateral transgluteal approach. We did not perform osteotomies of the greater trochanter or femur shortening osteotomies and the cup was placed where there was sufficient bone stock. The major determining factor in cup stability was the presence of sufficient anterior and posterior column. We also tried to insert the cup as medial as possible although in about half the group (25 out of 48), cup placement was superior and lateral. The limb length discrepancy was corrected by varying the neck length of the implant. A special stem was used in 5 cases.
The mean intraoperative time was 65 mins with minimal soft tissue disruption as compared with the classic methods. The patients were mobilized postoperatively in a couple of days.
Patients with DDH are known to be at risk of early degenerative changes to their hips. To date, no consensus exists as to the most appropriate management of this group, with many surgical options being associated with specific complications such as dislocation and early wear. In addition, modern resurfacing methods are considered by many to be contra-indicated in patients with DDH due to the technical difficulty of the procedure.
This prospective study analyses a single surgeon series of known DDH hips that underwent metal on metal resurfacing from November 1999 to July 2004 inclusive.
There were 31 resurfacings carried out on 28 patients (11 males, 17 females). The mean age of the study group at the time of surgery was 43.9+/−9.1 years. No patient was lost to follow up. Pre-operatively, 23 hips were classified as Crowe I (n=9), II (n=5), III (n=5) and IV (n=4). Patients were followed up to a mean of 46.4+/−18.1 months. The mean Harris Hip scores were 54.9+/−9.3 pre-operatively and 98.1+/−4.9 post-operatively (p< 0.001, Student’s t-test). Using the UCLA activity profile, the mean scores were 3.2+/−1.0 pre-operatively and 6.4+/−1.8 post-operatively (p< 0.001, Student’s t-test).
Although the management of young patients with early degenerative changes secondary to DDH remains controversial, the results of this study suggest that not only is resurfacing technically possible even in advanced cases, it also offers excellent functional outcomes and should be considered in appropriate cases.
Despite the fact that uncemented cup and stems are specifically designed for dysplasia to recover the true acetabular region in Crowe IV and sometimes Crowe III additional surgical procedure are required.
Purpose of the study is to analize surgical procedure and then reconstruction options on severe hip dysplasia.
64 cases were subjected to a greater trochanteric osteotomy. In 12 cases proximal femural shortening was associated. In 9 cases rotational abnormality and shortening were controlled with a distal femur osteotomy.
55 cases were treated by a shortening subtrochanteric osteotomy that allows corrections of any deformity. Only uncemented stems were used and in the majority of cases a specific device for displastic hip (Wagner Conus produced by Zimmer).
Despite this, the more promising outcomes are concerning shortening subtrochanteric osteotomy with uncemented stem but only early and mid-term data are available.
Methods: We conducted a two-arm matched pairs case-control study assessing the influence of patient characteristics sex, age, weight, BMI, diagnosis, and activity level (Charnley classification) on the odds for mechanical socket loosening. The cemented and uncemented fixation mode was analyzed separately.
Results: 299 cases and 986 controls were included in the cemented study arm and 510 cases and 3000 controls in the uncemented arm. Women had reduced loosening odds for the cemented (OR=0.59, p=0.0024) and uncemented (OR=0.63, p=0.0001) fixation compared to men (OR=1). Each additional year the intervention was postponed reduced the loosening odds by about 2 % for cemented (OR=0.98, p=0.017) and uncemented (OR=0.98, p=0.0002) sockets. In cemented sockets the weight group of 73–82 kg had lower loosening odds (OR=0.63, p=0.017) than the lighter (OR> 0.92) and heavier (OR> 1.1) weight groups. There were no significant effects of weight in the uncemented group. In contrast, obese patients (BMI> 30) with uncemented sockets displayed elevated loosening odds (OR=1.41, p=0.034) compared to an insignificant effect in the cemented arm. Osteonecrosis was the only main pathology revealing elevated loosening odds (OR=1.27, p=0.049) but only in cemented sockets. The Charnley classification as an indirect proxy of activity revealed changing and insignificant effects.
Conclusions: Female sex and a delayed intervention have similarly protective effects on the odds for cemented and uncemented socket loosening. Whilst a certain body weight range has a significantly protective effect in cemented sockets the more important finding is the significantly increased risk for uncemented socket loosening in obese patients. Patients with osteonecrosis are the only etiologic group at a significantly increase risk for socket loosening, but only with a cemented fixation. The Charnley classification as a surrogate for activity level had no influence on loosening risks in either socket fixation mode. Level of Evidence: Level III (case-control study)
There have been 4 infections, one of which required removal of prostheses and 2 stage revision. There was one case of fall post-operatively and fracture of the contra-lateral femoral neck. There have been 3 implant failures requiring re-revision. All failures were due to disarticulation of the liner, 2 of which occurred in the same patient on separate occasions. There have been no revisions for loosening, and there have been no cases of failure at the bone-cement interface or at the cement-cement interface with the cement-in-cement technique. Overall survival of the cemented constrained liner was 91.8% at average 3.8years.
In acetabular revision press-fit cups usually are used in smaller defects and contact to the host bone should be more than 50 %. Due to the thin wall thickness and the surface design the cementless press-fit cup Allofit S has a specific characteristic during implantation. Therefore this cup was used for revision with greater acetabular defects and analysed in a prospective study. The press-fit in these cases was 4 mm and additional 2 or 3 screws into the Os ilium were used.
64 cups were were followed prospectively for 38.3 months with a minimum of 24 months and examined clinically (Harris-Hip-Score) and radiographically for migration (Method of Nunn et al.) and loosening (Method of Delee and Charnley). Corresponding to Nunn et al. and Blum et al., cup migration was defined to be a change of position greater than 3 mm or referring to Cordero-Ampuero et al. and Dickob et al. a change of inclination greater than 5 degrees. There were 25 revisions of the cup and 39 complete exchanges of the prosthesis due to 54 aseptic and 10 septic loosenings (two-step revision with spacer and cementless reimplantation). There were acetabular defects of type Paprosky 2A in 12 cases, of type 2B in 15 cases, type 2C in 19 cases, type 3A in 16 cases and type 3 B in 2 cases. The average age of the patients was 70.9 ± 8.9 years.
The Harris-Hip-Score increased from 45.4 ± 14.9 points preoperatively to 81.8 ± 17.5 points one year and 82.3 ± 17.1 points two years postoperative. There was no loosing or significant migration of the cups.
The Allofit S press-fit cup shows good result in cup revisions with greater acetabular defects when using a press-fit of 4 mm and additional 2 or 3 screws. In these cases it seems to be a good and cheeper alternative to specific implants like trabecular metal cups.
Liposarcomas (LPS) are the most common soft tissue malignant tumor with a reported annual incidence of 2.5 per million people. The latest histopathologic classification of liposarcomas identifies three main groups: well-differentiated LPS; myxoid-round cell LPS; pleomorphic LPS. Dedifferentiated LPS is considered as a subgroup of well-differentiated LPS where there is an area of transition from a low grade to a high grade non lipogenic lesion (typically MFH or fibrosarcoma). The purpose of the present study was a retrospective review of the data of 146 consecutive patients affected by liposarcoma, with the aim to correlate the outcome of patients with treatment modalities and prognostic factors.
There were 89 males and 57 females with an average age of 54 years (range 16–92). The tumor grading following Broders criteria showed a low grade lesion in 48% of cases and a high grade lesion in 52% of cases. The histologic pattern showed a well differentiated liposarcoma in 25 patients (17%). The most frequent histologic finding was a myxoid liposarcoma in 55 cases (38%) while a round cell component of variable rate was seen in 22 cases (15%). A pleomorphic LPS was observed in 32 cases (22%). Dedifferentiated liposarcoma occurred only in 3 cases (2%). Surgery alone was performed in 31% of cases while chemotherapy (adriamycin and ifosfamide) and/or radiationtherapy were associated in 69% of cases. Brachytherapy was performed in 50 cases. Surgical margins resulted radical in 4 (2.5%) of cases, wide in 89 (61%), marginal in 45 (31%) and intralesional in 8 (5.5%) of cases.
In 10 cases (6.8%) a local recurrence occurred and in 33 cases (22.6%) a metastatic lesion was observed. Local recurrence were treated with surgical excision in 7 cases and with amputation in 3 cases. At an average follow up of 55 months, 68.5% of patients were continuosly disease free, 6.8% were disease free after local recurrence or metastasis excision or both, 4.8% were alive with disease, 14.4% were dead of the disease, 5.5% were dead of other cause. Eleven patients (7%) underwent an amputation, in 5 cases as first surgical procedure, in 3 cases after a local recurrence and in 3 cases for complications of the radiationtherapy. Local control was significantly correlated with the type of surgery at presentation and with surgical margins. Overall survival was significantly correlated with surgical margins, with grading and with the histotype of the tumor.
In the present series of soft tissue liposarcoma the combined treatment allowed limb salvage in 93% of cases (7% of amputations). Virgin lesions at presentation and free surgical margins resulted positive prognostic factors for local control. The histotype of the tumor, grading, and surgical margins resulted significative prognostic factors in survival, with round-cell and pleomorphic and high grade lesions showing the worse prognosis.
Harris Hip Score (HHS) was used for clinical evaluation (preoperative scores were retrospectively ascertained from patients’ charts). For radiological follow up plain X-rays of the pelvis a.p. and targeted views of the cup were used. Radiolucency, osteolysis (around cup, caudal hook, screws), migration (medial, cranial) and dumping was noted and the results divided into 3 groups: stable (no migration) at risk (cranial or medial migr.), loosened (cranial and medial migr.).
HHS improved from 36,4 to 69,3 points (max. 100). Pain: 15,5 to 36,8 pts (max. 44). Activity of daily living:14,3 to 36,8pts (max. 47). Walking distance 3,6–5,8 pts (max.11).
Radiological results (n=19, patient who died included in rad. FU): Radiolucency and osteolysis: Cup 5, hook 12, screws 10. Migration: medial:7 (all of those had medial bone defects), cranial:4, angulation > 4°:4 Outcome: stable: 11, at risk: 3, loosened 5 (1 died, 1 explanted, 3 control every 3 months)
A second follow up is starting recently with an average FU time of about 36 months.
Preliminary results using Trabecular Metal (TM) acetabular component (made of tantalum) in primary and in revision total hip arthroplasty are encouraging in few published papers in the literature.
Neoadjuvant therapy in soft-tissue sarcomas is still a controversial issues regarding indications, patients selection and treatment protocols. In the last fifteen years (1990–2005) at our Institution more than 600 patients affected by soft tissue sarcomas of the limbs and superficial trunk were surgically treated. Among these patients, 49 received preoperative chemotherapy (epirubicin plus ifosfamide, according to Italian Sarcoma Group protocol), associated to preoperative conventional external beam radiationtherapy in 36 cases (73.5%). The histologic types were liposarcoma (30,6%), synovial sarcoma (20,4%), fibrosarcoma (16,3%), pleomorphic sarcoma or malignant fibrous histiocitoma (12,1%), leiomyosarcoma (8,2%), other histotypes (12,1%). Tumor size was 10 cm or larger in 21 cases, 6 to 9 cm in 23 patients and 5 cm or smaller in 5 cases. Neoplasms were high-grade (Broders grade 3 or 4) in all cases but five.
After neoadjuvant treatment we performed a limb-sparing surgical excision of the tumor in 47 patients (96%), while a primary amputation of the limb was necessary in only two cases (4.1%). A vascularized miocutaneous flap was used in 8 cases, and adequate surgical margins were achieved in more than 70% of the cases.
Postoperative chemotherapy was given in 26 cases (53%), postoperative radiotherapy just in 5 (10%).
According to histologic examination of the resection specimen, average percent of necrosis after neoadjuvant treatment was 70.6% (range 30 – 99%). Wound dehiscence occurred in 6 patients but ultimately healed succesfully in all of them.
At an average follow-up of 23 months (range 3 – 82), 37 patients were continuously disease free (76%), two patients had local recurrence (one amputated), four patients were alive with metastatic disease, five patients had died with disseminated disease (at 4, 19, 28, 37 and 61 months after surgery), one patient had died of unrelated disease.
Due to the inconstant tumor response, neoadjuvant treatment in soft tissue tumors is still a controversial issue. On the basis of data presently available, we think that it can be a useful treatment in high-risk tumors (larger than 5 cm; high grade). In these cases, at a low and acceptable rate of local complications, the conjoined use of preoperative chemotherapy and radiotherapy can help to make a limb-salvage surgery possible and at the same time can maybe reduce the risk of distant metastasis.
In the last fifteen years (1990–2005) at our Institution more than 600 patients affected by soft tissue sarcomas of the limbs and superficial trunk were surgically treated. We investigated the outcome and risk factors in a homogeneous group of 112 patients, affected by high-grade soft tissue sarcomas of the limbs (not metastatic at presentation) and treated with limb-sparing surgery, brachytherapy and conventional postoperative radiation therapy. Postoperative chemotherapy was added in one fourth of the cases.
The histologic types were liposarcoma (21.4%), leiomyosarcoma (19.6%), synovial sarcoma (17.9%), pleomorphic sarcoma or malignant fibrous histiocitoma (14.3%), fibrosarcoma (9.8%), other histotypes (17%).
All the tumors were high-grade (Broders grade 3 or 4). Size of the neoplasm was 10 cm or larger in 8 cases, 6 to 9 cm in 60 patients and 5 cm or smaller in 44 cases.
A limb-sparing surgical excision was performed in all the cases; histologically adequate margins were achieved in 96 cases (85.7 %). In 28 cases a myocutaneous or fasciocutaneous flap was necessary for local reconstruction.
At an average follow-up of six years, 67 patients (59.8%) were continuously disease-free; 8 patients (7.1%) had presented metastatic disease (in one case combined with local relapse) but were alive with no evidence of disease at last follow-up; 3 patients (2.7%) were alive with metastatic disease; 28 patients (25%) had died with disseminated disease; 6 (5.4%) had died of unrelated causes.
Local recurrence occurred in 10 patients (8.9%) requiring an amputation in 2; metastatic disease occurred in 39 patients (34.8%).
Four more patients required an amputation for complications different from recurrence: one early amputation for surgery-related complications and three late amputations for radiation-related complications (two not-healing fractures, one unresolvable wound sloughing).
Wound sloughing occurred in 12 patients (5 surgery-related and 7 radiation-related).
Local control rate, disease-free survival, overall survival and limb salvage rate were examined at 5 and 10 years, aiming also to identify tumor or treatment characteristics with prognostic value for the outcome.
The use of brachytherapy is an important option for achieving a significant boost in radiation within the surgical bed. Combined treatment with limb sparing surgery plus brachytherapy and external beam radiation therapy seems to offer satisfactory results in terms of local control and limb salvage survival. The use of myocutaneous or fasciocutaneous flaps is often useful in this kind of surgery, making possible a limb-sparing procedure with adequate oncological margins. New protocols and randomized studies on chemotherapy need to be introduced to improve systemic control and overall survival.
The management of localized soft tissue sarcomas remains complex. This is a retrospective review of a single institution experience with manual afterloaded brachytherapy following intra-operative implantation of the tumor bed during surgery.
Ten patients over a 4-year period had resection for localized soft-tissue sarcomas and desmoids with insertion of intra-operative brachytherapy implants combined with resection for localized soft-tissue sarcomas. Manual afterloading of the implant with iridium wires was done postoperatively in all patients. The low dose rate brachytherapy dose varied from 13 to 20 Gy. Supplementary external beam radiation was administered pre-operatively or postoperatively to bring the total dose of adjuvant irradiation to 60–65 Gy.
After a median follow-up period of 30 months, the 4-year local disease-free survival rate was 80%. The 4-year actuarial survival rate was 85%. There were no failures within the high-dose region of the implant. No patients had locoregional failures. One patient developed distant metastases. No serious side effects were noticed. Pro-phylactic intramedullary nailing was done in 1 patient. Pathological fractures occurred in 2 patients. All patients had good cosmetic and functional outcomes.
Intra-operative implantation of the tumor bed in combination with tumor resection for soft-tissue sarcomas results in a high degree of local control with acceptable complications. This modality offers the patient a high chance of avoiding a more radical surgical procedure such as limb amputation.
They have been evaluated after a mean follow-up of 3,6 years (13 months–15 years).
Five patients had grade I sarcoma, 17 grade II, 28 grade III and 1 unstated (FNCLCC classification). All but 5 presented a localised disease at the time of diagnosis. The reason for ILP was extracompartimental location in 10, contiguity to nervous or vascular structures in 10, the size of the lesion alone for 10 (up to 28 cm), and local spread of the tumor at presentation or by former surgical procedures 21. Thirteen patients presented major or longlasting post-operative complications, mostly cutaneous and neurological. Twenty-five percent of patients had a complete response to treatment, 44% a partial response, 17% no change and the remaining 14% a progressive disease. Ten radical (R0), 20 marginal (R1) and 4 intralesional (R2) resections have been performed 5,3 months (1,5–42) after ILP. Seven patients had a primary amputation (14%) and 10 had no operation or refused it. A reconstructive surgery was performed in 32% of the patients, and 27% had a complmentary radio- and/or chemotherapy. With a mean follow-up of 3,6 years (13 months–15 years), 33% patients were free of recurrence, 13% had local recurrence only, 27% distant only, and 27% both local and distant. From the 19 patients (40%) with local recurrence, 12 needed at least one new operation, with 5 more amputations.
Overall time to distant recurrence is 27,9 months (2–43), and to local recurrence is 22,3 months (2–78) respectively. Two and 5 years survival are 60,3% and 43,5% respectively.
a) 29 synovial sarcomas males:femals 15:14 (mean age 36), b) 15 leiomyosarcomas m:f 8:7 (mean age 62) and between 1997–2004 c) 26 malignant fibrous histiocytoma MFH m:f 11:15 (mean age 69) cases were treated individually with multimodal therapy regimen (irradiation/chemotherapy).
R0 resection was archived by 71% of the synovialsarcomas, 60% of leiomyosarcomas and 73% of MFHs’. The histological garding of synovialsarcomas was: G1: 0%, G2:21%, G3:73% and Gx: 6%. The histological garding of leiomyosarcomas was: G1:7%, G2:20%, G3:73% with 11 primary recurrences and the grading of the MFHs’ was G1: 7,7%, G2: 15,4%, G3: 69,2% und Gx: 7,7%.
Synovial sarcomas: After a follow-up of 8 (2–14) years the overall survival was 57%, after R0-resection 65% and after R1 resection 0%. The survival of G2 und G3 was 67% and 53% respectively. The survival of T1 and T2-tumors was 100% and 39% respectively. The 2- and 4 year survival of patients with primary metastases and local recurrence was 50% und 28%. 55% of the patients developed local recurrence. Leiomyosarcomas After a follow-up of 8 (2–14) years the overall survival was 33%, after R0-resection 44% and after R1 resection 17%. The survival of G2 und G3 was 33% and 27% respectively. The survival of T1 and T2-tumors was 50% and 33% respectively. The 2- and 4 year survival of patients with primary metastases and local recurrence was 73% und 32%. 80% of the patients developed local recurrence. MFHs’ After a follow-up of 4,5 (1–8) years the overall survival was 73%, after R0-resection 90% and after R1 resection 50%. The survival of G1, G2 und G3 was 50%, 75% and 83% respectively. The survival of T1 and T2-tumors was 100% and 75% respectively. The 2- and 4 year survival of patients with primary metastases and local recurrence was 20% und 0%. 19% of the patients developed local recurrence.
Scores for function and quality of life after treatment were 79% (37%–100%) for synovial- and 76% (53%–93%) for leiomyosarcomas and 76% (44%–100%) for MFHs
The aim of the present study was to compare health-related quality of life in CTEV to a background population.
80 reported to have CTEV and the remaining 29,516 were used as controls.
The self-reported prevalence of CTEV was 0.0027 (95% confidence interval 0.0022–0.0034).
80 reported to have CTEV and the remaining 29,516 were used as controls.
In the CTEV group SF-12 PCSmean was 50.18 (SD 11.19) vs 53.09 (SD 8.11) in the controls.
p< 0.0007.
In the CTEV group SF-12 MCSmean was 50.58 (SD 10.52) vs 51.78 (SD 8.47) in the controls.
NS.
Mean follow up time for the patients after they had undergone the procedure was 8.5 months (range 3 – 15). The Mean correction achieved – 16.15 degrees (range 5 – 40)
A less invasive surgical treatment of clubfoot is increasingly considered, it aims to limit extensive exposure, to improve the functional and cosmetic outcome and to lower the risk of stiffness and recurrence of the deformity. The Ponseti method consists in an original casting technique followed, only in the most resistant clubfeet, by a percutaneous Achilles tenotomy. Critical decision is the selection of the clubfeet which needs tenotomy. Purpose of this study was to determine if ultrasound assessment of clubfoot may be helpful in making surgical decision.
Patients were reviewed clinically and completed questionnaires documenting pain, function and satisfaction before and after treatment at a mean follow-up of 44 months (range 14–131). All patient’s notes and radiographs were examined.
Complications included almost universal minor pin-site infections, flexion contractures of the toes in 5 feet and skin ulceration in 2 feet, 1 requiring a muscle flap.
It is difficult to predict the outcome or likely treatment that will be required for an individual child with a rigid clubfoot deformity at an early stage.
32 Dimeglio grade II, III or IV CTEV feet in 24 infants were treated with weekly serial casts according to Ponseti method. Graphical plots of the improvement obtained in Dimeglio scores during serial cast treatment of CTEV were subsequently analysed to identify characteristic features that would help predict the likely success of casting or the need and extent of surgical release. The rate of change in global Dimeglio score, hindfoot (equinus/heel varus) and midfoot (adduction/derotation) components were specifically studied.
During casting the rate of change over 4 weeks and a “plateauing” of the global Dimeglio score after 4–6 weeks of casting separated those feet that responded to casting alone from those that required additional surgery. Those with “plateauing” and minimal midfoot deformity by 4 weeks (adduction/derotation score < =2) required a posterior release. Failure to correct the mid-foot deformity by 4 weeks (adduction/derotation score > = 3) predicted the need for a combined plantarme-dial and posterolateral release. These parameters were clearly demonstrated by graphical plots that can be easily obtained in a busy clinic setting.
Graphical representation of the rate of change in Dimeglio parameters can predict the likely treatment needed for children with CTEV. A graphical algorithm has been developed that can be used during the first 6 weeks of treatment to guide Ponseti method casting and early surgical intervention.
All presented with vague viral symptoms and developed rapidly spreading purpuric rashes within 24hours. 8 children were admitted from A& E and 4 were transferred from other hospitals. All received antibiotics, fluid resuscitation, ventilation and inotropic support. One child died within 14 hours of PICU admission. Haemofiltration was used in 11 children (mean 14.8 days, range 2–60 days).
We were able to follow up 8 of the survivors clinically.
8 children were followed clinically. 7 were mobile with walking aids with a mean of 1.3 prosthetic lower limbs (range 0–2).
In our study 2 of our 7 patients who underwent fasciotomy the demarcation level receded distally post decompression leading to more distal amputation levels.
Fibrous dysplasia is a genetic not hereditary disease of the skeleton, most frequently located at the femoral bone. The extension and the radiographic morphology of the femoral lesion are variable, and the prognosis is unpredictable. The purpose of this study is to propose a radiographic classification of the femoral lesion, related to the prognosis and the natural history of the disease.
The authors reviewed the radiographic examinations of 25 patients affected by fibrous dysplasia of bone with femoral involvement, who were followed-up at least two years after diagnosis. Eleven patients had bilateral localization of the disease, for a total of 36 affected femurs. A radiographic classification of the femoral lesion was proposed based on the localization, the extension and the type of the lesion.
The authors classify the femoral lesions as lytic, lytic with surrounding sclerosis, lytic and sclerotic, sclerotic and complex. They observed a prevalence of the lytic lesions and involvement of the proximal part of the femur. Many lesions (40%) expanded with age, and the sclerotic component also increased. The lytic lesions worsened with age, causing severe deformity of the femur. However the mostly sclerotic lesions turned out to be stable at follow-up. The worsening of the lesion was not related to the sex of the subjects; 77% of the worsened lesions were observed in patients younger than 20 years of age, while 66% of the stable lesions were found in patients older than 20 years.
In conclusion, this study demonstrated that the prognosis of the femoral lesion in fibrous dysplasia is related to the type of lesion, as per the radiographic classification here in described. Prognosis is also related to the age of the patient and the presence of a sclerotic component, which suggested a greater stability of the lesion.
Investigations include MRI for one patient and CT for another USG was done for the remaining four. There was no post op complication for any of them. None of them have shown any recurrence during the follow-up.
Cytogenetic evaluation often shows chromosomal anomalies of tumour cells like abnormalities of the long arm of chromosome 8, leading the rearrangement of the PLAG1 gene. Biopsy of the lesion is recommended, as clinical and radiological diagnoses can be misleading.
These tumours tend to spread locally and may recur in case of incomplete resection; metastatic potential has not been reported.
Differential diagnosis includes myxoid liposarcoma, welldiffrentiated liposarcoma, spindle cell lipoma, typical lipoma and soft tissue sarcoma.
Early detection and management of developmental dysplasia of the hip (DDH) yields simpler and more effective the treatment. Diagnosis by ultrasound has changed the clinical view of the disease. However, the need and the way of ultrasound screening is still controversial. Diagnosis by ultrasound has shown that morphological abnormalities may not be associated with clinical signs.
In Hungary all newborns are screened clinically within the first and also the third week of life, and controlled at the age of four month. Clinical examination is performed by an Ortopaedic specialist. Ultrasound screening is first performed for children with clinical signs and for children at risk at three weeks of age. Radiological examination, when necessary, is first performed at the age of four month.
In the five year timeline (2001–2005) that was re-evaluated 7339 children presented 9706 times for screening for DDH at the University of Szeged (Hungary) Department of Orthopaedics. Out of these cases 6991 (95.2%) children were found to be healthy and 348 (4.8%) were diagnosed for DDH. Children with dysplasia presented 896 times for treatment and follow-up. Patient compliance in the DDH group was average 2.5 visits, while for the healthy group it was only average 1.2 visits. Because of clinical signs or risk factors 1569 (21%) children had ultrasound examination, all-together 2169 times. 84% of the initial ultrasound examination showed Graf stage Ia hip. Out of the diagnosed 348 DDH cases 31 patients (Graf IIa-IIc) were administered with Pavlik harness, and 314 (Graf Ib-IIa) were treated with splinting. Remaining 3 cases were diagnosed late, where no ultrasound examination was performed. In the DDH cases 832 ultrsonographic examination was performed during the treatment (average 2.4 examination/case).
Radiographic control of all treated children excluded avascular necrosis in all cases. For this population 14 first operative procedure was needed so far. In our experience clinical screening and selective ultrasound examination is effective in the screening and early detection of developmental dyspalsia of the hip. In our practice, we promptly treated all patients with detected morphological changes as a deficiency in hip development. This way selective screening has helped us in the management of developmental dyspalsia of the hip. Hopefully, with the selective indication the number of false positive cases was reduced, while the „silent” clinical instabilities were given a chance for better long term development.
In group A (Weight bearing patients), 30 patients had mild temperature and 1 had moderate temperature. All of these 31 patients had normal WBC, CRP and their ultrasound showed effusion from 0 – 7mm. 12/31 patients had URTI.
In group B (Non weight bearing patients), 5 patients had mild temperature with normal WBC, CRP and their ultrasound showed effusion from 0 – 6 mm. 1/5 patient had URTI.
All the remaining 115 patients in group A and 17 patients in group B had normal WBC and CRP values.
No associated medical problems were found in 102 patients in group A and 12 patients in group B. Upper respiratory tract infection was noted in 40 patients in group A and 9 patients in group B. Gastroenteritis was noted in 4 patients in group A and 1 patient in group B.
. There is less information on normal foetal hip . Magnetic resonance imaging (MRI) allows development to be followed in the healthy baby.
To establish normal patterns of hip development.
To obtain charts that could be used to detect abnormality earlier.
There are three aspects to this study:
Validation – analysing MRI scans of babies hips prior to post mortem (the gold standard) would verify MRI as a valid tool for such studies. Measurements will be gained for foetus in utero Similarly for pre and term babies.
For the initial validation process, parents who had consented to post mortem were asked to consider additionally an MR scan of their neonate’s hips, a total of 30 cases.
Measurements were made, by two independent observers, of the width and depth of the acetabulum and the radius & diameter of the femoral head, volume and area were calculated. Inter-observer variation was assessed.
With the exception of the acetabular width each dimension showed little development until week 20 when the line of growth rose exponentially. The acetabular width showed only a slow rate of growth despite the changes seen in the femoral head. Levels of observer agreement were high (ICCs = 0.98) for all but depth (ICCs = 0.86). The measurements for all dimensions were in line with previous post mortem studies.
Follow up radiographs were graded for the presence of AVN by the Bucholz and Ogden method. Radiological outcome was graded by the Severin score. Average follow up was up to the age of 6.6 years (SD 2.9) for the closed reduction group, open reduction group 8.0 (SD 3.6) and femoral shortening group 9.0 (SD 3.9)
AVN scores
Closed Reduction (n=34) : Grade 1 : 5. Open Reduction (n= 11) : Grade 1: 2, Grade 2: 1, Grade 3: 1. Open, with shortening (n=24): Grade 1: 5, Grade 2: 1. Severin Scores: Closed I: 22 II:3 III:8 IV:0 Open I:6 II:1 III:2 IV:2 Shortening I: 8 II:8 III:3 IV:2
1) To determine the predictive value of a simple stability test in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation. 2) To determine the effect of cast quality as reflected in the skin cast distance (distance between the cast and the skin in the plane of major displacement or angulation) and the cast index (the inside diameter of the cast in the sagittal plane divided by the inside diameter in the coronal plane) on re-displacement rates in children’s wrist fractures treated with simple manipulation and plaster of Paris (PoP) cast immobilisation.
We looked at the re-displacement rate amongst these children that required a second procedure. We also sought predictive factors for redisplacement if any.
Redisplacement of fracture after initial satisfactory reduction was seen in 9 cases (12.7%) & required a second procedure. The secondary procedure involved closed reduction and percutaneous K wire fixation in 4 patients and open reduction in 2 cases. 3 cases had closed remanipulation & change of plaster.
We reviewed the factors responsible for re-displacement after a closed reduction such as initial displacement, angulation, adequacy of initial reduction, associated ulna fracture, type of plaster, and initial post-operative images.
Average age has been 12.7 years. 3 out of 5 (60 %) completely displaced fractures treated by closed reduction and manipulation required a second procedure. Only 1 in 16 cases of incompletely displaced fracture required a second procedure.
Volar angulated fractures tend to redisplace after closed reduction, 3 out of 7cases (42 %) required a second procedure. Associated ulna fracture (22.7%) increased the risks of redisplacement.
5 out of 24 epiphyseal injuries redisplaced but these were either severely displacement or had volar angulation. 3 out of 4 cases (75 %)that were severely displaced had inadequate primary closed reduction & underwent a second procedure.
In management of paediatric distal radius fractures, primary reduction with percutaneous Kirschner wire has better outcome and lower incidence of redisplacement in selected cases with features of complete displacement and volar angulation especially in the older age group (> 11 years).
The controversial issues in the management of distal radius fracture involve what constitutes a degree of fracture displacement and angulation likely to be compensated by remodelling with growth over time, indications for fracture stabilisation with wires or other invasive methods compared with plaster casting alone, details of the position of the arm during immobilisation in a cast, and whether the cast should immobilise the wrist alone or both, the wrist and the elbow. The management of buckle fractures of the distal radius is relatively uncontroversial, involving splintage for symptomatic relief from pain. Some authors have advocated removable wrist supports, with discontinuation of splintage at the parents’ discretion.
We performed a systematic review of all areas of the management of distal radius metaphyseal fractures in children. Growth plate injuries were not included for analysis.
Types of outcome measures:
Radiological deformity Effect of cast index Complications of k-wiring Remanipulation rates Compliance with splintage Cost of various forms of splintage Effect of intact ulna Upper limb function while immobilised Wrist and elbow ROM
10 studies complied with the inclusion criteria and were analysed using Review Manager software provided by the Cochrane Collaboration
Regarding displaced metaphyseal fractures:
K wire fixation reduces redisplacement There is no proven increase in complications with k wires Intact ulna favours redisplacement Long casts do not reduce displacement Short casts allow better early function
Regarding stable compression fractures:
Removable splints are not associated with displacement Patients prefer removable splints for buckle fractures Removable splints cause less discomfort and allow better early function
Objective: To determine the usefulness of computed tomograpy (CT) scans in the management of ankle fractures in children.
Distal femoral growth plate (DFGP) fractures were originally described as the ‘wagon wheel’ fractures, because they were noted to occur in the young boys who ran alongside wagons passing at speed and got their leg caught between the spokes. The resultant high energy injury was a forceful hyperextension and twisting of the knee. There was a significant incidence of severe complications with these injuries. In our setting, in a developing country, we noted that DFGP injuries appeared more common and tended to occur with a lower energy mechanism of injury.
To investigate if this were a real phenomena, we designed a prospective study looking at DFGP injuries with the primary outcome measure being the mechanism of injury and the secondary outcome measures including method of fixation and functional outcome.
The inclusion criteria for the study were all patients that presented with a DFGP fracture over a period of one year. There were no exclusion criteria. All data was collected prospectively on a standard proforma. Patients were treated according to a standard treatment regimen: where the fracture could be reduced closed and was stable, plaster cast only. Where a fracture could be reduced closed and was unstable, percutaneous pin fixation, where a fracture could not be reduced closed, open reduction and internal fixation.
Forty-three patients were included in the study. 39/43 (91%) of the patients were boys, and the average age was 15.5 years (standard deviation, SD, 3.2 years). Thirty-three (77%) of the injuries resulted from low energy trauma, with the majority (28/33) resulting from sporting injuries, predominately football, with others having simple falls (3/33) or falling off bicycles (2/33). The 10 high energy injuries resulted from pedestrians (3/10) or cyclists (1/10) hit by cars and falling from a height (6/10). Some significant differences were seen in the mean ages of the high and low energy groups. The low energy group were significantly older, with a mean age of 16.3 years (SD 2.8 years) compared to 13.1 years (SD 3.1 years) for the higher energy group (Student’s t-test, p=0.004). When comparing the type of fracture, according to the Salter Harris classification, significantly more Salter Harris IV and V fractures were seen in the high energy group (Chi Squared test, p=0.039) compared to the low. Open fractures were 1/10 (10%) of the high energy group, but there were no open fractures in the low energy group. Complications including infection and amputation, only occurred in the high energy group.
This is the first study to show, that in some countries, the DFGP injury may be more commonly due to a low energy mechanism of injury. The reasons for this may include delayed physeal closure, that has been previously shown in this group.
A prior fragility fracture is one of the strongest predictors for a subsequent one, and this should be a target for secondary fracture prevention. All injured patients admitted to the emergency floor, Ume̊ University Hospital, Sweden, were registered. Between 1993–2004, there were 113,668 injury events, including 29,190 fracture events (one or more fractures at the same time), of whom 12,635 patients were _ 50 years. 1,994 of them had at least two fracture events; 500 had 3; 131 had 4; 35 had 5; and 11 had _ 6 fracture events. Mean age at the baseline fracture was 72.2 years and 75.5 at the second one. Thus, over 50 years of age, not less than 37% of all fractures were serial fractures, and 20% of the patients are serial fracturers.
Hip and radius fracture were the most common ones, but 20% were fractures not traditionally labelled as fragility fractures. However, since more than 78% were caused by falls in the same level, most presumably have a fragility component.
The interval between the two first fractures was longer than reported in several previous studies, mostly on patients participating in clinical trials. However, our material is population-based and unselected, since there is just one trauma facility in the area, and the general population is healthier than in-hospital or trial patients. On the other hand, there is a cut-off bias, so the interval is likely to be even longer.
Interestingly, the difficult-to-treat hip fracture was the second common baseline fracture, the most common subsequent one, and hip-hip fractures were the most common combination, not less than 8.5% of the serial fractures. It is therefore clinically important to use the information provided by the fracture event, a fragility fracture may actually be regarded as a biomechanical test or a natural experiment. Trauma units, therefore, have an onus to screen for risk factors and inform patients about the treatment options, and to organize fracture liaison services. This seems to be especially cost-efficient for our oldest and frailest patients, but alas this is rarely done. A similar neglect of secondary prophylaxis and treatment after cardiovascular disorders would be an outrage! Secondary prevention is especially important since serial fractures are so common, often preventable, having a high impact on health-related quality of life
Even in patients with pronounced osteoporosis, fragility is rarely a sufficient or necessary cause of fracture. Almost always a trauma involved. Exposure to injuries varies with eg sociologic and climatologic. Since 1993 all injuries admitted to Ume̊ University hospital, Sweden, up to 58 parameters have been registered, eg mechanism, environment, involved products and diagnoses. The 12-year population-based injury register now comprises113,668 injuries (29,190 fractures).
The absolute number of fractures is important from a practical clinical point of view. Most fractures occur in the extremities of life, perhaps due to both a weaker skeleton in growth and senescence and to exposure to injury. The earlier fracture peak in girls is caused by their earlier growth spurt. The higher and broader fracture peak in boys also reflects behavioural factors. Men continue to have more fractures until around 50, showing the effect of menopause.
Radius fracture incidence in Ume̊ was about 15% higher than in Malmö, Sweden. But surprisingly hip fracture incidences were in the same order of magnitude in Malmö and Ume̊, which is remarkable considering the 8o latitude difference. But this may be explained by the different injury mechanisms in the two fractures
Low energy-trauma (fall in the same level) was most common in the extremities of life. However, most of the other mechanisms also involved low-moderate trauma, and high-energy trauma was rare. In this sub arctic register, outdoor slips was a common cause of fracture in middle age but as in other materials such injuries became less common with age.
A further detailed analysis of the mechanisms causing fractures and soft tissue injuries could be a useful tool in prevention of fall injuries. Is it possible to identify frequent fallers or other accident prone people, before an incapacitating injury? This would indeed be a major public health challenge
Pharmacological treatment for osteoporosis (%, Upon discharge vs. at 6 months): Global (38,1 vs. 31%), Calcium +/− vitamin D (8,2 vs. 18%), Ca-VitD + biphosphonate (28,1 vs. 10,8%), Biphosphonate only (3,4 vs. 1,7%). The patients that had received treatment upon discharge were morle likely to receive it at 6 months (RR 2,2, CI95% 1,5 – 3,2). Women, patients that had been sent to a temporary nursing home and patients that had a better functional status were more likely to receive treatment (p< 0,05). There was no significant correlation with patient age or previous fractures.
RESULTS: In the younger women (age 50–59) the HRQoL was lower compared to Swedish normative data. The EQ-5D index and VAS scores correlated moderately to the physical component summary (PCS-12) of the SF-12 (rs=0.73 and rs=0.69, respectively). The correlation to the mental component summary (MCS-12) of the SF-12 was lower (rs=0.32 and rs=0.22, respectively). Women who reported comorbidity and low physical activity scored lower in the corresponding items of health in both questionnaires.
These were analyzed for presence of any Distal Radius Fractures (DRF) prior to first admission for hip fracture and time period between first and second admission. It was also analyzed whether a DRF was sustained between these two episodes.
Out of these ninety five patients a small minority of patients had a DRF preceding their first hip fracture. Those sustaining DRF prior to their second hip fracture was also studied and statistical methods were employed to predict the presence of DRF prior to hip fractures
establish a method to directly quantify anatomic acetabular version on AP pelvic radiographs and to determine the validity of the radiographic “cross-over-sign” to detect acetabular retroversion.
Highly cross-linked polyethylene (XLPE) has been introduced in total hip arthroplasty in an effort to reduce polyethylene wear and the associated periprohetic osteolysis. Cross-linking is a procedure in which irradiation and subsequent heating stabilize the internal structure of PE. Most of the conventional PE’s used, are gamma irradiated in air or an inert environment with a dose level of no more than 25 to 50 kGy. By irradiating PE at a higher dose, optimally around 95–100 kGy, a definite reduction in wear rate has been achieved. History already provided us some mixed in vivo results regarding altered PE. Therefore, present time surgeons are cautious when it comes down to using a new PE.
Some short follow up in vivo studies already suggested reduced wear rates with XLPE in comparison to conventional PE. Our aim was to demonstrate these reduced wear rates in a 2-dimensional head penetration model using the DICOMeasure™ computerized edge detection method (GreyStone, France) and to perform a clinical comparison of both groups using the Harris Hip Score and SF-36 questionnaire.
Sixty hips with a Trilogy XLPE liner (Zimmer Co.) were age and BMI matched with a control group of twenty conventional Trilogy PE liners (Zimmer Co.).
No differences in clinical performance were seen, but a statistically significant reduction of 67% in steady state wear rate was observed in the XLPE group.
It is clear that, due to the reduction and stabilization of free radicals in polyethylene, a reduction in annual wear can be achieved.
At 8-years the wear rate was significantly (p< 0.01) lower for Duration [0.088 ± 0.03 mm/yr (0.02–0.14)] than conventional PE [0.142 ± 0.07 mm/yr (0.05–0.31)]. This reduction (−38%) compared well to the simulator (−45%) and did not change over time (−33% at 5-years). Radiolucencies and signs of osteolysis were also less in the Duration group (n.s.).
The annual wear rates were compared and intra-observer variability was calculated as the difference between both measurements (precision). The average time it takes to measure one image (without format conversions) was documented and practicality of daily clinical use was evaluated.
The precision was (mean +/− SD): Martell = 1.74+/−1.53, Hyperview = 0.36 +/−0.92, Pro-X = 0.10+/−0.11 Roman = 0.08 +/−0.08.
The average measuring time per image was: Martell = 94s, Hyperview = 94s, Pro-X = 92s Roman = 158s.
In all cases a specialized dedicated surgical instrumentation was used. Inclusion criteria to enter the study group (A-B-C Groups) were:BMI< 30, diagnosis of primary osteoarthritis, age< 75 years.
Following parameters were evaluated: intra and post operative complications, total blood loss, time of surgery, component placement, length of hospital stay and functional outcomes (HHS, WOMAC) at six weeks.
In control group D (149 patients) the following complications were observed: one proximal femoral fracture, one case of cup malposition and one infection.
66% do not use articular resurfacing, 33% are using short implants. 49% are using cellsaver regular, 99% are using wounddrains.
For minimal invasive procedure there is most used a lateral approach, for standard procedure the Kocher approach. New implants are used by every third surgeon, navigation by every fourth surgeon.
Different approaches for minimally invasive implantation of hip TEPs are currently the subject of lively discussion. The technique presented here is a tissue-saving procedure, independent of the implants used, and considerably accelerates early patient rehabilitation. The paper describes the double incision version of the Yale method with its special anatomical features, in particular contrast to Berger’s technique (Chicago). It is possible to work under accurate visual guidance in the acetabular and shaft areas without an X-ray intensifier. The structures of the pelvic and trochanteric muscle origins as well as the iliotibial band remain completely intact.
The results of the first implantations (n = 251) show shorter hospitalisation times, the possibility of muscle-compensated pelvic stabilisation on the first postoperative day, complete weight-bearing without crutches, reduced blood loss and the required EC substitution. The Merle d’Aubigne score both immediately after surgery and on completion of the follow-up rehabilitation shows higher values than conventional techniques. Analysis of the VAS shows considerably less postoperative pain than with conventional techniques.
The peri- and postoperative complications are discussed.
In summary, the Yale technique is a tissue-saving approach to the implantation of hip endoprostheses with pronounced advantages in early rehabilitation for the patient in the sense of immediate postoperative weight-bearing and muscular stabilisation of the pelvis and less pain.
In fall 2004 we started with minimal invasive hip surgery at our clinic. Our requirements: Use of our standard implant system (Bicon threaded cup and Zweymüller stem), fast realization of the minimal invasive procedure through the continuation of the used, anterolateral Watson-Jones approach, modified for this technique, retaining the supine position with unchanged orientation concerning the positioning of the implant parts. Our expectations: Reduction in operative trauma through lower blood loss with less post-operative pain, less limping especially during the first weeks, less trochanter pain through the preservation of the gluteal muscle tendons, fewer posterior dislocations by preservation of the dorsal capsule, and a better cosmetic result.
The patient is placed in supine position on the standard OR table with the option of tilting the legs down. The contralateral leg lies on a leg holder in extended position, flexed by approx. 20 degrees. This allows to bring the leg in hyperextension (without hyperlordosis of the lumbar spine), adduction and external rotation during broaching the femur. The main criterion of the minimal invasivness is the preservation of the gluteal tendons and not primarily the reduction of the length of the skin incision. An extensive capsular release with partial dissection of the rectus tendon for exposure of the acetabulum is necessary. For the stem implantation a notching of the piriformis can be necessary in addition to this. During the stem preparation the soft tissues should not influence the axial entrance of the rasps into the femoral canal otherwise there is a danger of a dorsolateral perforation. Right-left-lateral-double-offset rasps and the use of manipulation rasps as trial prostheses have worked satisfactorily. Retrospective analyses of numerous peri- and post-operative data were accomplished, as well as radiological evaluations regarding the optimal position of the implanted joints, and compared with a conventional control group.
After a learning curve the OP duration was the same in both groups. The development of the haemoglobin and hematocrit levels were identical, 1/3 of the patients needed blood subsitution (autologous or stored blood). 90% of the analysed postoperative x-rays in standing position showed equal bilateral leg length corresponding to the preoperative planning, the planned offset was achieved in 93%. Deviations of the remaining were without clinical relevance. The complication rate was 2,5%.
The fear of high complication rates, repeated surgery and component mal positioning, especially early in the surgeon’s experience, can be an obstacle for starting a new technique like minimally invasive THR.
The aim of the present investigation was to report on our learning curve of the first 100 consecutive minimally invasive total hip replacements through an anterior approach and to focus on intraoperative and postoperative complications as well as on the quality of implant positioning.
In order to have a comparison, the last 100 THR performed through our previously used direct lateral approach were retrospectively evaluated. In both groups, complex acetabular and femoral reconstructions were excluded as they were performed though a digastric trochanteric osteotomy. Every change of the initial surgical plan was considered an intraoperative, every change in the rehabilitation plan considered a postoperative complication. The quality of implant positioning was evaluated in a standardized anteroposterior pelvic x-ray and a cross table lateral view at the 3 month follow-up visit and included the positioning of the cup and the stem in both views and the amount of leg-length discrepancy.
In terms of age, gender, BMI, ASA-score and origin of osteoarthritis both groups differed not from each other. Intraoperative and postoperative complications were more frequent in the MIS-Group (17 versus 7) and occurred within the first 30 cases. 12 were solved during the same anesthesia and 2 during the same day without manifest disadvantage at the 3 month follow-up visit. In one case a dislocation occurred. In two patients neuralgia of the lateral cutaneous femoral nerve was successfully treated conservatively. Implant positioning and leg-length discrepancy did not differ between the two groups.
Overall, starting a minimally invasive technique was associated with more frequent complications; however, if recognized and appropriately managed nearly none of them resulted in disadvantages for the patient at the 3 months follow-up visit.
Patients were divided into two groups according to the injected drug. Group 1 or the injected group (n=91) received a caudal extradural injection (CEI) that consists of 12 to 15 ml of 2% xylocaine together with 1 ml of Betamethasone Dipropionate and Betamethasone phosphate. Group 2 or the placebo group (n=52), received a caudal extradural injection that consists of 6–8 ml of 2% xylocaine mixed with 6–8 ml of water for injection. The mean duration of symptoms was comparable between the two groups.
In order to estimate the degree of recovery from symptoms, all patients answered a specific questionnaire. The Oswestry Disability Index Questionnaire (ODI) was answered by all patients on the first day of clinical examination, and on different follow-up periods after caudal injection.
The straight leg-raising test was evaluated in all patients at the same follow – up periods.
We investigated the effectiveness of the TriaC™-Brace regarding the primary curve correction in Idiopathic Scoliosis (IS).
At the beginning of the therapy with the new orthesis the Risser sign was 2,68 at an average.
The daily wearing time was instructed with 22–23 hours.
Lumbar curves showed an average cobb angle of 26,1 degrees (standard deviation=8,6) and thoracic curves of 24,4 degrees (standard deviation=6,5).
The radiological assessment of primary curve correction (cobb-angle) was performed 6,2 weeks after the beginning of the therapy (anterior posterior radiograph of the spine in standing position with orthesis).
Further radiological controls were performed every six months. We evaluated the wearing time, comfort and leisure activity with a valid scoring system (Quality of Life Profile for Spine Deformities).
The overall mean wearing time of the Triac™-Brace was 14,7 months.
A insufficient primary curve correction (defined as < 30% of the initial cobb-angle) was observed in 16 thoracic curves (89%) and in 4 lumbar curves (30%).
An increasing correction during the therapy as reported by Veldhuizen (2002) could not be observed.
There was a curve progression of at least 5 degrees of the cobb-angle in 4 cases.
The evaluation by the scoring system (response in 85%) resulted in a high score for cosmetics (4,2/5) and mobility of the back (4,6/5). The wearing time was reported by 90% of the patients with 22–23h.
Larger studies are necessary to investigate the effectiveness of the orthesis in lumbar curves. The improved wearing comfort and cosmetics are a potential advantages of this new orthesis.
Aprotinin has been shown to reduce blood loss in a number of surgical specialities. Patients with Duchenne Muscular Dystrophy (DMD) bleed more during surgical procedures than patients without this condition. The aim of this study was to evaluate the effect of aprotinin in reducing blood loss in scoliosis correction surgery in patients with DMD.
A retrospective analysis of case notes was performed. Thirty two patients diagnosed with DMD who underwent surgical correction for scoliosis over the last 25 years were included. All patients underwent posterior spinal fusion and instrumentation, between the levels T3 and L3. All procedures were carried out by the same lead surgeon. Patient age, body weight, length of procedure, and estimated blood loss were recorded. Blood loss as a percentage of total circulating volume was calculated and compared between patients who had not received aprotinin (seven patients), and those who did (25 patients). Blood loss as a percentage of total circulating volume in the group of patients with aprotinin (range 37% – 107% mean 67%) was significantly lower (P< 0.05) than the group without aprotinin (range 67% – 157% mean 111%). There was found to be no statistically significant relationship between blood loss and length of procedure. There was no statistically significant difference in the duration of the procedure between the two groups of patients. Despite the small number of patients this study shows a beneficial effect for aprotinin in reducing blood loss during scoliosis correction surgery in patients with DMD.
In 1993 standardized, lateral radiographs of the lumbar spine were recorded and the bone mineral density (BMD) was estimated by digital x-ray radiogrammetry of standardised hand x-rays.
In the litterature patients suffering Mb. Scheuermann (MS) have been reported to experience more back pain and other back related constrains compared to subjects matched for age and sex. We have been unable to find publications on health-related quality of life by SF-12 or SF-36 in MS. The aim of the present study was to compare health-related quality of life status in MS to the background population.
The average postoperative kyphotic angle was 41.1 degrees (range 25–54 degrees) giving an average correction of 42.2 degrees per patient. The average postop lumbar angle was 51.8 degrees (range 20–70 degrees). The average follow up time was 25.3 months (range 6–60 months). At follow up the kyphotic angle was found to be 42.8 degrees average (range 24–55 degrees) and the lumbar angle was 57.6 degrees average (range 42–70 degrees). This technique is superior as it avoids sudden stretching of the anterior vasculature and possible rupture of the anterior longitudinal ligament (ALL) and provides correction at multiple levels, avoiding build-up of stress at any single level.
Pre- and post-operative Knee Society Scores for 2105 Total Knee Replacements (TKRs) with minimum three year follow-up were evaluated. The effect of gender, age at operation and BMI at operation on Knee Society Data at pre-operative review, at one year post-operatively and at three years after TKR was analysed.
Total Knee Score pre-operatively, and at both one year and three year review was found to be independent of gender, age and BMI. There was no effect of the three demographic variables on the component scores for pain, range of motion, stability, alignment, extensor lag and flexion contracture.
Lower Function Scores were associated with female gender (p< 0.001), age greater than 70 at time of operation (p≤0.004) and obesity (p< 0.001). Median Function Scores were consistently higher in males than females by 5 points pre- and post-operatively (p< 0.001). At three years post-operatively, the median Function Score in the 80 and over age group was lower than all other age groups (p< 0.001), by between 15 and 20 points. Whilst the normal and overweight groups had similar Function Scores the class I obese and class II obese groups consistently had lower median Function Scores by 5 (p< 0.001) and 10 points (p< 0.001) respectively.
We conclude that whilst the Knee Score and its component scores are independent of gender, age and BMI, all three of these demographic variables can be associated with significant differences in Function Score.
The objective of the present study was to analyze in vivo the knee joint kinematics in the sagittal plane in a patient population that had received either a fixed or a mobile TKA in a prospective, randomized, patient- and observer-blinded, clinical study.
All patients had been operated in a prospective, randomized, patient- and observer-blinded, clinical study, and had received either fixed or a mobile bearing, cruciate retaining Genesis II TKA for primary osteoarthritis.
Fluoroscopic radiographs were evaluated by measuring the „patella tendon angle” as a measure of antero-posterior translation as well as the “kinematic index” as a measure of reproducibility.
This research was supported by funding from Stryker UK.
To decrease haematoma formation, primary soft tissue homeostasis and adequate tissue repair are essential. Growth factors, especially PDGF (platelet derived growth factor) and TGF-β (transforming growth factor-beta), play a crucial role in the biochemical cascade at the site of repair. These growth factors are mostly derived from platelets.
The objective of this study was to evaluate the effect of autologous platelet concentrate on blood loss (postoperative decrease of haemoglobin concentration), wound healing complications, range of motion, pain reduction and outcome scores when used in total knee arthroplasty.
The peri-operative haemoglobin concentration, peri-operative range of motion, haematoma formation, number of days of wound drainage and complications were collected. The pain score (VAS), IKSS, 12 questionaire score and SF-36 score were recorded at regular intervals.
All patients completed the Oxford Knee Questionnaire preoperatively as well as at 1 and 2 years postoperatively. Their stated kneeling ability and total scores were analysed with a perfect score for kneeling ability being 4, and 48 the maximum total score.
There was a more striking difference with respect to kneeling ability with the fixed bearing variants performing better, (Rotaglide 1.4; 0.9 and Uniglide 1.9; 1.4), However, the greatest difference was between the UKR and TKR groups (UKR 1.7; TKR 1.2). Pre-operatively less than 2% of TKR patients (7% of the UKR patients) could kneel. Post-operatively, the patients’ kneeling ability improved with 21% for the mobile bearing, 32% of fixed bearing UKR patients. The TKR patients kneeling ability was 13% of the mobile, 26% of fixed bearing patients were able to kneel with little or no difficulty. In all groups the stated kneeling ability was poor with less than 50% of any group being able to kneel with ease or only minor difficulty.
Loosenings needing revision: 10 times (2%) in the cemented group, 2 times (1,5%) in then cementless cases.
The radiological investigation showed less radiolucent lines in the cementless cases.
The merit of staging bilateral total knee arthroplasties (separate procedures) versus replacing both joints at the same anaesthetic (sequential) is a topic debated in literature. The aim of this study was to evaluate & compare the clinical outcome in patients who had undergone either bilateral staged or sequential total knee arthroplasties (TKAs).
METHODS: Computerized database and medical records of patients who had had bilateral TKAs in the Tayside region between 1984 and 2003 were retrospectively evaluated. Outcome was assessed using Knee Society Score, Pain Score, Function Score and Range of Movement.
RESULTS: 438 sequential and 526 staged procedures were evaluated. The sequential group had better function score at 1 and 3 years (P< 0.001). There was no other statistically significant difference in the outcome measures.
The mean ages of the sequential and staged study groups were 70.67 and 69.19 years, respectively (P=0.011).
Frequently surgeons performing total knee replacements are faced with the dilemma of whether to notch the anterior cortex or overhang the medial and/or lateral cortices when implanting the femoral component. This is almost always seen in female patients. There is also a higher incidence of patellar alignment problems in female patients post total knee replacement. A unique 3D to 3D matching study of 202 cadaveric femurs has demonstrated a significant difference in the average comparable shapes of male versus female distal femoral anatomy. For the same AP dimension, female distal femurs are more than 5mm narrower. Also the angle formed between the anterior condyles and the posterior condyles are significantly different with the female being more trapezoidal in shape.
Most existing total knee femoral component designs follow the ratio similar to that found in the average male distal femur. Options for management of this gender variability have been either utilizing instrumentation that references the anterior cortex to avoid notching or placing additional flexion on the distal femoral cut to allow downsizing. Both techniques are potentially problematic. Total knee implants systems are now utilizing this anthropomorphic data to redesign for separate male and female femoral components taking into consideration the relatively narrower female distal condylar width, lower medial anterior femoral condyle, and greater patellofemoral Q-angle.
With regards to vancomycin release, high antibiotic levels were detected within the first 3 days and low concentrations after the first week. Cement samples from Group II eluted significantly more antibiotic (80%–100%) in comparison with samples from Group III during the first days.
Gentamicin and vancomycin are detectable in measurements at 150 and 180 days samples.
All patients were evaluated prior to surgery. The patients with coexisting inflammatory disease or peri-prosthetic fracture were also evaluated.
A hip was diagnosed as infected on the basis of positive intra operative microbiology samples three or more out of five and or histological evidence.
14 patients had an underlying inflammatory arthritis and 5 were peri prosthetic fractures. The inflammatory markers tended to be elevated in these patients. Excluding these 19 patients and using the same criteria, the positive predictive value was 65% and the negative predictive value was 97%
There were two smokers and one patient was very overweight.
Plasma D-dimer levels were measured as a prerequisite test in all patients before undergoing VQ scan to confirm the absence of PE. All patients had either mechanical, such as foot pumps, or chemical DVT prophylaxis.
The classical triad of dyspnoea, pleuritic chest pain and haemoptysis occurred in only 2 patients. Signs of DVT were present in 3 patients. The electrocardiographs were normal in only 4 patients, though changes particularly suggestive of PE (S1Q3T3, Right bundle branch block or right heart strains) were absent in all of the patients. Chest X-ray changes were of limited value. None showed any of the supposedly characteristic changes.
All of the patients had a VQ scan were started on chemical treatment for PE and non of them had definite PE, 12 the patients had probable PE Those patient with probable scan were not subsequently given anticoagulants owing to their medical conditions
i) powdered vancomycin or teicoplanin, ii) aqueous solution of vancomycin or teicoplanin.
With regards to samples from Groups IV and V (aqueous solutions of antibiotics) mechanical properties were significant deteriorated in comparison with cement samples from the other groups.
Aqueous solutions of antibiotics must not be added to the bone cement because they dramatically impair mechanical properties of the cement.
Implantation of antibiotic-loaded beads is accepted as an efficient option for local antibiotic therapy in orthopedic-related infections. However, recent reports have emphasized the bacteria growth persistence on antibiotic-impregnated bone cement. Hence, the aim of this study was to elaborate if bacterial adherence and growth could be determined on explanted gentamicin- and gentamicin-vancomycin-loaded beads after infection eradication. 18 chains of antibiotic-loaded beads (11 gentamicin-, 7 gentamicin-vancomycin-loaded) were examined. Indications for primary beads implantation included postoperative infections after total hip or knee arthroplasty, rotator cuff reconstruction, chronic foot osteomyelitis, anterior cruciate ligament reconstruction and dorsal spondylodesis. Among the isolated organisms, Staphylococcus epidermidis, Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) were the most frequent ones. In 4 cases (3 × S. epidermidis, 1 × MRSA) bacteria growth persistence could be determined on the beads. S. epidermidis-strains persisted only on gentamicin-loaded beads, MRSA could grow on gentamicin-vancomycin-impregnated cement. In one case, the emergence of a gentamicin-resistant S. epidermidis-strain could be observed despite preoperative susceptibility. Bacteria growth persistence on bone cement is a hazardous problem in the orthopedic surgery and should therefore be born in mind. Adherence to cement can lead to emergence of bacteria resistance despite preoperative antibiotic susceptibility and might result in clinical recurrence of infection.
1) observational study to analyse surgeon’s and anaesthetist’s attitude to transfusion 2) prospective study to analyse the influence of perioperative haemoglobin concentration (Hb) on post-operative fatigue, hand grip strength, duration of in-patient physiotherapy and post-operative morbidity score (POMS) and also the prognostic factors to predict functional recovery.
200 patients (88 THR, 99 TKR, 13 hip resurfacing) were evaluated. Blood Hb, hand grip strength and vigour scores using fatigue questionnaire were estimated both preoperatively and at 3 days following surgery. POMS and the required duration of in-patient physiotherapy were also noted. The protocol for blood transfusion was for those with Hb less than 8 g/dL and/or post-operative symptoms attributable to anaemia.
A greater fall in postoperative Hb correlated significantly with a greater reduction in post-operative vigour score (p=0.02). Also a greater fall in vigour score was found to correlate significantly with the duration of in-patient physiotherapy (p< 0.001). A reduction in Hb of > 4g/dL from the pre-operative Hb predicted a significantly higher reduction in vigour score (p=0.03). A weak correlation was seen between a fall in Hb and POMS (p=0.09).
A higher pre-operative Hb did not reduce the required duration of in-patient physiotherapy (p=0.72). There was no correlation between post-operative Hb and POMS (p=0.21) or duration of in-patient physiotherapy (p=0.20).
A higher pre-operative grip strength predicted an early date of discharge by the physiotherapists (p=0.02).
Immunosuppressive drugs such as glucocorticoids or methotrexate may increase the susceptibility to bone infection by decreasing AP-expression levels in case of microbial challenge. Novel approaches to management are required particularly in the era of multi-resistant bacterial strains. Current investigation will focus on the regulation of human β-Defensins in bone and may allow artificial amplification for prevention of bacterial bone infection in the future.
Rivaroxaban is an oral, direct Factor Xa inhibitor in clinical development for the prevention of VTE after major orthopaedic surgery. Data from three phase II trials of twice-daily (bid) rivaroxaban in patients undergoing elective, total hip or knee replacement were pooled to determine whether age, gender or weight affected the efficacy or safety of rivaroxaban, and thus whether dose adjustment would be necessary. Patients received 5–9 days of oral rivaroxaban (2.5–30 mg bid, post-operatively), or s.c. enoxaparin. A logistic regression model using total daily dose of rivaroxaban as a covariate, and adjusted for differences between dose groups with respect to study, age and gender, was used to estimate rates of the primary efficacy endpoint (DVT, PE or all-cause mortality; n=1380 intention-to-treat patients) and clinically relevant bleeding (major and non-major clinically relevant bleeding; safety population, n=1854). Rivaroxaban at total daily doses of 5–20 mg had similar efficacy and safety to enoxaparin. Overall, logistic regression showed a positive dose–response relationship with rivaroxaban for clinically relevant bleeding (p< 0.001), and a flat relationship for the primary efficacy endpoint (p=0.115). The risk of VTE increased with age – the efficacy endpoint was estimated to occur in 17.3–9.4%, 18.7–17.3% and 26.6–20.2% of patients aged < 60 yrs, 60–70 yrs and > 70 yrs receiving rivaroxaban (total daily dose 5–60 mg), respectively, in separate regression models. Age was also prognostic for clinically relevant bleeding with rates of 1.4–12.0% (< 60 yrs), 2.7–15.4% (60–70 yrs) and 5.7–15.4% (> 70 yrs). The rates are for a population distributed equally across the studies and genders. Incidences of the efficacy endpoint were higher in females (25.8–20.5%) than males (16.6–10.7%), while clinically relevant bleeding occurred more frequently in males (5.4–16.3%) than in females (1.7–11.6%), after adjustment for age. Weight was not prognostic for the efficacy endpoint or clinically relevant bleeding (p=0.87 and p=0.48, respectively, after adjustment for age, gender and study), nor did it modify the dose–response relationships with rivaroxaban. Incidences of the efficacy endpoint for a population of equal study and gender distribution and of mean patient age were 23.4–15.7% and 19.1–14.6% in patients weighing < 65 kg and ≥90 kg, respectively, with corresponding bleeding rates of 3.3–16.5% and 3.2–17.5%. This analysis indicates that age, gender or weight did not affect the dose–response relationships (or lack thereof) between rivaroxaban and the primary efficacy endpoint or clinically relevant bleeding. As expected, age was prognostic for VTE and bleeding. These findings suggest that rivaroxaban may not require dose adjustment for age, gender or weight in orthopaedic patients.
Patients and methods: A total of 500 (430 primary THR and 70 revision THR) consecutive patients were included in the study performed between January 2004 and May 2005 in Frederiksborg County (Denmark). They were to be followed for 90 days after surgery. Patients were interviewed before surgery for medical history and on days 5 (while in hospital) and 90 (by telephone call) for signs and symptoms of acute myocardial infarction (AMI), pulmonary embolism (PE), deep-vein thrombosis (DVT), transitory cerebral ischemia (TCI)/stroke and retinal vein thrombosis (RVT). The validity of the events was confirmed using files from hospital, general practitioner and international criteria.
Results: Overall, 498 patients were followed-up for 90 days, 2 patients having withdrawn consent. In-hospital pharmacological thromboprophylaxis was performed in 499 patients. Twenty-four patients (4.8%) experienced at least one serious TEC up to day 90: 2 (0.4%) patients died from surgical-related complications (no autopsy was performed); 1 (0.2%) patient experienced AMI, 5 (1.0%) had PE, 10 (2.0%) DVT, 4 (0.8%) TCI, and 2 (0.4%) RVT. Moreover, 2 patients experienced two TEC: AMI followed by TCI in a first patient, PE and TCI in a second patient. The first event occurred up to day 5 in 9 patients (38%) and after day 5 in 15 patients (62%). Five patients (1%) had clinically relevant bleeding complications: 3 patients had a single, minor, upper gastrointestinal bleeding episode while in hospital, one patient developed a huge expanding haematoma at the operation site treated with hip spica and another patient a peritoneal haematoma leading to re-operation.
Conclusion: This study performed in an unselected population clearly shows that THR still results in serious TEC in spite of a wide use of modern anaesthesia techniques, thrombosis prophylaxis and early mobilisation. In the future, we need to better identify at-risk patients in order to optimise their management, in particular post-discharge care, and reduce the risk of serious TEC.
Recently, the International Consensus Statement Group reported that mechanical prophylaxis with foot-pumps should be considered “Grade A” recommendation for prevention of deep-vein thrombosis after total hip replacement. Mechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of thomboembolic disease following major orthopaedic surgery procedures. Recent duplex ultrasound studies have suggested that simultaneous use of graduated compression stockings (GCS) may hinder the pneumatic compression effect of foot pumps. The hypothesis of this prospective study was that the use of foot-pumps without GCS does not affect the efficacy of DVT prophylaxis, and improves patient compliance.
846 consecutive patients admitted at a single institution undergoing total hip (THR) or knee replacement (TKR) were included in the study. The A-V Impulse System® foot-pump units (Orthofix Vascular Novame-dix, Andover, UK) was used in all patients. Forty-six patients discontinued the use of foot-pumps, leaving 400 patients who received foot-pumps in combination with GCS and 400 patients with foot pumps alone.
Eleven patients of the stocking group (2.7%) and 9 patients of the no-stockings group (2.3%) developed postoperative symptomatic DVT (p=0.07). DVT was more frequent in TKR (10 of 364; 2.7%) than in THR (10 of 436; 2.3%). Non-fatal pulmonary embolism occurred in 4 patients out of 20 with symptomatic DVT, 2 each of the stockings and no stockings groups. The foot pump discontinuation rate of patients treated with stockings was 7%, versus 4% of patients treated without stockings (p< 0.05).
In conclusion, management of patients with foot-pumps without GCS does not reduce efficacy of DVT prophylaxis after THR and TKR, and improves patient compliance.
97 grade III open fractures in 95 patients 64 required temporary spanning ex-fix: 23 applied at trauma centre/41 at DGH 14/64 ex-fixes required revision (prior to definitive Ilizarov): poor plastics access(6)/instability(2)/both(6) All 14 revised had been applied in a DGH, i.e. 14/41 DGH ex-fix needed revision (34%) Ex fixes revised after application at trauma centre vs. DGH = 0/23 vs. 14/41, p<
0.01 ×2 Revision of Hoffman hybrid vs. monolateral ex fix = 4/4 vs. 10/60 p<
0.001 ×2 Non modular system (Orthofix) vs. modular systems (Hoffman II/AO) = 7/17 vs. 0/39 p<
0.001
All Hoffman hybrids needed revision, due to both instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular (Hoffmann II/AO), due to poor plastics access.
The mean Haemoglobin of the reinfused blood in the hip group was 6.9 gm/dl significantly lower (p< 0.05) than the drained blood Hb. of 10.9. Similarly the Haemoglobin of the blood reinfused in knee replacements was significantly lower at 6.8 gm/dl. (p< 0.001). This was less than half of the average Hb. content of homologous blood transfusion.
Tourniquet induced ischemia-reperfusion syndrome (IRS) may trigger systemic inflammatory response following a total knee arthroplasty. The IRS will be studied in a prospective randomized controlled study in humans undergoing total knee arthroplasty, by measuring blood inflammatory mediators and blood gases.
The aim of this study was to establish an atrophic non-union model in the rat femur under well defined biomechanical conditions and with minimised interactions between the processes in the healing zone and the implant by using external fixation.
Sudeck’s atrophy was observed in 10 patients (18.6%) that healed within four months. Three pin tract superficial infections (5.6%) were resolved without removal of the device. Three patients (5.6%) showed thalamic displacement following early weight-bearing but did not require further surgery.
Single centre prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation.
Operations performed by several different surgeons including senior author.
Definitive fixator used as a reduction tool in 34 cases, fracture reduction device used in 162 patients – ST.O.R.M
Followed up in a dedicated external fixator clinic by the senior author until one year post fracture healing.
Fracture healing was determined by fracture stiffness measurements.
111 right sided and 85 left sided.
166 male and 30 female.
116 fractures due to low energy and 80 due to high energy.
Mechanism of injury: football 75, fall 52, RTA 49, direct blow 7, assault 4, rugby 3, crush 2, dancing 2, bowling 1, roller skating 1.
33 patients had an additional 74 injuries: 35 fractures (3 open), 7 compartment syndromes, 3 dislocations, 7 head injuries, 16 chest injuries, 9 soft tissue injuries.
According to AO classification system: 33 A1, 47 A2, 42 A3, 15 B1, 46 B2, 7 B3.
Time to # healing was 19 weeks on average (range 9–87)
X ray data: 15 patients had deformity > 5 degrees in the coronal plane and 1 of these also had deformity > 10 degrees in the saggital plane.
One patient underwent osteotomy for correction of malunion.
85 patients had a total of 279 pin site infections requiring Abx (6 with 14 pin infections requiring iv abx), and 33 pins were removed due to persistent infection. 15 patients had 32 ring sequestra which settled with debridement under GA.
7 fixators removed early due to pin site infection.
1 established osteomyelitis-lautenbach.
7 refractures, all healed(5 with pop, 2 with further fixator)
Non-union: 5 hypertrophic, 2 atrophic-all healed with further external fixation.
Malunion: 1
Our study also uses a well validated end point to define fracture healing and does not rely on the difficulty of defining healing on clinical or radiological grounds which is known to be unreliable. This is the first time this highly repeatable methodology has been used for such fractures.
Pin placement into the medial calcaneus places a number of structures at risk of damage. Research evidence suggests that the greatest risk of posterior pin placement is to the medial calcaneal branch of the tibial nerve. By using palpable anatomical landmarks, we attempted to redefine the safe zone taking into account possible variations. The medial heel region of twenty-four cadavers was dissected to find the major structures at risk. The inferior tip of the medial malleolus (point A), insertion point of tendo calcaneus (point B), navicular tuberosity (point C) and the medial process of the calcaneal tuberosity (point D) were all selected as anatomic landmarks from which to measure the identified structures using digital electronic calipers. The commonest variation in origins of medial calcaneal nerves was found to be one arising before the bifurcation of the tibial nerve along with one arising from the medial plantar nerve (10/24). The safest zone for percutaneous pin placement has been calculated as beyond two-thirds of the distances AB, CD, AD and CB. More posterior pin placement reduces the risk of damage to the medial calcaneal nerve and its branches, although the risk remains and blunt dissection before pin placement is recommended.
Open reduction and reconstruction with osseous grafts (autologous grafts in 22 cases and heterologous grafts in 52 cases) were used in 74 cases. In 8 cases (all of Bohler II type) grafts weren’t used. Osteosynthesis with plate and screws was performed in 26 cases and with pins in 56. The 2 groups were similar in what concerns age, sex ratio, BMI, degree of comminution. The surgical procedure was delayed in both groups (average − 6 days). Pins were removed at 6 weeks and the plates at 12 months.
Reduction was performed by an extended lateral approach, and checked under fluoroscopy. Joint reduction was fixed by screws. The reconstruction plate, bent in a standard way, was then placed laterally, from above the tuberosity towards the inferolateral part of the anterior process. All but one or two posterior screws ideally converge to the sustentaculum tali (ST), building a strong support below the posterior facet. Postoperatively partial weight bearing below the threshold of pain was allowed in the majority of cases. Clinical results were assessed using the French Orthopaedic Society (SOFCOT) functional score for both series, and AOFAS (American Foot and Ankle Society) score, and Mary-land Foot Score (MFS) for the recent series.
Reduction was assessed anatomic on the postoperative Broden view in 90.5% of cases. The average Böhler’s angle remained stable. Secondary fusion of the subtalar joint was required only in 4 cases (2.1%). Wound healing was delayed in 19.7%, but generally, it was spontaneously obtained in a few weeks. Three deep late infections (1.6%) healed after plate removal.
Opinions is divided among surgeons whether to operatively fix displaced calcaneal fractures in elderly patients and heavy smokers. In a long term follow-up of operatively treated calcaneal fractures, we considered several factors that could affect outcomes and complication rates.
Method: 59 calcaneal fractures in 54 patients that underwent operative fixation for displaced intra-articular fractures from April 1995 to January 2006 were reviewed. There were 18 Tongue type and 41 Joint depression fractures on X-rays. Of 38 available CT scans, 25 were Sanders Type II and 13 were Types III and IV fractures.
Average interval to surgery was 6 days. Postoperative mobilisation regime was passive range of motion immediately following surgery with non weight bearing for 6 weeks. Weight bearing was started at 6–8 weeks. On follow-up, patients were assessed with clinical and radiological exam, completed Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot scale and Visual Analogue Scale (VAS) scores.
Smoking was not associated with early or late complication rates and did not affect outcome.
Between 2000 and 2004 we used subtalar arthrodesis to treat 44 patients for continued pain after intra-articular calcaneal fracture. All the fractures were due to laboral accidents.
Average time to union was 3 month(2 to 4 months). Complications were minor in 12 patients and major in 10 patients.
Lenght of follow-up was 23 months.
Hindfoot scores (clinical rating system of the American Orthopaedic Foot and Ankle Society)improved from 35,11 to 67,22.
The results were excelent in 7 patients, good in 24, fair in 7 and bad in 6 patients. Return to previous activities was possible in 26 pacients.
We concludes that subtalar arthrodesis represents a rather effective treatment of the subtalar arthritis due to inta-articular calcaneal fractures.
The majority of patients can have improvement with surgical reconstruction but pain relief is usually not complete.
1) the ulnar lip or trough of the radiocapitellar joint in pronation and 2) the posterior or midportion of the MRPUJ.
In cases in which the contralateral side can not be tested or is known to be abnormal the relevance of the ballottement test is compromised.
Based on the observation that distal radioulnar joint passive mobility decreases in normal subjects when the wrist is radially deviated we propose a modification of the ballottement test in which mobility of the DRUJ is tested both in radial and ulnar wrist deviation.
Our clinical case series reports the review of clinic notes and operative records of 32 patients (age gender) (32 wrists) who demonstrated an abnormal modified ballottement test and whose degree of instability granted surgical intervention.
All patients in the case series were found to have an ulnar detachment of the dorsal aspect of the TFCC (Palmer 1B) for which they underwent open repair.
The observed decreased mobility of the DRUJ is likely to be due to tightening of the ulno-carpal ligaments.
An abnormal modified ballottement test was an indicator of severity as those with a positive result required surgical intervention and also correlated with the anatomical lesion found at surgery (Palmer 1B TFCC tear)
We believe the proposed modification enhances the diagnostic value of the DRUJ ballottement test and also allows to detect abnormalities in those cases in which the contralateral side can not be examined.
Our study investigated a consecutive series of 53 cal-caneal fractures treated at Southend General Hospital during a 4 year period. In total 75% were intrarticular and 25% extrarticular. Overall 51.92% of patients underwent operative intervention 66.67% of these being intrarticular. All patients underwent AOFAS scoring. The minimum followup period was 6 months and the average was 18 months.
In the non-operative group (Undisplaced intra/extrarticular with Bohler’s angle 20–40 degrees) the < 50 year old group had an average AOFAS score of 86.3 versus 63.64 in the > 50 year old group.
In the operative group the AOFAS score was heavily dependent upon restoration of Bohler’s angle. This study shows that if Bohler’s angle is < 20 degrees the average AOFAS score after followup was 51.00 but if the angle has been restored to > 20 degrees the average score is 69.53. This result is reinforced by the fact that 75% of patients returned to work in the > 20 degree Bohler’s angle group wheras only 33.34% returned to work in the < 20 degree group.
This study shows that surgical restoration of Bohler’s angle to > 20 degrees gives a better outcome than for conservative treatment.
We report the 15 year follow-up of displaced intra-articular calcaneal fractures from a randomised controlled trial of conservative versus operative treatment. Of the initial study, 46 patients (82%) were still alive and 26 patients (57%) agreed to review.
The clinical outcomes were not different between operative versus conservative treatment. American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scale: p = 0.11; Foot Function Index (FFI): p = 0.66; and calcaneal fracture score: p = 0.41. The radiological outcomes also were not different between both groups. Böhler’s angle: p = 0.07; height of calcaneum: p = 0.57; and grade of osteoarthritis of the subtalar joint: p = 0.54. There was no correlation between Böhler’s angle and the outcome measures in either group.
The results of this 15 year follow-up of displaced intra-articular calcaneal fracture randomised controlled trial demonstrate similar findings to those at one year follow-up.
The ICC value between the secondary measurements of the observers was,9980 and considered torsion to be significant. (p< 0.0001)
The ICC value between the both measurements of the first observer was,9975 and the found torsion to be significant. (p< 0.0001)
The ICC value between the both measurements of the second observer was,9956 and the found torsion to be significant. (p< 0.0001)
The results of surgical treatment of post-traumatic elbow contractures in adolescence have been conflicting in the literature. Some authors suggest that contracture release in this age group is less predictable and results less favorable than in adults. A retrospective review of the senior author’s patients produced 16 patients under the age of 21 that had post-traumatic elbow contracture releases. Three patients with arthroscopic releases and one patient lost to follow up were excluded from this study.
Twelve adolescent patients (mean age 16.7 years, range 13–21) had open release of post-traumatic elbow contractures. All releases were initiated through a lateral approach with anterior capsular release and were supplemented by posterior release (in 4 patients) through the same incision. Medial-sided pathology was addressed through a separate medial incision in 3 patients. In three patients the radial head was excised. Muscle lengthening was used in only one patient.
The mean follow-up was 18.9 months (range 10–42 months). Preoperative flexion was increased from 113 to 129deg (p< 0.01), extension from −51 to −15deg (p< 0.001) for a mean total gain of 54deg in the flexion-extension arc (p< 0.001). Pronation was improved from 58 to 77deg and supination from 56 to 62deg, but these improvements did not reach statistical significance. At the final follow-up the patients maintained 93% of the motion that was achieved intraoperatively. All patients achieved a functional ROM of at least 100deg in the flexion-extension arc. No patient lost motion. One patient had a superficial infection that was treated conservatively
Our experience with post-traumatic contracture release in adolescent patients has been rewarding; all patients reached a functional range of motion. The advantage of the lateral approach used in these patients is that it allows simple and safe access to the anterior capsule, which is often adequate to regain full extension. Through the same approach the posterior structures can also be addressed without violating the lateral collateral ligament. The medial approach is more demanding and was reserved only for patients with medial sided pathology. Fractional musculotendinous lengthening was rarely necessary in post-traumatic contractures. Open release in adolescent patients with congruent stiff elbows has yielded satisfactory results in our hands.
This study also discusses various issues regarding operative techniques (surgical approaches, debridement of joint and capsular releases).
The new tissue obtained was tested using the ICRS classification, and analysed biomechanically by the Artscan 200 series. We performed besides immunohistochemical evaluation of cartilage to check collagen type I.
Four weeks after transplantation immunohistological analysis show in the treatment group cartilaginous tissue; The cells in the repair cartilage were round and arranged in numerous small clumps; the matrix showed strong metacromasia, indicating that this was hyaline cartilage. eight weeks after transplantation, the cells were largely distributed on the area and the repair tissue still resembled hyaline cartilage. After eight weeks the repair tissue implanted was fibrous with prevalence in extracellular matrix of Type II collagen.
To demonstrate evidence of Chronicle Compartmental Syndrome we performed a diagnostic test based on the measure of the intracompartmental pressure after stimulating their usual sportive activity. We considered a positive test when the measured an IMP> 15 mmHg after effort. We also performed a dynamometric of their grip and strength of the thumb-index forceps before and after surgery.
- From 15 to 20 mmHg of IMP after effort, 8 cases. - From 20 to 30 mmHg of IMP after effort, 11 cases. - Over 30 mmHg of IMP after effort, 13 cases.
Minimal invasive surgery based on fasciotomy was performed to release compartmental pressure in flexor and extensor compartments of the forearm.
The purpose of this study is to determinate if the inoculation of chondrocytes under periosteal flaps does improve the chondrogenic potential of periosteal flaps.
Chondrocyte and Fibroblast Implantation:
A parapatellar incision was performed on both knees. Defect was cleaned and on study group the periosteum taken from the tibia was sutured leaving one edge free to inoculate the chondrocytes or fibroblast according to group using a needle Then the defect was closed using fibrin glue. The animals were euthanatized 8 months postoperative.
The ACI group showed a tissue type means II (ICRS) (95% CI: 28–99%) Collagen type 2 was evident only in the deep layers. The fibroblast group did show a reparative tissue, tissue type mean II (95% CI: 28–99%) Collagen type 2 was evident in deep layers
DISCUSSION: According to this study the inoculation of chondrocytes under periosteal flaps does not improve significally the chondrogenic potential of periosteal flaps.(p: 0,77). Comparing the same procedure with chondrogenic and non chondrogenic cell lines could determinate the role of different chondrogenic components (periosteum and chondrocytes). Probably the chondrogenic capacity of the periosteum is sufficient to stimulate a reparative tissue. However none of these procedures could establish an adult normal cartilage hyaline tissue.
The mean clinical follow-up was 39.4 months (13mths to 8 years) and the mean timing of biopsy was 14.8 months. The mean age at the time of surgery was 32 years (15 to 55 years). The site of defect was as follows: medial femoral condyle-95, lateral femoral condyle-25, trochlea-7, patella 27 and multiple sites- 12. The mean proportion of viable cells available for implantation was 96.3 % (range: 86 to 100) and the mean number of multiplication of cells during culture was 90 (range: 9 to 667).
The most favourable sites were lateral femoral condyle and trochlea where as the least favourable site was patella. There was no correlation between the mental score of patients and the final clinical result. Improvement in functional score was significantly higher among those who had a higher pre-operative function (p< 0.001). There were 7 patients who had previously failed micro-fracture and all of them obtained significant improvements in pain and function. Those who had a higher proportion of viable cells after cell culture demonstrated a tendency towards better outcome, but failed to reach statistical significance (p=0.14). There was no correlation between the number of cell multiplications at the time of cell culture and final clinical outcome (p=0.65). There was no significant difference in clinical outcome between the ACI- C and MACI techniques of ACI (p> 0.05).
Our set contains of 51 patients (28 men and 23 women) with the chondrograft implantation (39 knees and 12 ankles). An average age of patients was 27 years and 3 month with average follow up 3 years and 7 month.
Lysholm score in knee operations were before surgery 37,5, one year after the surgery 81,4 and after two years 83,1. Weber score in ankle operations were before surgery 17,3, one year postoperatively 4,6 and after two years 4,5.
21 patients required knee replacement at an average of 24 months (range: 6–48 months) from the initial microfracture. 17 out of 21 patients had kissing lesion and all showed grade 4 degenerative changes
Cadeveric studies showed that single bundle ACL reconstructions were successful in limiting anterior tibial translation but were insufficient to control a combined rotatory load of internal and valgus torque. One possible cause of these condition could be that current single bundle procedures cannot realistically reproduce the complex anatomy of the ACL, especially the different function of its anteromedial(AM)and posterolateral(PL)bundle. The hypothesis of our study is that the addition of the PL bundle to the AM bundle, in an “in vivo” double bundle computer assisted ACL reconstruction, is actually able to reduce the internal rotation of the tibia at 30° degrees of knee flexion. Computer assisted ACL reconstruction has been used because it could be very effective in evaluating the global performance of the reconstructed knee.
Ten consecutive doble bundle ACL reconstructions were performed in our Hospital using hamstrings graft and the 2.0OrthoPilot-B. Braun-Aesculap ACLnavigation system. The average age of patients was 27.8 years.
The double-looped semitendinosus tendon replicating the AM bundle was fixed first at 60° of knee flexion. Than the gracilis tendon replicating the PL bundle was fixed at 15° of knee flexion. Maximum manual A–P displacement at 30° of flexion, maximum internal and external rotation of the knee were evaluated using the navigation system before surgery and after single(A–M)and double (AM+PL)bundle reconstruction. Statystical anlisys was done using paired T-test.
Before ACL reconstruction mean manual maximum AP displacement was 17.2mm;mean manual maximum internal rotation was 19.8mm and mean manual maximum external rotation was 16.8mm. After AM bundle reconstruction mean manual maximum AP displacement was 6.1mm;mean manual maximum internal rotation was 17.0mm and mean manual maximum external rotation was 16.3mm. After AM+PL bundles reconstruction mean manual maximum AP displacement was 5.3mm;mean manual maximum internal rotation was 16.2mm and mean manual maximum external rotation was 14.6mm. There was no statistically significant difference in the tibial internal rotation at 30° after single bundle(AM)and double bundle(AM+PL)reconstruction.
In this study the effectiveness of the PL bundle in controlling the internal rotation of the tibia, responsible of rotational instability of the knee, was evaluated in “in vivo” ACL reconstruction. The navigator system allowed us to obtain “in vivo” the real and correct value of AP displacement and internal and external rotation of the tibia before and after reconstruction.
Our hypothesis that the addition of the PL bundle to the AM bundle is actually able to reduce the internal rotation of the tibia at 30° degrees of knee flexion, minimizing the pivot shift phenomenon, on the basis of our study has not been confirmed.
There were 2 traumatic and 1 unclear graft failures in the control group. Mean gained Lysholm& Gillquist score was 34,35(+−8,86SD) and mean gained Marshall score was 12,33(+−2,88SD). 45,46% of the patients in the control group returned to the unlimited sport and work on the preoperative level, additional 36,37% has minor limitation in sport or work and 1 patient despite stable knee was unable to return to the work. There was 1 case of deep vein thrombosis of the operated leg and 1 neuroma in the arthroscopy portal area in the control group. MM lesions in 12 cases (54,5%) and LM lesions in 5 cases (22,7%) were found intraoperatively.
The average KT-1000 side-to-side difference in the study group was 2,88 mm and in the control group 2,73 mm.
Non-scar related numbness corresponded to the innervation of the branches of the Saphenous nerve. Only 39% of patients with non-scar related numbness and 47% with scar related numbness recovered completely. None of the patients who had numbness of the entire shin recovered. Interestingly only 3 patients reported that this numbness bothered them.
The chioce of the graft and its fixation in LCA reconstruction is basic for the outcome of the surgical procedure. Several solutions have been proposed; each of them had advantages and disavantages. The choice of the graft and the surgical technique is often due to surgeon’s opinion.
The goal of the fixation is stability which allowes incorporation of the graft in the bone tunnels. Bone-patellar tendon-bone graf has the advantage of bone to bone fixation which is impossible using tendon grafts. Femoral fixation techniques for hamstrings can be classified in: compression tecniques, expansion tecniques and suspension tecniques (cortical or canellous).
TTS (Top Traction System) is a new tecnique for femoral fixation using hamstrings. The fixation is achieved by a retrograde screw that allowes fixation to the antero-lateral cortex of the femur. A ring is fixed to the screw to allow tendons passing. The screw is sefl-threading, its lenght is 28 millimeters and its diameter is 6,5 millimeter; its pull-out strenght is 1350 N. The screw is built in titanium alloy and only one size.
Surgical technique is simple an reproducible and the instruments are easy to use. The positioning of the screw is fully guided by instruments that minimize errors.
This fixation device allowes further graft traction after tibial fixation without twisting hamstrings. Results after 5 years are good but we need long term follow-up for final opinion.
The purpose of this study is to identify the optimal amount of knee flexion required to drill the femoral tunnel in ACL reconstruction using the transtibial technique in order to ensure the correct alignment between the femoral tunnel and the interference screw.
This study identifies a mathematical formula for the optimal amount of knee flexion required to drill the femoral tunnel in ACL reconstruction using the transtibial technique in order to ensure the correct alignement between the femoral tunnel and the interference screw.
Placement of the screw adjacent to the tendon graft and thus against the bone tunnel appears to provide superior results compared to screw placement in the middle of the graft sleeve device. This effect may be due to direct contact of the osteoconductive material to the adjacent bone bed.
[1] Walsh et al., Arthroscopy 2006, in press.
Despite several anatomical and neurophysiological studies have demonstrated the sensory role of anterior cruciate ligament (ACL), it is still unclear how significant the absence of the ACL will affect knee proprioception. Also because some mechanoreceptors has been discovered in the injured bundle commonly resected during ACL reconstruction.
In fact recently it has been observed that subjects with long standing ACL deficiency have not a knee joint pro-prioceptive deficit as measured by threshold of passive movement detenction and the ability to reproduce flex-ion angles, commonly accepted methods.
The aim of this study was to investigate the possibility to recognize a sensorial and behavior impairment in ACL deficient knee.
Through a computerized device the kinaesthetic data were collected from 120 sportsmen between 20–49 years (mean 32,4) affected by unilateral isolated ACL injury diagnosed with MRI and verified arthroscopically. The protocol consisted in four exercises, two bipodal on static and dynamic stance and two monopodal on healthy and injured lower limb. The balance index was divided in four areas on two dimensional plane for a qualitative assessment.
The mathematical and statistical elaboration revealed on bipodal static test a significant and costant displacement on the left side indipendently by the injured side and age. The kinaesthetic awarness was confirmed also by a significant increase of balance index in all exercises. Further studies are necessary to a better knowledge as a possible new tool.
In conclusion, this is the first report of a typical sensorial and behavior impairment in ACL deficient knee with intriguing clinical significance.
Hip fractures are a major challenge and impose high demand on orthopaedic services.
DHS has been proved to be a gold standard method of treatment in uncomplicated extracapsular fractures. The introduction of Intramedullary devices has provided us with a wider choice of construct. Since there was conflicting literature evidence comparing the outcomes of DHS and IMHS, we set out to analyse the same in our practice.
Forty patients in each group operated in the year 2000, comparable in fracture pattern, age and sex distribution were studied. The operating time, fluoroscopic exposure, blood loss, complications (Intra-op, Post-op and Deaths), duration of hospital stay and the discharge destinations were studied from the clinical notes and Hospital information system. Statistical analysis was carried out using SPSS for all the available data.
Statistically, the DHS has a lesser duration of surgery, lower fluoroscopic exposure and lesser duration of hospital stay. However, clinically it appears that the IMHS is fraught with more complications.
Results: The length of the implanted CMI ranged between 3 and 5.5 cm and required 4 to 8 stiches.
The IKDC subjective evaluation was normal in 18 patients, nearly normal in 18, abnormal in 5 and severely abnormal in 1. Range of motion was normal in 28 patients and nearly normal in 14. KT 1000 examination was normal in 32 patients, nearly normal in 7, abnormal in 1 and severely abnormal in 2.
The X ray findings were normal in 28 patients, nearly normal in 6 and abnormal in 8.
Complications included 2 saphenous nerve neuritis, 1 ACL graft tear with CMI implant breakage and 2 knee stiffness that required mobilization.
40 patients returned to work. The average time to resume work was 5.5 months
The comparability of studies of extra-articular proximal femur fractures is compromised by the lack of a widely accepted, simple classification system with clinical and prognostic relevance. The aim of the study is to define the complication profile as well as differences relating to age, gender and survival rate of simple trochanteric fractures (typ 1), intertrochanteric comminute (typ 2) and subtrochanteric fractures (typ 3).
The records of 335 consecutive patients were analysed prospectively. Patients had a mean follow-up of 10 (0–56) months, and were treated operatively with three intramedullary nailing systems.
Simple trochanteric fractures (n=67) show only wound healing problems (1.5%). Median age is m/f 76.4(45–98) years/82.7(39–101), and the two-year survival rate is m/f 50.3%/84.9%. Intertrochanteric comminute fractures (n=204) demonstrate the highest complication rates (25%) with 9.7% femur head perforations, 3.5% other hardware related problems and 11.8% wound healing problems. Median age is m/f 72.5(41–94) years/83.6(54–100), survival rate is m/f 92.7%/66.5%. We observe a complication rate of 17.0% in subtrochanteric fractures (n=64), no femur head perforation but 9.1 % other hardware problems and 7.8% wound healing problems. Median age is m/f 61.1(24–91) years/81.6(38–99), surviving rate is m/f 92.3%/67.9%. The overall complication rate is nearly twice as high in females compared to males (19% versus 10%).
The 3 types of proximal extraarticular femur fractures show diferrences in epidemiological data such as median age and surviving rates. Furthermore intramedullary nail osteosynthesis of extraarticular proximal femur fractures lead to different complication patterns in simple trochanteric fractures, in comparison to inter-trochanteric comminuted fractures and subtrochanteric fractures. The recommended surgical treatment in Type 1 fractures leads to a low complication rate. Type 3 fractures exhibit an acceptable complication level; pseudarthrosis and intraoperative shaft fissures as well as wound healings problems are the main complications. Type 2 fractures represent fractures whose treatment is problematic, with the highest complication rate of hardware-related problems (13.2%), including femoral head perforation (9.7%), and the highest number of wound healing complications (11.8%), more than a third of which are infections.
Many studies exist that assess intramedullary and extra-medullary fixation of these fractures, but few exist that compare the two. We performed a retrospective cohort study to compare the above implants in the management of subtrochanteric femoral fractures. 100 fractures in 95 patients were studied, with 47 in the recon nail group and 53 in the DCS group, with 33 male and 62 females, average age 68 years (16–98 years). Data was obtained by review of case notes and x-rays of all cases. The following information was obtained :- age, sex, energy/mechanism of injury, fracture classification (AO & Russell-Taylor, single observer), grade of surgeon, duration of surgery, ASA grading, co-morbidity (using Covinsky score), pre-operative mobility, postoperative mobility (using D’Aubigne & Postel score), mortality, intra-operative complications, post-operative complications, revision surgery/implant failure, follow-up and radiological assessment of reduction/implant position(single observer). Statistical analysis of the data was performed using chi-squared, Fisher’s, Mann-Whitney U and unpaired t-tests. Results showed no significant differences in co-morbidity, complications, mortality, duration of surgery, hospital stay, sex, surgical grade or pre-operative mobility. There were significant differences in age, fracture classification, radiological assessment of reduction/implant position, mechanism of injury and post-operative mobility. Overall 28-day mortality was 8%, post-op complications were seen in 54% and 19 cases required further surgery (detailed breakdown to be presented). Certain areas of bias were identified, in that the DCS had a higher number of complex fracture patterns, thus affecting post-op mobility, whereas the recon nail group had a higher proportion of pathological fractues.
The aim of the study was to compare mortalitiy and complication rate after operative treatment of pertrochanteric fractures with primary cemented arthroplasty, dynamic hip screw (DHS) or proximal femoral nail (PFN).
283 patients, which were treated betwen 1992 and 2005 for pertrochanteric femoral fractures, except pathologic fractures and a minimum age of sixty years were included. 132 of these 283 patients were treated by primary arthroplasty.
Up to the end of 1999 all unstable fractures were treated by primary total hip replacement. In the year 2000 the PFN was introduced and only patients with severe osteoarthritis and osteoporosis received primary arthroplasty. I possible, more stable fractures were treated with a DHS.
One year mortality was chosen as main indicator as it depends on the surgical trauma as well as the rapid return to preinjury activity and further complications. A one year period was chosen as the mortality ratio approaches that of an age matched reference population after this interval. Influencing cofactors were eliminated by stepwise logistic regression analysis.
It was shown that restoration of the preoperative ambulatory level correlated with survival rate after one year. As elderly patients are often unable to cooperate with partial weight bearing, the primary stability of the device is crucial to allow early mobilisation
Mortality was significantly influenced by age, gender and comorbidities but not by fracture classification. One-year mortality was significantly higher for primary total hip replacement (34.2 %) than for internal fixation (DHS: 18.4 %; PFN 21.4 %) and hemiarthroplasty (13.3 %). Since the PFN and hemiarthroplasty were introduced the over all mortality was reduced from 29 % to 18 %.
Squeaking is a rare complication of hard-on-hard hip bearings. Occasionally the noise is troublesome enough to warrant revision surgery. The purpose of this study is to contribute to the understanding of the mechanism(s) underlying squeaking.
We analyzed 10 alumina ceramic-on-ceramic bearings from squeaking hips collected at revision surgery. The reason for revision was given as squeaking (6 cases) or squeaking and pain (4 cases). Six of the 10 patients were male, average patient age was 48. Bearings were retrieved after an average of 23 months in service (11 to 61 months). There were 4 different designs of acetabular component from 2 different manufacturers. Nine have an elevated metal rim which is proud of the ceramic and one does not. Two bearings were 36mm in diameter, 6 were 32mm and 2 were 28mm.
All 10 bearings showed evidence of edge loading wear. Mean dimensions of the wear patch were 37mm by 12mm on the acetabular component and 32mm by 13mm on the femoral heads. Wear dimension was not related to bearing diameter. Seven of the 10 implants also had evidence of impingement of the femoral neck against the elevated metallic rim or the ceramic insert or both. There was no chipping or fracture of any of the ceramic components.
Squeaking is a recently recognized complication of hard on hard bearing surface. This retrieval study is the first of its kind, to our knowledge attempting to unravel the mechanism of this undesirable complication. Although impingement seems to be present in majority of cases, the latter does not seem to be necessary. Edge loading wear was the common factor in all cases and this may prove to be a critical mechanism.
There are 521 hips in 441 patients with ceramic/ceramic bearings. I am reporting this consecutive series.
These hips are generally inserted into patients with a 20+ year life expectancy. This ranges from 18 to 74. Mean age is 52.4 years. These young patients are mostly active and many are working.
Amongst the indications were osteoarthritis 297, hip dysplasia 76, and ankylosing spondylitis 18. Thirty eight had had previous childhood hip disorders, and 19 had rheumatoid arthritis. The series also includes 43 with AVN and 7 revisions from cemented hip replacement
All the patients are assessed using the Harris Hip Score before and after surgery. They are assessed annually. Post operative scores show 22 patients with Harris Hip Scores of less than 80, but only 9 patients have problems attributable to HAC hip surgery. These include 2 patients with infection, 3 fractured ceramic acetabular liners, two broken heads and 2 patients with loose cups, one from aseptic loosening. Apart from this one case, aseptic loosening has not been a problem.
Wear in ceramic bearings will be negligible. Third body inclusions must be avoided to prevent wear or fracture.
The femoral spigot must not impinge on the acetabular margin causing subluxation which may lead to fracture.
The ceramic material has to be supported to prevent fracture.
The outcome of the patients in this sub-group has been rewarding. Alumina/alumina hip arthroplasty should be considered where life expectancy is substantial.
There has been no general agreement about the use of uncemented hip prostheses in patients with rheumatoid arthritis (RA). In the present study we compared the results for the cemented and uncemented stem that most commonly had been used in RA patients in the Norwegian Arthroplasty Register.
Particulate debris has been demonstrated to have a major role in the aseptic loosening of artificial joints. Biological activity is stimulated by particles of size 0.1 to 10 microns with maximum affect being seen in particles of approximately 0.5 microns. This study investigated the particle size of wear debris produced at the stem/cement interface in cemented artificial hips comparing different materials and surface finishes of the stem.
Test plates were manufactured in each material and with each of the three surface finishes.
The plates were opposed to cement pins in a sliding wear tester. The debris produced was collected, filtered and examined under an electron microscope. Representative samples of particles produced by each test series were measured and aspect ratios calculated.
Plates were also measured pre and post test to ensure no significant change in surface roughness during testing.
For any given surface roughness the size of particles produced was smallest for the hardest material (cobalt chrome) and largest for the softest material (titanium alloy).
Hip arthroplasty has its true genesis in 1962 when the Charnley Total Hip was first implanted. The system comprised a stainless steel femoral stem with fixed 22,225mm head articulating against an all polyethylene acetabular cup. Both components were fixed in position with acrylic bone cement. There have been a number of changes in design, materials and surgical technique but the essential concept remains the same. The system was widely used by both senior and junior surgeons. Numerically implantations peaked at ~45,000 per annum in the late1980’s and is still at around ~25,000 per annum in the mid 2000’s. Geographically the system was used in all five continents. Patients varied widely both in age, activity, and diagnosis. It would therefore seem an appropriate vehicle to examine the variations in results of total hip replacement by patient profile, geography, and era of implantation.
A search was carried out on the US NCBI website for publications reporting on results with the Charnley system up to the end of 2002, and which comprised a follow-up of more than 10 years, and gave survivorship data. This resulted in 28 papers with 14 countries of origin available for review. For all studies basic data such as age and diagnosis, range implantation dates, likely specific design of prosthesis, origin of study and number in study was either reported or could be deduced. A ten year survivorship was reported in 16 studies for stem and cup and 7 for stem only. If the longest follow-up was considered for each study then 18 reported on stem and cup (9392 hips, implanted 1962–92) and 15 on stem only (4243 hips, implanted 1966–91). A total of 11 studies had four of more points on a survivorship curve, seven with stem and cup, four with stem only.
There are a number of points of interest in this data. The first is that with one exception the performance is remarkably consistent as shown by the survivorship curves. There is no significant difference in the survival rates from different centres, countries, and with implantation dates ranging from 1962 through to 1992. Secondly, there appears to have been little or no change in the average age of patients with implant date. There is some evidence to indicate from the 10 year data that failure rate per year is lower in older patients but does not seem to be affected by implantation date. The latter despite the fact that both surgical technique and component design changed over the 30 year implantation period. A further observation is that the failure rate per year is lower in studies with greater numbers of patients.
The general conclusion from this review is that the Charnley Total Hip is remarkably consistent in its performance both over time and location of implantation. Its performance also seems to have been affected very little by changes in technique or design.
i) centre of rotation of the socket (COR), ii) height of the centre of rotation from the teardrop, iii) lateralisation of the centre of rotation from the teardrop, and iv) the width of the cement mantle in the three acetabular zones.
These values were compared with the equivalent measurements made for a normal contralateral hip. In addition to these measurements, any radiolucent line in any zone was recorded. The post-operative film was templated using Orthoview (TM, Southampton, Hampshire) software, which is a digital X ray templating system.
From 18 to 60 months of follow up we observed a significant rise in BMD in all Gruen zones but zone 4 and 7. Despite this the total periprostetic BMD decreased during the study periode. There was no significant decrease in BMD in the contra lateral hip. In the spine, we observed a significant rise in BMD.
When component failure was used as the endpoint, the survivorship of the acetabular component was 78% at 15 years (CI, 64% to 87%), 66% at 20 years (CI, 48% to 80%), 43% at 25 years (CI, 21% to 62%) and 12% at 30 years (CI, 2% to 32%). The survival of the femoral component was 76% at 15 years (CI, 62% to 85%), 67% at 20 years (CI, 48% to 80%), 47% at 25 years (CI, 25% to 67%) and 7% at 30 years (CI, 1% to 26%). The survival of both components was 74% at 15 years (CI, 59% to 83%), 64% at 20 years (CI, 44% to 78%), 43% at 25 years (CI, 20% to 64%) and 7% at 30 years (CI, 1% to 27%).
(Previous report: Charnley low-friction arthroplasty for Paget’s disease of the hip.
J Arthroplasty. 2000 Feb;15(2):210–9).
For press-fit cups we observed highly significant (p< 0,01) cancellous BD loss in all sectors (−17% to −53%), cortical BD loss ventral and dorsal to the cup (−12% to −23%) and very limited BD loss cranial (−4% to −13%) to the cup.
Vast amount of literature is available on mechanical properties of PMMA, but not about the composite specimens of old and new cement. This is important, as in cement revision has become established technique with good clinical results. Originally Greenwald and later Li described properties of such specimens. However in these studies the old samples were only few days old, unlike clinical situation, where the old cement is a few years old.
We therefore decided to test short-term mechanical properties of composite specimens and compare these with new uniform specimens. We choose specimens of cement 3–17 years old (median 11.8) for the manufacturing of the composite specimens.
The 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- the lack or loss of proximal stem support.
The concept, design and the surgical technique cater for a limited slip of the C-stem within the cement mantle transferring the load more proximally. With a follow-up past 12 years and 4063 primary procedures there have been no revisions for aseptic stem loosening and no stem is radiologically loose.
We have reviewed 1008 primary C-Stem hip arthroplasties performed by 23 surgeons with a minimum of 5 years clinical and radiological follow-up. The mean follow-up was 7 years (range, 5 – 12) and the mean age at surgery was 57 years (range (15 – 85). In 58% the underlying pathology was primary osteoarthritis, 20% congenital dysplasia, 10% quadrantic head necrosis, 5% rheumatoid arthritis, 5% slipped upper femoral epiphysis and 4% protrusio acetabulae.
The concept of the triple tapered stem is validated radiologically with an improved proximal femoral bone stock in over 20% of cases and a maintained bone stock in 60%.
There were no post-operative complications within 1 year in 87% and no late complications (after 1 year) in 91%. The main late complications were 3.9% aseptic cup loosening, 1% infection and 0.8% dislocation. There were no aseptic loose stems.
Twenty-eight hips have been revised (2.8%), 3 for infection, 2 for dislocation and 23 for aseptic cup loosening. There were no revisions for aseptic stem loosening.
The results support the concept but place a demand on the understanding of the technique and its execution at surgery.
We present the results of the polished triple tapered C-stem femoral component.
Prospective data was collected on a consecutive single surgeon series of 326 hip replacements in 293 patients performed between 2000 and 2005. All operations were performed via the posterior approach with a cemented all polyethylene acetabular component and third generation cementing of the femoral component.
There were 169 (58%) female patients and 124 (42%) males. There were 111 (34%) left sided procedures, 149 (46%) right sided and 33 bilateral (10%). Average age at time of surgery was 66.3yrs (25 – 89), with an average duration of follow-up of 50 months (12 – 78). The majority of the replacements were for osteoarthritis (271 hips 83%).
Nine patients (10 hips) died during the follow-up period at an average of 36 months (18 – 52), but outcome data was available on all patients and none were lost to follow-up. There was 1 temporary femoral nerve palsy, 2 non-fatal pulmonary emboli and 3 undisplaced trochanteric fractures. There were no dislocations, fatal pulmonary emboli, deep infections or revisions for any reason.
The stem was neutral in 90%, varus in 8% and valgus in 2%. There were no progressive radiolucencies in any Gruen zones and no distal femoral cortical hypertrophy. The average subsidence was 0.83mm, with none in 21%, < 0.5mm in 28%, 0.5 – 1mm in 41%, 1 – 2mm in 8% and 2 – 4mm in 2%.
There were no revisions and no stems demonstrated any features suggestive of current or future loosening. The study and prospective data collection is ongoing.
We have investigated whether improvements in design have altered outcome for patients undergoing endoprosthetic replacement of the distal femur following tumour resection.
Survival of the implant and ‘servicing’ procedures has been documented using a prospective database and review of the implant design records and case records.
A total of 335 patients underwent a distal femoral replacement with 162 having a fixed hinge design and 173 a rotating hinge. The median age of the patients was 24 years (range 13–82yrs). With a minimum follow up of 5 years and a maximum of 30 years, 192 patients remain alive with a median follow up of 11 years. The risk of revision for any reason was 17% at 5 years, 33% at 10 years and 58% at 20 years. Aseptic loosening was the most common reason for revision in the fixed hinge knees whilst infection and stem fracture were the most common reason in the rotating hinges. The risk of revision for aseptic loosening in the fixed hinges was 35% at ten years but appears to have been abolished by the use of a the rotating hinge knee with a hydroxyapatite collar. The overall risk of revision for any reason was halved by use of the rotating hinge.
Improvements in design of distal femoral replacements have significantly decreased the risk of revision surgery but infection remains a serious problem for all patients. We believe that a cemented, rotating hinge prosthesis with a hydroxyapatite collar offers the best chance of long term prosthesis survival.
Purpose of this study is to report the preliminary results of the clinical experience of the Rizzoli with a new modular reconstructive tumor prosthesis for the lower limb (GMRS-Stryker).
Between October 2003 and march 2006 this system was implanted at the Rizzoli in 85 cases. This series included 42 males and 43 females, ranging in age from 8 to 76 years. The sites of prosthetic reconstruction were distal femur in 60 cases, proximal femur in 7, total femur in 1, proximal tibia in 17 cases.
There were 79 oncologic and 6 non oncologic diagnoses. The histological diagnoses of the oncologic cases included 11 giant cell tumors and 68 malignant tumor: 52 osteosarcomas, 7 spindle cells sarcomas, 6 Ewing’s sarcoma, 3 chondrosarcomas. Of the 79 oncologic cases 55 were primary reconstructions with GMRS prosthesis and 24 secondary reconstructions for failure of a previous reconstruction.
In 16 cases HMRS/GMRS hybrid implants were used in reconstruction or revision, using adaptors.
All patients are periodically checked in the outpatient clinic of the Rizzoli.
Complications were reported and analyzed, x-rays were reviewed and pertinent information achieved for each patient. Functional results were assessed according to the MSTS system.
There was 1 case of infection, treated with removal of the implant and spacer with antibiotics. There were 3 disruptions of the knee extensor apparatus, 1 patellar instability treated by revision of the prosthesis.
Functional result were evaluable in 59 cases and showed a function of 26% to 50% in 14% of pts, of 51% to 75% in 19%, over 76% in 67%. Results were considered good or excellent in 86% of the evaluated patients.
Proximal humerus is the common site for primary bone malignancies that surgical treatment consists of wide excision of the tumor and reconstruction with tumor resection prosthesis or allograft. The ultimate function of the shoulder depends on the degree of sacrification of adjacent structures. Thirty-two patients with primary malignancies have been treated by wide excision and endoprosthetic replacement by senior author between 1989–2005 12 patients were female, 20 patients were male, mean age was 26,6 years (range 7–69 years). Histological diagnosis was 14 osteosarcoma, 4 Ewing’s sarcoma, 4 chondrosarcoma, 3 parosteal sarcoma, 4 giant cell tumor, 1 aneurysmal bone cyst, 2 synovial sarcoma. Synovial sarcoma, osteosarcoma and Ewing’s sarcoma patients received neoadjuvant chemotherapy prior to excision. Mean follow-up was 50,4 months (range 6–153 months). Oncologic results were 20 patients NED (no evidence of disease), 2 patients AWD (alive with disease), 10 patients DOD (died of disease). Functional outcome was scored according to Musculo-Skeletal System Tumor Society (MSTS) rating scale, 7 patients were excellent, 22 patients were good and 3 patients were poor. Regarding complications 2 patients developed local recurrence, 2 patients had superficial infection. Infected cases were treated by systemic antibiotic treatment. All patients had dexterity of the hand and elbow. Regarding shoulder abduction and forward flexion, 7 patients whose deltoid muscle and axillary nerve could be spared got nearly normal shoulder function but even the patients with loss of deltoid had limited abduction owing to elevation of scapula by shrugging. Elongation of the newly formed shoulder capsule was seen in patients that artificial mesh augmentation was not used. Prolene mesh was used to create a new substitute instead of resected shoulder joint capsule. These patients did not show any elongation at long-term follow-up. All arthroplasties was hemi-type without glenoid reconstruction. Hemiarthroplasty by a modular tumor resection prosthesis system after wide excision of proximal humerus seems to be an effective method of treatment after shoulder malignancies. The main determinant of the function is the status of deltoid axillary nerve and rotator cuff but the patients deprived of structures had a functional upper limb with a good command of the elbow and the hand.
Infection was reported in 15 patients (24.2%): 2 early infections (healed with surgical debridment), 1 femoral stem septic loosening (treated with early revision with cemented stem); in 8 cases removal of the infected APC was required followed by implant of a new prosthetic device after cement spacer; two infections did not healed and patient underwent amputation; in two cases a good functional result was achieved removing the infected graft and covering the proximal tibia with cement and no other surgery was required.
Non union of the graft was observed in 8 patients (12.9%): in 4 patients autologous bone grafting was necessary to heal the osteotomy line. In other 3 cases non union was associated with graft fracture. In one case non union was associated with tibial stem loosening and revision of the whole implant was done.
Polyethylene wear was assessed in 5 patients (8%) and revision of the polyethylene components was always required.
Nine patellar tendon rupture (14.5%) were assessed and repaired was performed in seven cases.
The functional outcome of 42 patients with more than two years of follow up was excellent in 25 cases, good in 13, fair in 2 and poor in 2.
Intraarticular osteoid osteomas account for approximately 13% of osteoid osteomas. The hip is the commonest location of intraarticular osteoid osteomas.
We present 16 patients with intra-articular osteoid osteomas of the hip treated with RFA. These were 13 men and 3 women, with a mean age of 27 years (range, 16–48 years). Eight osteoid osteomas were located in the femoral head, 6 in the femoral neck, and 2 in the acetabulum.
The approximate mean duration of the procedure was 82 min (range, 50–125 min). The mean hospitalization time was 8.7 h (range, 6–12 h). All patients had pain improvement within the first 24 h. Five patients had pain relief within the first 3 days, 9 patients within the first week, and 2 patients within 2 weeks post-procedural. Twelve patients continued to have some restriction of their physical activities up to one month after the operation. All patients returned to their previous status of physical activity within the first 2 to 3 months post-procedural. At the latest follow-up, there were no residual or recurrent symptoms. Five patients complained for mild pain, which was probably due to hip synovitis that resolved within a week. One patient experienced transient paresthesias and pain in the buttock at the site of the trocar and electrode insertion.
Intra-articular osteoid osteomas have clinical and imaging features significantly different from those seen in extra-articular lesions. CT-guided percutaneous RFA is a simple minimally invasive, safe and effective method for most intra-articular osteoid osteomas.
The fixation of the displaced fractures is well accepted, but more controversy is seen with the fixation of nondisplaced fractures.
Surgery offers less cast time, and faster return to daily and sports activities.
Surgical treatment was performed with a volar percutaneous fixation with a Herbert canulated screw. Patients were casted for 1–2 weeks and then rehabilitation was started.
Functional evaluation 2 months postoperative were flexion 60°, extension 55°, radial deviation 21, ulnar deviation 18°.
Patients returned to sports activities at 11 weeks and at 13 weeks to their previous work.
Time to bone union was 9 weeks
In 5 cases pain in the place of the surgical scar were present, we had one case of sensitive branch lesion.
The purpose of this study was to analyse the long-term results of prosthetic joint replacement in patients suffering from metastatic bone disease. The treatment was performed in order to prevent or treat pathological fractures, to control the pain and improve the functionality of the lower limb.
120 patients suffering from metastatic disease of the lower extremities were treated with prosthetic replacement between 1992 and 2004
The patients, 80 females and 40 males, having an age at the time of surgery ranging from 32 to 83 years, were treated by the same equipe in the San Raffaele Hospital in Milan.
The primary tumor included breast carcinoma (66), lung carcinoma (19), kidney tumor (17), prostatic tumor (7), plasmocytoma (5), non identified tumor (5), melanoma (1). The metastasis was located in the proximal femur in 112 cases, in the distal femur in 3, in proximal tibia in 5. In 8 out of 120 patients, the metastatic lesion was the first sign of carcinoma, 25 patients had a pathological fracture and the bone metastases were detected from 6 mounth to 13 years after the diagnosis of the primary tumor.
Knee: in our casuistry 8 patients with a metastasis in proximal tibia or distal femur were operated with modular prostheses: in 1 case of this group (single lesion of kidney tumor), we have implanted an allograft-prosthesis-composite.
Proximal femur: for the treatment of this site, we have included also those patients having a life expectancy inferior to 1 month. In 30 cases the lesion was located in the epiphysis and neck and we have implanted 5 endoprosthesis, 5 total hip prostheses and 20 bipolar prostheses. In 82 patients with a metastasis located in the metaphysis we used a modular prosthesis with a femoral resection up to 16 cm.
69 patients are alive with a follow-up ranging from 6months to 12 years. 5 patients died in early post surgical period. 13 patients developed local recurrence. These latest have suffered from a pathological fracture, which had occurred before the first surgical treatment. Pain relief was achieved in all patients after surgery with acceptable functionality of the operated limb.
We considered the risk of pathological fractures more important than life expectancy. Moreover, we believe that the surgery to these patients should be definitive. In fact, the use of prostheses allow for a wide resection of the lesion. This condition represents also an advantage in those cases where radio- or chemiotherapy can not be performed. Moreover, the prostheses permit an immediate weight bearing, a good functional recovery and also, in patients with critical general condition, a more easy assistance. In conclusion, for patients with metastatic bone disease, we consider a correct approach the radical excision of the lesion and the implant of a prosthesis.
Frequent imaging after a completed multimodal therapy of osteosarcoma is recommended by therapy optimization studies to detect local or systemic tumor recurrence. Considering the low rates of local recurrence, regular local imaging has to be questioned.
150 patients with osteosarcoma were treated in our department between 1991 and 2005. The median age of patients with osteosarcoma was 17 years with a range of 4 – 79 years and a female:male ratio of 1:1.1. The primary tumors of 147 patients were treated surgically, while 3 patients refused to be operated. After a wide resection, a tumor endoprosthesis was implanted in 103 (70.1%) of the 147 patients, 16 (10.9%) patients underwent a Borggreve rotationplasty, a resection and biological reconstruction was implemented in 10 (6.8%) patients, while further 18 (12.2%) patients were amputated. The median follow up was 95 months.
Local recurrences appeared in 2 (1.4%) patients which had been treated with a hemipelvectomy. After implantation of a tumor endoprosthesis, local recurrences were not observed. Postoperative complications observed after the implantation of a tumor endoprosthesis included infections (n=14; 13.6%), loosening, fractures and wearing of endoprotheses (n=7; 4.8%), luxation (n=1; 0.7%) as well as traumatic shaft fractures of involved bones (n=5; 3.4%). All complications included specific symptoms and were diagnosed outside the routine follow up.
In conclusion, local radiological imaging after resection of an osteosarcoma and reconstruction with a tumor endoprosthesis as a routine examination should be questioned, however it is definitely indicated in patients with specific symptoms.
Radiofrequency ablation (RFA) is a relatively new technique to produce cell death by radiowaves (460– 480 kHz) caused by an alternating current emitted from the tip of a needle electrode and causing local ions vibration producing heat. In orthopaedic fields RFA has been proposed for the treatment of osteoid osteoma and painful metastases.
Treatment of advanced Kienbock’s disease is challenging, and controversial. Palliative procedures should be chosen.
The goal of this study was to analyse the results of scaphocapitate arthrodesis with lunarectomy in advanced cases. Fourteen consecutive wrists in 13 patients were re-examined at a ranged follow-up of 31,7 months (range 3 to 103). Preoperative radiographs showed Lichtman stage 3a disease in 4 patients, stage 3b in 9 patients, and stage 4 in the last patient. Eight patients were women, and the involved wrist was the dominant in 8 cases. The age at operation averaged 36,6 years (range 24 to 55). Symptoms consisted in pain or pain with stiffness. Operative techniques consisted through a dorsal approach in excision of the dorsal interosseus nerve, lunarectomy, and scaphocapitate arthrodesis. Autologous bone graft was used in 8 cases, and osteosynthesis used K wires or staples. The wrists were immobilized in arm cast during 6 weeks, and rehabilitation was started. Postoperatively, one patient developed a complex regional pain syndrome.
At longest follow-up, patients were very satisfied in 8 cases, satisfied in 4, and poorly or not satisfied in 2 cases. Three wrists were painless, and only one wrist had no improvement. One wrist had no improvement. All the employed patients returned to their original work. Mean wrist motion increased slightly. Flexion increased from 33.3 to 33.9°, extension from 39.6 to 39.3°, ulnar deviation from 20 to 23.7°, and radial deviation from 18.8 to 17°. The arc of motion was useful (Flexion- Extension: 73.7° range, Pronation-Supination: 172.7°) Grip strength increased and reached 64.5% of the controlateral wrist. The mean gain was 5.6 Kg (+199%). The improvement was slow and very progressive over one year. On radiographs the arthrodeseses were consolidated in all cases, but the union seemed partial but asymptomatic in two wrists. Correction of scaphoid in flexion was difficult to obtain. No arthritis or degenerative changes were observed, but the distal radial epiphysis seemed to be reshuffled to the new joint and articular surfaces, with progressive disappearance of the radial lunar notch
Scaphocapitate arthrodesis associated with lunarectomy allows getting a painful and functional wrist. This simple procedure theoretically decreases load across the radiolunate joint, prevents further carpal collapse, and stabilizes the midcarpal joint.
The patients were assessed clinically (modified Mayo wrist score) and radiograhically. The grip and pinch strength were also studied.
Negative ulnar variance, lunate shape and increased load transmission are associated with Kienbock’s disease. This may reflect trabecular alignment being more susceptible to shear forces along “fault planes” in Type 1 lunates, causing microfractures and avascular necrosis. The aim of this study was to assess the relationship between lunate bone structure, density and ulnar variance.
Standard 90/90 radiographs of 22 cadaveric wrists were taken for ulnar variance and lunate shape. The lunates were harvested and routine CT scans (1mm) were taken in 22/22 in the coronal, sagittal and transverse planes. DICOM files were analysed using Mimics (Materialise, Belgium) to measure Hounsfield units. MicroCT scans (SkyScan, Belgium) (40 μm) were taken in 10/22 in the coronal plane and measured for trabecular angle at the proximal and distal joint surfaces and the ‘tilting angle’ (between scaphoid and radius joint surfaces). Data was anlaysed using one-way ANOVA tests using SPSS for Windows.
Negative ulnar variance was noted in 7/22, neutral 10/22 and positive 5/22. Lunate shape according to Zapico was 0/22 Type 1, 18/22 Type 2 and 4/22 Type 3.
Lunate bone density was significantly lower in the ulnar positive specimens compared to ulnar negative and neutral (p< 0.001) (fig. 1).
The average trabecular angle measured 84.7° (+/− 4.5°) at the proximal and 90.3° (+/− 2.6°) at the distal joint surfaces and tilting angle was 115.7° (+/− 12.0°) (fig. 2). The 50% slice on the microCT correlated best with xray measurements of this angle.
This study quantifies the previous finding that load transmission through the lunate and hence lunate bone density is related to ulnar variance and that this is higher in ulnar negative wrists. MicroCT is a useful modality to assess trabecular structure and supports the ‘fault plane’ hypothesis of Kienbock’s Disease.
Arthroscopic debridement and pinning is not considered to be effective in dynamic scapholunate (SL) instability treated more than three months post injury; open procedures (capsulodesis, tenondesis, SL ligament reconstruction, intercarpal fusions) are preferred for these patients. The best procedure for this problem is yet to be determined. A restrospective review of the senior author’s records produced thirteen patients with late presenting dynamic SL instability who were unwilling to undergo an open procedure and were treated initially with aggressive arthroscopic debridement and pinning. The mid-term results of this approach are presented.
Eleven of the initial thirteen patients were available for follow-up. Their mean age was 36 years (range 23–50) and the mean time elapsed from injury was 7 months (range 4.5–10). The diagnosis of dynamic SL instability was based on a positive Watson’s test, SL gapping on grip view radiographs and arthroscopic findings of a Geissler type III (in 5 patients) or type IV (in 6 patients) SL tear. The SL angle was under 550 in all patients. The procedure included aggressive arthroscopic debridement of the torn portion of the SL ligament to bleeding bone in an effort to induce scar formation in the SL interval. The SL interval was subsequently reduced and pinned (with 2 pins through the SL and one pin in the scaphocapitate joint) under fluoroscopy. The pins were removed at a mean of 9.6 weeks (range 8–14).
The mean follow-up was 36 months (range 12–76). Three patients were re-operated at 9, 10 and 11 months after the initial procedure. Re-operations included a dorsal capsulodesis, a four-corner fusion and a wrist arthrodesis. The eight remaining patients achieved two excellent, four good, one fair and one poor result with the Mayo wrist score. Patients diagnosed with Geissler III tears were found to be younger and achieved better final wrist score (mean 86 points versus 76 points in patients with Geissler IV tears). Two pin track infections were treated conservatively.
Late (more than three months post injury) arthroscopic debridement and pinning was found to be only moderately successful for dynamic SL instability (6 out of 11 patients achieved a good or excellent result without re-operation). This approach, however, does not preclude subsequent open surgery. It is best suited for patients with Geissler type III tears (not a gross drive through sign) who are unwilling to undergo an extensive open procedure provided they understand the risks and benefits of this approach.
Tests were done on 10 intact specimen and the process included the initial drilling and final placement of an osteosynthetic screw. Postoperative placement was controlled with a 3-D scan. Results concerning a defined optimal screw positioning and drill failures attempts were done by another independent surgeon.
The 3-D imaging modality allows a direct control of the reduction and screw placement intraoperatively. Our tests did not include simulated fracture conditions, a general use of our new technique can now only be implemented to non displaced fracture types, while clinical and further laboratory tests have to improve our findings for all types of scaphoid fractures.
The final diagnoses after wrist arthrogram and arthroscopy were 42.5% with TFCC injuries, 20% with SNAC pathology, 20% with synovitis with no other pathology, 10% with carpal ligamentous pathology and 7.5% with radiocarpal osteoarthritis.
Therefore, the arthrogram is another tool in the diagnosis of wrist pathology, and should not be forgotten. It is especially useful in patients with chronic wrist pain, where the diagnosis may be more complicated.
Ulnocarpale Impaction Syndrom is diagnosed by clinical evaluation as well as typical radiologic findings. If non operative treatment leads to unsatisfactory results few operative options can be considered. Ulnar shortening osteotomy is one of them.
Costings of theatre time and out-patient time were obtained from the hospital management.
Based on a cost of £216 per out-patient clinic session, the cost of the out-patient procedures was calculated at £1872 over 6 months, or £3744 per annum. Based on a theatre cost of £1785 per session, to perform all the clinic procedures as formal operations would have cost £60,690 over 6 months, or £121380 per annum. The cost savings were therefore £117636 per annum.
- Arthroscopy (+) 37 cases out of 50 (64%) - Ultrasound (+) 21 out of 37 (+ Art)) - MRI (+) 22 out of 37 (+ Art)
According to this results we can easily calculate the sensibility/specificity and PPV/PNV of both tests:
- Ultrasound Sensibility/Specificity: 58,3 %/36,8 % - MRI Sensibility/Specificity: 61 %/47 % - Ultrasound PPV/PNV: 58 %/31,8 % - MRI PPV/PNV: 68 %/37 %
Despite the widespread use of demineralized bone matrix (DBM) allografts there are few clinical studies comparing DBM to iliac crest bone grafting (ICBG). A comparison of DBM to ICBG is presented in patients who underwent four corner fusions of the wrist by one surgeon using identical operating technique.
The senior author’s first fourteen consecutive patients in which DBM was used for four corner fusion were compared with fourteen patients selected from a total of 48 patients in which ICBG was used. The ICBG group was matched for age, indication and healing impairing co-morbidities (mainly smoking). Patient radiographs from the 8th, 12th and 24th postoperative week follow up were digitized and blinded. Three orthopaedic surgeons, not involved in the patients care, rated the degree of bony union in a scale of 0 (no evidence of healing) to 3 (solid bony healing). The operating technique and fixation was identical in all patients. K-wires were removed at a mean of 8.2 weeks for DBM and 7.7 weeks for the ICBG group.
All patients had a minimum follow-up of one year. All fusions healed both radiographically and clinically without complications. Review of the radiographs revealed significantly less visible healing at 8 weeks in the DBM group (mean score 1.50 versus 1.74 of the ICBG group, p< .05). Lower scores were also obtained for the DBM group at 12 and 24 weeks but they did not reach statistical significance.
In this study both DBM and ICBG were equally effective in achieving solid bone union for intercarpal fusions. However, the statistical power of this series is not adequate to conclude that healing rates are equal between the two graft materials. The radiographic appearance of bridging bone lagged behind in the DBM group. The biological significance of this finding is not clear; it could indicate delayed mineralization at the fusion site. Such a delay may be significant in graft choice for patients with healing impairment.
In this study 10 patients (13 implants), that were tretated with this type of prosthesis between february 2002 and january 2005 were studied. All but one patient were satisfied with the postoperative situation and would agree to another operation.
A significant pain reduction was observed. The average ROM was 58degrees. Five patients demonstrated a free extension, two patients had a swan neck defomity, which could be actively compensated for, and the remaining six patients had an extension deficit of 30–45degrees. The average flexion was 76° (+/−12°).
X-ray examination was unremarkable in eight patients with a regular position of the endoprosthesis. However, in five patients significant radiolucent lines (> = 1mm) were observed. So far, a luxation of the prosthesis has not occurred and all implants are still in-situ. However, a dorsal tenoarthrolysis had to be performed in 3 patients.
The results of this study show a high rate of patient satisfaction with a significant pain reduction. The radiological results have to be closely monitored in the future.
Long-term results with a higher number of patients are necessary. A central registry for finger implants is recommended.
Conclusion: Our study shows that the incidence of Linburg –Comstock Syndrome is much higher than previously thought based on the clinical examination. However cadaveric dissections did not confirm a distinct structural connection except in one case where there was a fibrinous connection. It is likely that at least in some cases it is a acquired anomaly in response to repeated use/overuse of thumb and index fingers.
Between 1994 and 2001, 43 non-cimented trapeziometacarpal prosthesis ARPE® (Biomet™) was implanted by the same operator for isolated trapezio-metacarpal degenerative osteoarthritis. The minimal follow-up is 5 years.
The aim of this study is to evaluate the fonction of the thumb with a 5 year-old or more trapeziometacarpal prosthesis. The technique is described and the revisions are analysed.
7 revisions (16%) were necessary on average after 34 months (1 month in 10 years) : 5 for loosenning, 1 for premature dismantling and 1 for recurrent partial dislocation. 6 were treated by trapeziectomy with tendinous interposition of palmaris longus according to the technique of F.E. Jones.
In the first 13 months, 4 revisions is necessary. The ablation of the cup is easy but the extraction of de metacarpal still is often difficult. The scaphometacarpal height is constantly lowered (34,5 % on average). Aesthetically, 2 patients are disappointed and preferred their thumb with prosthesis.
At our institution, a well-documented and structured program of non-operative or opeartive management of Achilles tendon rupture with use of either casts or operation has been devised based on Ultrasound findings of the ‘Gap/distance between the two ends of the Tear’.
Treatment of chronic Achilles tendon ruptures can be technically demanding due to tendon retraction, atrophy and short distal stumps. Although rare, re-rupture following surgical treatment is a major late complication.
Biomechanical studies on the strength of reconstructed Achilles tendon using autologous tendon grafts have not been well documented.
This study examined the time zero in vitro mechanical properties of a reconstructed Achilles tendon (TA) using the peroneus brevis (PB) or the flexor hallucis longus (FHL) tendons in a human cadaver model (n=17).
The TA was reconstructed using the same technique for all specimens. Biomechanical testing was performed using an MTS 858 Bionix testing machine and structural properties (failure load, stiffness and mode of failure) were determined.
Average failure load was significantly higher in the PB-group (p=0.0116) (PB: 343.82 N (+/− 124.90 N, FHL: 241.54 N (+/− 82.17 N)). There was no significant difference in stiffness (p=0.212), (PB: 16.53 N/mm (+/− 6.25 N/mm), FHL: 14.00 N/mm (+/− 3.84 N/mm)) or energy (p=0.075).
Mode of failure was the same for all specimens, with the tendon graft cutting through either the distal or proximal TA-stump. Reinforcement of these stumps could lead to increased failure loads. Based on the biomechanical data, the present study supports the use of either FHL or PB to reconstruction chronic TA tendon ruptures. The greater failures loads for PB may not be clinically relevant considering the peak loads. The addition of the suturing pattern, whilst is does reconstruct the tendon, does not provide a similar ability to resist the load.
We examined 52 patients with acute Achilles tendon rupture (ATR), 43 men and 9 women, with a median age of 43 (28–68) years after percutaneous Achilles tendon repair with early functional therapy. 11 patients were treated in a cast (C) and 41 had a specially designed shoed (S). The mean follow-up was 56 (36–95) months. Patients suffering from health problems, which could affect their gait and balance (e.g. OA, spinal stenosis,…), as well as patients suffering from complications postoperatively, were excluded from the study. The mean Hannover Achilles Tendon Score was 81 (50 – 95) points (C = 81, S = 81).
Their calf muscle function studied three to eight years after treatment were found to have a significantly impaired dynamic muscle function of the calf muscles when tested in a specially constructed heel-raise test device. The Wilcoxon matched-pairs signed-ranks test showed a two-tailed P value of < 0,0001.
The average calf size was 38 (31–46,5) cm on the uninjured side and 36 (32–44,5) cm on the injured side. Only two patients had an equal calf size. Comparing the uninjured and injured side the two-tailed P value was found to be extremely significant < 0,0001.
The correlation between the maximum force and functional heel raise testing to the calf size on the injured side was weak with a Spearman correlation coefficient (r) = 0,33–38. There was no difference found between the patients treated in a cast and the patients treated in a shoe with percutaneous Achilles tendon repair and early functional therapy.
The principle finding in the present study was that the impact of an ATR is of great importance for the functional outcome than the treatment that is given. The difference in flexion strength and endurance between the injured and the uninjured side remained even after a 56 months follow-up. Therefore, calf size and functional muscle testing is a good tool to test functional outcome after Achilles tendon rupture. However, there was only a weak correlation between the size of atrophy and the amount of force reduction.
A supplementary incision for the first intermetacarpal space was made. The patients were free to return to their activities the third postoperative day and they were reviewed after 3, 6, 12, 24 months by an independent doctor. Their data were also recorded conform the protocol
Carpometacarpal arthritis of the thumb is a common source of morbidity particularly in post-menopausal women. It is commonly and successfully treated by trapeziectomy with or without ligament reconstruction and tendon interposition. This randomised prospective study compared the results of trapeziectomy alone or combined with tendon interposition and ligament reconstruction in 125 patients. Each patient had subjective and objective assessment of thumb pain, stiffness and strength and were scored using the D.A.S.H. and P.E.M. scoring systems. Patients were assessed pre-operatively and at 3 months and 1 year after surgery. The results of the two procedures revealed statistically improved pain levels but there was no statistically significant difference between the two in terms of pain relief, stiffness, weakness, grip strength, keypinch and thumb key pinch as well as in the D.A.S.H. and P.E.M. scores. The study shows that in the short term soft tissue reconstruction in addition to a simple trapeziectomy provides no improved benefit to the patient.
The factors affecting patient satisfaction with the outcome following treatment of Tendo-Achilles rupture were assessed. 35 patients were reviewed. 14 were treated non-operatively and 21 by open surgical repair.
Mean follow up was 2 years (range 9 months- 4 years). Evaluation consisted of questionnaire and information from medical records. Mechanism of injury, type and time of injury, co-morbidity and follow-up were noted from the medical records. From the questionnaire, pre injury activities, occupation, post-injury activities and overall satisfaction with their function were collected. The overall satisfaction level was quoted by the patients themselves by grading 10 for excellent recovery and 1 for the poor recovery.
Reduced post injury leisure activity, delay in initiation of treatment and post treatment physiotherapy had a significant influence on patient satisfaction with outcome. There was no significant difference in the overall outcome between the operative and non-operative group.
Fusion of the subtalar joint is an accepted method for numerous hindfoot pathologies. Various open techniques have been reported with similar good to excellent results. We designed this prospective analysis to evaluate the efficacy of arthroscopic subtalar fusion to compare the outcome with standard open techniques.
Method: 51 adults with a mean age of 42 years (range 21–75) were operated due to persistant pain and impaired function of the hindfoot unresponsive to symptomatic treatment. Patients were excluded if a significant deformity was present. Scoring was done according to the AOFAS ankle-hindfoot scale preoperatively and at each follow-up exam. A summery of the surgical technique is further given.
Results: 53 arthroscopic subtalar fusions were performed in 51 patients. At final follow-up (minimum 2 years) the AOFAS score improved from 52 preoperatively to 88 points. Non-unions were not observed. Clinical outcome was good and excellent in over 95% of all cases. Progression of degeneration in adjacent joints was minimal. Through the arthroscopic approach intraoperative visualization and preparation of the fusion site is superior to the open technique. Furthermore the clinical outcome supports the use of the endoscopic technique for the treatment of painful osteoarthritis of the hindfoot.
Stronger flexor tendon repair techniques achieving excellent zero time biomechanics are considered the cornerstone of the early active motion rehabilitation protocols in digital flexor tendon surgery. Stronger suture materials are being introduced constantly without being tested biomechanically. The purpose of this study was to identify the role of the suture material on the flexor tendon repair techniques.
Seventy two tendon segments from thirty six cadaveric flexor tendons were lacerated and repaired with 2 different repair techniques and 3 different suture materials. The repair techniques involved an easier form of the popular Strickland technique and the stronger Modified Becker technique. Ethilon, Ethibond and the newer Fiberwire sutures were used, creating a wide range of materials with diverse biomechanical properties. The repair constructs were tested in an in vitro linear load to failure model where the ultimate strength, the 2 mm gap load and the mode of failure were recorded. Furthermore, a similar test was performed using only suture materials tied in a loop in order to compare the materials without any tendon or repair technique interaction.
The Modified Becker repairs demonstrated higher loads to failure than the Modified Strickland repairs irrespective of the suture material. Stronger suture materials increased significantly the strength of the modified Becker repair. The biomechanical characteristics of the modified Strickland technique were not influenced by the different suture materials. The 2 mm gap loads were not influenced by the suture material with either technique. The mode of failure was by suture breakage in the case of the Modified Becker repair and mostly by suture pullout in the case of the modified Strickland technique. The superior strength characteristics of the Fiberwire over the rest of the suture materials were also observed in the suture material study.
Suture materials do not have a significant effect on the biomechanical characteristics of every flexor tendon repair technique. Techniques most likely to benefit are those that grasp the tendon substance tightly and are limited only by the breaking strength of the suture material itself.
Meshing increased the gliding resistance by approximately 20% and 30% in phase 2 and 3 respectively. Edge tying decreased the gliding resistance by 27% below that of normal pulley
No animal was killed for the study.
The standard treatment of arthrosis of the ankle joint is arthrodesis while new prosthesis leed to good clinical results. Currently there is much controversial discussion, and knowledge of the fundamentals of biomechanics is becoming ever more important.
Ten macroscopically and roentgenographically normal foot specimens were tested comparing tibio-talar arthodesis vs. nativ situation on a kinematic gait simulator. The stance- phase of normal walking gait was simulated from heel-contact to toe-off. Ground reaction forces were simulated by a tilting angle- and force-controlled translation stage upon which a pressure measuring platform was mounted. Force was applied to the tendons of the foot flexor and extensor muscle groups by cables attached to an additional set of six force-controlled hydraulic cylinders. Tibial rotation was produced by an electrical servo motor.
The change after arthrodesis was a varying degree of relocation of average force and maximum pressure from the lateral onto the medial column of the foot; the increase force on talonavicular joint and decrease on calcaneocuboid joint is statistically significant. The average force increased from native 66.7N to 80.8N upon arthrodesis in the talonavicular joint and decreased in the calcaneocuboid joint from 71.9N to 58.5N. Peak pressure increased from 3728kPa to 4552kPa in talonavicular joint and decreased in calcaneocuboid joint from 3809kPa to 3627kPa. After arthrodesis, we measured inconsistent changes in Chopart joint. On some feet, the changes in stress were slight, but on majority, relocation of force and peak pressure was significant. The result was a change in the function of Chopart joint with increased extension load on talonavicular joint at time of highest joint load during push-off.
These in vitro observations explain the clinical observations that have followed ankle arthrodesis. For one, there are reports on tibiotalar arthrodesis patients who are largely mobile and free of complaints, which correlates with the observation that not all preparations indicate a clear relocation of force and intraarticular peak pressure onto the talonavicular joint. In these cases, the ability of strong muscular plantar flexion could explain a good functional result. In contrast, and in addition to subtalar joint degeneration, arthroses in the talonavicular joint have been frequently observed following tibiotalar arthrodeses. The relocation of both force and intraarticular peak pressure onto the medial column of the foot in the majority of preparations explain the degeneration on the extensor side of the joint with osteophyte formation impressively.
The preoperative diagnosis was primary arthrosis in 19 cases, arthrosis secondary to trauma in 7 cases and subtalar instability secondary to neuropathic conditions in 4 cases. Patients are placed in a prone position. All arthroscopic procedures were done with non-invasive distraction, thigh tourniquet. Two portals, one each side of Achilles tendon, 2,5-3,0 cm above the junction of posterosuperior surface of the calcaneus and the Achilles tendon. A 4,0 mm 30 degree oblique arthroscope and a rotatory 4mm burr were used. Fixation was done with dynamic cannulated screw from calcaneus into talus.
A new design of total ankle replacement was developed. According to extensive prior research, the design features a spherical convex tibial component, a talar component with radius of curvature in the sagittal plane longer than that of the natural talus, and a meniscal component fully conforming to these two. The shapes of the tibial and talar components are compatible with a physiologic ankle mobility and with the natural role of the ligaments.
Within an eight-centre clinical trial, 114 patients were implanted in the period July 2003 – September 2006, with mean age 62.2 years (range 29 – 82). The AOFAS clinical score systems and standard radiographic assessment were used to assess patient outcome, here reported only for those 75 patients with follow-up longer than 6 months.
Intra-operatively, the components maintained complete congruence at the two articulating surfaces of the meniscal bearing over the entire motion arc, associated to a considerable anterior motion in dorsiflexion and posterior motion in plantarflexion of the meniscal-bearing, as predicted by the previous mathematical models. Mean 10.0 and 23.5 degrees respectively of dorsi- and plantar-flexion were measured immediately after implantation, for a mean additional range of motion of 19.2, which was maintained at follow-ups. Radiographs showed good alignment and no signs of evolutive radiolucency or loosening. The mean AOFAS score went from 40.8 pre-op to 66.2, 74.6 and 77.2 respectively at 3, 6 and 12 month follow-ups. One revision only was performed successfully three days after implantation because of a technical error.
In the score system utilized, Function and RoM sections scored better than any average previous total ankle result, Pain scored similarly. The satisfactory though preliminary observations from this novel design encourage continuation of the implantation, which is now extended over a few European countries. Instrumented gait and three-dimensional fluoroscopic analyses are in progress to quantify functional progresses.
We present the functional and radiological results after implantation of thirty four uncemented Buechel Pappas total ankle replacements. The average follow-up period was 5 years. All consecutive uncemented Buechel Pappas total ankle replacements were performed by the senior author (MSA) between 1990 and 2005, at Corbett District General Hospital, Dudley. Thirty four ankle replacements were performed. One patient died before follow-up. All ankle replacements were performed for osteoarthritis. The patients were assessed clinically and radiologically.
Thirty four ankle replacements were performed on thirty three patients. There were eight female and twenty five male patients. One patient had died 2 years after her ankle replacement. The average age of the patients was 69(58–84). All ankle replacements were performed for osteo-arthritis. 59% had post traumatic osteoarthritis.
The average body mass index was 30 (22–37). One hundred percent of patients were happy with their ankle replacement. Fifty nine percent of patients were completely pain-free, or had occasional twinges. All patients were mobile, forty seven percent of patients required no walking aids and only six percent required 2 walking aids. One patient complained of occasional instability. One patient sustained a medial malleolar fracture intra-operatively which was fixed with two partially threaded cancellous screws. The patients were placed in a back-slab post-operatively and were non-weight bearing for a period of 6 weeks. No revision operations were performed to date.
Clinical examination revealed forty two (5–57) degrees of movement in the ankle replacement at follow-up. Radiological examination revealed forty five (0–57) degrees of movement in the ankle joint. Pearson Correlation coefficient was 0.956, p< 0.001. There was excellant correlation between clinical and radiological assessment of range of movement.
Examination of the radiographs demonstrated no evidence of gross subsidence, or lucency. One implant had a poorly positioned talar component, but so far this has been assymptomatic.
The American Foot and Ankle Society Scores were 34.6(20–56) pre-operatively compared with 76(54–100) at follow-up. This was significant improvement p< 0.001. Average scores for pain, function and alignment were 30(20–40),40(29–50) and 9(5–10).
There was one intra-operative fractured medial malleolus and two superficial wound infections (with negative swabs) treated with antibiotics.
We compare our results with others published and feel the Buechel Pappas Uncemented Total Ankle replacement performs well and is a good alternative to ankle arthrodesis preserving ankle movement and biomechanics. The results are comparable to other uncemented total ankle replacements.
To evaluate whether endoprosthetic ankle replacement is an adequate treatment option. the following studies involving total ankle replacement (TAR).
From June 1997 to December 2004 a total of 68 TARs were performed in 66 patients, of whom 22 received cemented implants, 40 cement-free implants, and 4 hybrid implants. The indications for TAR included post-traumatic joint destruction in 54 patients, rheumatoid arthritis in 6 patients, and idiopathic osteoarthritis in 8 patients. Bilateral TAR was performed in two patients with rheumatoid arthritis, one of whom developed surgical site infection six months after the first implantation, thus requiring arthrodesis through external fixation; follow-up of this patient revealed no abnormality, and extension/flexion was 15-0-25°. Upon follow-up visits conducted 10 to 72 months following TAR patients were grouped according to ankle score, visual analog scale, subjective symptoms, and walking distance. The average preoperative ankle score did not exceed 70 points (17–67). Thirty-nine out of 66 patients displayed a balanced gait with only minor walk abnormality as well as ranges of movement between 30° and 55° including extension above neutral (excellent and positve outcome). Fifteen out of 66 patients complained of persisting discomfort located in the medial, lateral and anterior sides of the upper ankle joint and showed extension deficits of 5 to 15° (adequate outcome). Twelve patients had a poor outcome.
A total of 34 wound revisions were required in 25 patients, including: osteosynthetic treatment of malleolar fractures in 7 patients, wound revision in 4 patients, exostosis removal in 4 patients, and extension of the Achilles tendon in 3 patients. Three arthroscopies were performed due to persisting discomfort.
Implant loosening occurred in 13 cases and was treated as follows: tibial plateau replacement (6 cases), inlay replacement (4 cases), total implant replacement (2 cases), and arthrodesis (5 cases).
Out of 66 patients, the treatment outcome was excellent in 8 patients, positive in 31 patients, and adequate in 15 patients; in 12 patients no significant therapeutic benefit in terms of upper ankle joint function and symptoms was obtained. In view of the short observation time no long-term results are available so far. In the short and medium term TAR appears to improve the range of movement of the ankle joint in two-thirds of patients who fulfil the indications for TAR, which include a satisfactory range of movement (minimum 40°) and lateral ligament stability.
The procedures were reviewed with primary focus on perioperative blood loss, length of surgery and neurovascular complications. Patients who underwent combined surgery of acetabulum and femur were excluded.
Data are presented as mean with 95% confidence interval (CI) in brackets.
The MI group had 1 case of major arterial bleeding, however no blood transfusion. The II group had 2 cases of arterial thrombosis and one transient sciatic nerve palsy. One patient received blood transfusion.
The rate of homologous blood transfusion (HBT) following primary total hip replacement (THR) can be as high as 30–40% and is not without risk. Postoperative blood salvage (POS) with autologous blood transfusion may minimize the necessity for HBT but the clinical, haematological and economic benefits have yet to be clearly demonstrated for primary THR.
The aim of this randomized prospective study was, therefore, to determine if the use of post-operative salvage affects post-operative haemoglobin and haematocrit values and reduces the rate of homologous blood transfusion. Secondary outcome measures included length of hospital stay and patient satisfaction. A cost analysis was also conducted on the basis of the results obtained.
The patients were randomized during the operation (at the point of reduction of the primary THR) to receive either two Medinorm vacuum drains or the autologous retransfusion system. A power calculation estimated that 72 patients would be required in each group to detect a significant difference of 0.7 gdL-1 in post operative haemoglobin level (at 80% power with an value of 0.05). This assumed a standard deviation of 1.5 gdL-1 obtained from a previous retrospective study.
There were 82 patients in the Medinorm vacuum drain group and 76 patients in the autologous retransfusion group. In the group with the autologous system, 76% of the patients were retransfused with a mean of 252mls. There was no significant difference between the groups when comparing haemoglobin and haematocrit values. However, significantly fewer patients in the group with the autologous system had a postoperative haemoglobin value less than 9.0 gdL-1 (8% vs. 20%, p = 0.035). Furthermore, significantly fewer patients with the autologous retransfusion system required a transfusion of homologous blood (8% vs. 21%, p = 0.022). There was a small overall cost saving in this group.
This study has shown that use of an autologous retransfusion system for primary THR reduces the necessity for HBT and is cost effective. POS also results in significantly fewer patients dropping their post-operative haemoglobin level below 9.0 gdL-1. As a result our unit routinely uses the autologous retransfusion system for primary THR.
The purpose of this study was to investigate the energy cost of walking after total ankle arthroplasty (TAA), and to investigate if possible differences could be attributed to changes in external mechanical work required for the step-to-step transition.
Eleven patients, 6 months to 4 years after successful unilateral TAA, and 11 healthy controls walked on a treadmill at a self-selected speed (SWS) and a fixed walking speed (FWS, 1.25 m/s). Ground reaction forces and oxygen uptake were measured. External mechanical work was analyzed using the double inverted pendulum model.
At SWS, velocity in the TAA group was reduced (v=1.29 vs 1.42 m/s, p=0.05) but metabolic energy cost was not different (E=2.50 vs 2.24 J/kg/m, p=0.32). At FWS, metabolic energy cost in the TAA patients was significantly higher (E=2.58 vs 1.96 J/kg/m, p=0.003). The difference in metabolic energy cost at FWS coincided with an increased negative work in the leading leg and reduced positive work in the trailing leg with TAA during double support. Although this indicates that the mechanical work for the step-to-step transition increases, the total external mechanical work over a complete stride was not different between the TAA and the control group.
TAA patients walk at a higher metabolic energy cost. This cannot be explained by differences in external mechanical work. Other factors, such as changes in muscle function, should be taken into account.
Routine prophylaxis is recommended to prevent venous thromboembolism (VTE) – manifesting as deep vein thrombosis (DVT) and/or pulmonary embolism (PE) – in patients undergoing major orthopaedic surgery. Rivaroxaban (BAY 59-7939) is a novel, oral, direct Factor Xa inhibitor in development for the prevention and treatment of VTE. The efficacy and safety of 5–9 days’ prophylaxis with rivaroxaban were investigated in three randomized, double-blind, phase IIb trials in patients undergoing elective, total hip or knee replacement (THR or TKR), relative to subcutaneous enoxaparin.
Two trials (one in patients undergoing THR, N=722; and one in patients undergoing TKR, N=621) investigated twice-daily (bid) rivaroxaban (at total daily doses of 5–60 mg); the third (in patients undergoing THR, N=873) investigated once-daily (od) rivaroxaban (at doses of 5, 10, 20, 30 or 40 mg od).
Rivaroxaban – at all doses tested – had similar efficacy to enoxaparin in the bid trials. This promising finding was strengthened by the od trial, in which the observed incidences of the primary efficacy endpoint (DVT, non-fatal PE or all-cause mortality) were lower in patients receiving rivaroxaban 5, 10, 20, 30 and 40 mg od (14.9%, 10.6%, 8.5%, 13.5% and 6.4%, respectively) than enoxaparin (25.2%). Although there was no significant dose–response relationship between rivaroxaban and the primary efficacy endpoint in these trials, there was with major VTE (proximal DVT, PE or VTE-related death; p=0.0072) in the od trial (incidences were 8.5%, 2.7%, 0.9%, 1.9% and 1.1% with rivaroxaban 5, 10, 20, 30 and 40 mg od, respectively, vs 2.8% with enoxaparin).
Significant dose–response relationships between rivaroxaban and major bleeding were observed in all three trials. In the bid trials, major bleeding rates with rivaroxaban were similar to those with enoxaparin at total daily doses of 5–20 mg. In the od trial, major bleeding occurred in 2.3%, 0.7%, 4.3%, 4.9% and 5.1% of patients receiving rivaroxaban 5, 10, 20, 30 and 40 mg od, respectively, and in 1.9% of those receiving enoxaparin.
Rivaroxaban was generally well tolerated in the bid and od trials, and the incidence of nausea and vomiting with early post-operative oral rivaroxaban administration was low for all doses tested.
The bid trials suggest that oral rivaroxaban at total daily doses of 5–20 mg may be a safe and effective alternative to enoxaparin for the prevention of VTE after major orthopaedic surgery. The od trial suggests that the more-convenient od regimen is feasible and that 10 mg od, a dose within the range identified by the bid trials, should be investigated further. As a result, oral rivaroxaban 10 mg od is currently being investigated in four phase III trials for the prevention of VTE after major orthopaedic surgery (the RECORD trials).
The aim of this study is to evaluate techniques which may reduce intra and Post-Operative (PO) bleeding in hip surgery.
Methods: In this prospective study, from 9/2005 to 6/2006, we evaluated Blood Loss (BL) after primary total hip arthroplasty. Exclusion criteria were anti-coagulant drugs not discontinued 10 days before surgery and patients whose condition precluded weight bearing PO. We included total hip arthroplasty with posterior surgical approach, spinal anaesthesia, hypotensive surgery and peri-operative blood salvage (Ortho PAS, Euroset). When appropriate, the Mini-Invasive Approach (MIA) was used. In a different sub-set of patients, including some of the minimally invasive patients, a new bipolar Radio-Frequency sealer (TissueLink) was used. The PO program had pain control, LMWH for prevention of DVT, exercise from the day of surgery and walking on crutches from the next day. We analysed: blood loss after surgery and for 3 days; haemoglobin values (g/dL) before surgery and for 5 days PO; thigh circumference pre-op and at 5 days and adverse events such as transfusions and luxation. For the statistical evaluation the paired “t-test” was used, with a level of significance set at 95%. Differences and p values of < 0.05 were considered significant.
Results: 324 patients (mean age 68; range 23 to 89; 179 F & 145 M) were admitted to the study. Mean BL was 305ml intraoperative, 501ml at 6 hours PO, 304ml at 1day PO, 132ml at 2 days PO and trace at 3 days. Rather than simple unit measures, we analyzed the Percent Change in Hb from preoperative levels (%CHb). The patients had a mean %CHb of 23,09% at 1day PO, 26,67% at 2 days PO, 28,13% at 3 days and 29,07% at 5 days. Transfusion rates (TR; trigger set at Hb< 8g/dL) were related to the preoperative Hb and age. Overall TR was 15% (51/324), the prevalence of homologous transfusion was 7% (24/324). The TR for each Hb value: 21% (15/69) for Hb=12–13, 20% (20/98) for Hb=13–14, 17% (15/88) for Hb=14–15 and 5% (1/29) for Hb=15–16. The mean value of pain during rehabilitation was 3,11(VAS). MIA (53/324) was associated with reduced BL (mean %CHb at 1st day PO 19.12; TR 9%), but with high variability. The use of bipolar sealer (58/324) was associated with a significant reduction in overall BL (mean %CHb at 1st day PO 15.83; TR 5%) as well as a reduction of thigh swelling (37%) and of mean rehabilitation pain (30%; VAS=2.15).
Discussion: Reduced blood loss, reduced post-operative pain and a faster functional resumption are obtained with both the minimally invasive approach and the TissueLink sealer approach. In addition, MIA provides muscle preservation and the use of the TissueLink sealer provides reduced post-operative swelling.
Conclusion: This study shows that both the minimally invasive surgical approach and the use of an irrigated RF bipolar sealer can lead to reduced blood loss and faster functional resumption following hip surgery.
This phase III, multicenter, double-blind placebo controlled study evaluated safety and efficacy of aprotinin in reducing blood transfusion in subjects undergoing THA.
Subjects were stratified by preoperative autologous blood donation and randomized to receive aprotinin (1 mL test dose; load, 2 million KIU and 0.5 million KIU/hour) or placebo. Subjects were assessed at baseline, postoperative days 1, 2, 3, 7 (or discharge) and 6±2 weeks. Primary efficacy variable was percentage of subjects requiring blood transfusion through day 7 or discharge. Safety was based on adverse event (AE).
Of 359 randomized subjects, 175 in each group completed the study. Demographics of the groups were similar. Aprotinin reduced by 46% the requirement for any transfusion (17% vs 32% of subjects, p=0.0009). Aprotinin reduced allogeneic blood transfusion in subjects regardless of predonation status (11% vs 22%, p=0.0063), who made no predonation (13% vs 24%, p=0.0216), and who predonated (32% vs 62%, nd). The aprotinin group had a reduction of the number of any (48 vs 109 units; p=0.0003) and allogeneic (30 vs 72 units; p=0.0041) units transfused and total fluid loss (709 vs 957 ml; p=0.0002) compared with placebo.
One patient died in the placebo group. AEs were reported in 83% of aprotinin-treated and 86% of placebo subjects, with 10% and 11%, respectively, described as serious AEs. No clinically important differences between aprotinin and placebo AEs were observed. Hypersensitivity to aprotinin was not reported.
In this study, full-dose aprotinin was safe and effective in decreasing blood transfusion in subjects undergoing THA.
Preoperative co-morbidities such as known coronary artery disease have commonly deemed a patient at ‘high risk’ for primary elective Total Hip Arthroplasty (THA). We prospectively collected data on 1744 patients who underwent primary elective THA between 1998 and 2004. 273 had a history of cardiac disease defined as a previous hospital admission with a diagnosis of angina pectoris or myocardial infarction. 594 patients had hypertension defined as that requiring treatment with antihypertensives.
We also had data on preoperative age, sex and body mass index (BMI).
There was no statistically significant increase in early mortality at 3 months with a history of cardiac disease or hypertension and this remained so when adjusting for the other factors in a multivariate analysis. Sex or BMI also did not have a statistically significant effect on the risk of death within 3 months. Increasing age was the only significant risk factor for early mortality (P< 0.001).
Longer term mortality at 2 and 5 years in relation to these factors was also examined. Statistical analysis revealed that coronary history now showed a highly significant association (P< 0.001) with long term mortality, in patients who survived more than 3 months. 95% confidence intervals for percentage mortality at 5 years were 9.7 – 21.7 with a cardiac history compared to 4.8 – 8.8 without a cardiac history. This remained significant (P=0.002) when adjusted for the other factors. Hypertension continued to have no effect, as did BMI. Age remained a significant risk factor. Females had a slightly lower long term death rate than males, following THA.
The overall long term mortality following THA was less than expected from the normal population, even in the subgroup with a coronary history.
This study will assist clinicians when advising patients seeking primary elective THA, who have one of these common risk factors.
There was no significant correlation between clinical leg length change, measured in the operating theatre and the leg length change predicted by navigation. Accuracy of cup and stem placement was assessed by comparison of the homogeneity of variances, the Levene statistic, in the navigated and control groups. The range of cup inclination, cup version and stem version was significantly narrowed in the navigation group (p< 0.05).
To target postoperative patients in need for prolonged pharmacologic thromboprophylaxis due to persistent coagulation activation, we developed and evaluated a qualitative test method, which detects the urinary excretion of prothrombin fragment 1+2 (uF1+2). The test was developed as a dip-stick device consisting of a one step rapid lateral flow immunoassay with visual readout on one test line and one control line. The assay time was between 5 and 10 minutes.
Spot urine samples were collected in 113 patients undergoing elective hip arthroplasty preoperatively and on day 5 after operation. Specimens were frozen immediately and stored until batch analysis. Pharmacologic thromboprophylaxis was administered according to national guidelines until day 7±2 after the operation. The results of the new dip-stick device were compared with the results of a laboratory based enzyme-linked-immunosorbent-assay (ELISA) method and a predetermined cut-off value. Patients were followed for development of vascular thrombotic complications/unexpected death until day 90 after the operation.
10 (8.8%) patients experienced an event during the study: 2 (1.8%) died unexpectedly and 8 (7.1%) had a vascular thrombotic event. All patients with clinical events had significantly raised postoperative levels of uF1+2. The clinical accuracy of the dip-stick test was acceptable with a sensitivity of 100% and a negative predictive value of 100%. Compared to the standard ELISA method the dip-stick test had a sensitivity of 93% and a specificity of 48%.
Laboratory ELISA analysis of urinary excretion of uF1+2 is neither feasible nor applicable in postoperative patients. Bed-side testing of persistent coagulation activation, however, could help to determine the need for prolonged thromboprophylaxis. The new dip-stick urine test was very easy to use, had a high negative predictive value and sensitivity and thus appears to be safe. However, the number of false positive test results prompts a fine-tuning of the test device. In terms of clinical applicability the test was acceptable. The study showed that about one third of the patients could be excluded from further extension of thromboprophylaxis beyond the first week.
In THA navigation systems mostly the anterior pelvic plane (APP) is used as reference for cup orientation. For the femoral torsion the sagittal plane of the leg in 90° knee flexion is used as reference. The common procedure is associated with a pointer based palpation of anatomical landmarks. But sometimes it shows difficulties especially in obese patients. The purpose of the current prospective study was to evaluate the THA navigation based on palpation of the APP and the femoral sagittal plane using a novel intra-operative ultrasound device in comparison to standard palpation technique.
1) 82 patients with THA (40 who had at least one dislocation, and 42 matched patients without instability randomly selected, 19 of these 42 underwent a profile X-ray of the pelvis before and after THA insertion) 2) and 24 standard subjects who underwent lying and weight-bearing profile X-rays of the pelvis to assess the modifications of orientation of the pelvis between these two positions.
After THR, trochanteric soft tissue abnormalities may be associated with residual trochanteric pain and limping. However, normal MR appearance of the trochanteric region after THR is not known. The aim was to evaluate MR imagings in asymptomatic and symptomatic patients after THR through a transgluteal approach.
Triplanar MR images of 25 asymptomatic (14 men, mean age 60.4 years, 11 women, mean age 60.2) and 49 symptomatic patients (19 men, mean age 62.7 years, 20 women, mean age 64.3) at least 1 year after THR were analyzed by two blinded radiologists. In 14 symptomatic patients MR imaging was correlated to surgical findings.
Tendon defects were uncommon in asymptomatic and significantly more frequent in symptomatic patients (gluteus minimus 8% vs. 56%, p< 0.001; lateral gluteus medius 16% vs 62%, p< 0.001; posterior gluteus medius 0% vs18%, p< 0.025). Signal changes within tendons were very frequent in both groups except for the posterior gluteus medius tendon which demonstrated this finding more frequently in symptomatic patients (20% vs 59%, p=0.002). Changes in tendon diameter were very frequent in both groups but significantly (p=0.001–009) more frequent in symptomatic patients. Fatty atrophy was evident in the anterior two thirds of the gluteus minimus muscle in both asymptomatic and symptomatic patients. In the posterior superior third of the gluteus minimus muscle differences of fatty degeneration were significant. Fatty atrophy of the gluteus medius muscle was only present in symptomatic patients. Bursal fluid collections were more frequent in asymptomatic (32% vs 62%, p=0.021). MR diagnosis was confirmed in all 14 patients undergoing revision surgery.
Although more frequent in symptomatic patients many MR findings are frequently found in asymptomatic patients. However, defects of the abductor tendons and fatty atrophy of the gluteus medius and the posterior part of the gluteus minimus muscle are rare in asymptomatic patients.
The incidence of post-operative peri-prosthetic fractures is increasing. This is a consequence of the larger number of revision cases being undertaken, the increase in the use of cementless implants and a number of patients who develop undetected osteolysis as a result of poor follow up. The Vancouver classification has been shown previously, in North America, to be a valid and reliable method for determining the configuration of a periprosthetic fracture. This is essential in directing the fractures further management appropriately and the classification system has been adopted by surgeons throughout the world.
The reliability of any classification system depends on the reproducibility between the clinicians who are making the management decisions. We have revalidated this classification system, independently from the original authors, at a centre in Europe. The radiographs from 30 patients with peri-prosthetic fractures were reviewed by 6 expert consultant surgeons, 6 non-experts at registrar level and 6 medical students, who had received no specialist teaching in this area, in order to assess intra and inter-observer reliability and reproducibility. Each observer read the radiographs on 2 separate occasions and classified the fracture according to its type (A, B1, B2, B3, and C). The results were subjected to weighted kappa analysis and were: 0.76 (substantial agreement) for experts; 0.68 (substantial agreement) for non-experts; and 0.61 (substantial agreement) for medical students.
Our results confirm the reliability and reproducibility of this classification system. In addition we have shown that substantial agreement can even be found between individuals with no specialist training. This is a classification system that can be reliably used by non-experts, between centres and across continents.
Material and Methods: 31 patients with a mean age of 77 years (56–94) were operated of a periprosthetic fracture which happened 73 months (0–300) after the index arthroplasty
Fractures were classified following the Vancouver system: 1 patient presented a type Al(3%), 4 a B1(13%), 23 suffered a B2(74%), 1 a B3(3%) and 2 patients presented a type C(6%)
The risk factors described in the literature were evaluated, as well as the different types of treatment with their clinical and radiological results.
Personal: 21(68%) patients were women Previous condition of arthroplasty: 22(71%) non cemented, 23(74%) total prosthesis, 3(10%) revision surgery; 13(54%) presented osteointegration, 2(8%) stable fibrous fixation and 9 (38%) were unstable; in (7%) there was subsidence Surgical technique: 11(52%) patients had insufficient size of the implant and 15 stems were in varus (54%) Bone status: 5 femur (20%) presented stress risers and 29(97%) diffuse osteopenia Polyethylene wear: 10(50%) of THA Osteolysis was observed in 21 patients (70%): 19(90%) in zone 1, 4(19%) in zone 2, 3(14%) in zone 3, 2(10%) in zone 4, 2(10%) in zone 5, 4(19%) in zone 6 and 15(71%) in zone 7. 5(24%) patients presented osteolysis in one zone, 9(43%) in two zones, 4(19%) in three zones, 2(10%) in four zones and 1(5%) in six zones Type of treatment: 19(61%) patients were treated with open reduction and internal fixation (ORIF) without revision of the prosthesis, 11(35%) with revision surgery plus ORIF and 1(3%) with a resection arthroplasty. Bone graft was used in only 1(3%) patient Type of osteosynthesis: 16(52%) only cables, 1(3%) cables and plates, 2(6%) plates and screws, 11(35%) plates and cables and screws, 1(3%) intramedullary nail
There were 0(0%) infections and 0(0%) exitus but 7(23%) patients suffered postoperative medical complications The mean time for allow weight-bearing was 3 months (2–6) For the 25 patients that achieved the complete follow up, maximum recovery was recorded after 9 months (3–13); 24(89%) patients recovered their previous status and 15(60%) had no pain. 15 patients maintained the instrumental level before the fracture and 10(66%) recovered it
The mean time for fracture union was 6 months (3–18). At the end of follow-up 1(4%) patient presented non-union 0(0%) patients presented mal-union, 2(8%) a refracture, and 6(24%) evolved to implant loosening
Patients with periprosthetic fractures present a high number of previous local risk factors Surgical treatment achieves a very low mortality rate and a good/excellent clinical result Overuse of ORIF without prosthesis revision obtains consolidation in most cases but with a high risk of loosening
Malposition of cups and stems in THA leads to a higher rate of dislocation and wear, to leg length discrepancies and to a higher revision rate. Surgical navigation of the implant components should lead to a more accurate position of THA.
1481 consecutive THA were evaluated from November 2001 to June 2006. In a first series until December 2002 127 THA with navigated cups were compared with 110 manually implanted THA. In a second series all following 766 THA with navigated cups were compared to 384 THA with both navigated cup and stem. Navigated surgery was done as a routine procedure by all surgeons, from residents to consultants.
Evaluation was done for radiographs, clinical results, the navigation system data for cup anteversion and inclination, centre of rotation, leg lengthening, offset and antetorsion of the stem, technical exclusions and intra- and postoperative complications as dislocation, seroma, thrombosis and duration of surgery.
The results showed a better alignment in inclination and anteversion of navigated cups compared to non navigated cups and additional improvement when cup and stem were navigated. In stem navigation a good control of the leg lengthening and a reliable prediction of the safe range of motion could be seen. The overall dislocation rate was 0.3% in the navigated groups after December 2002. Thrombosis, seroma and infection were seen in a very low rate in all groups.
58,109 primary hip replacements for osteoarthritis were investigated for effect of age group, sex and fixation method. Age group and sex were not significant risk factors in revision for dislocation. Studying fixation method, cementless acetabular components were implanted more frequently (49,027, 84%) than cemented (9,082, 15.6%). In total, there were 428 (0.7%) revisions for dislocation, 369(0.8%) with a cementless acetabulum and 59 (0.6%) with cemented. Relative risk (cementless v cemented acetabulum adjusted for age group, sex and head size) of 1.59 (CI 1.19 to 2.12, p< 0.01). Head sizes of > 30mm, 28mm, 26mm and 22mm had significantly increasing relative risk (p< 0.001).
Results: When the Vancouver system was applied 2.85% of the fractures were classified as type A, 87.2% as type B and 10% as type C. Within the type B group 13.2% were subtype B1, 12% subtype B2 and 62% subtype B3. 1 out of 6 Mennen, 4 out of 16 Dall/Miles and 2 out of 20 DCP plates failed. Overall 68% healing, 5% non-union, 4% infection, 23% re-fracture rate at 12 months follow-up. Better healing was achieved when impaction grafting was used for B3 fractures (p=0.001). Better healing was achieved when the revision stem was bypassing the most distal fracture line by at least 2 ipsilateral femoral diameters and impaction grafting was used for B3 fractuires (p=0.01).
Heterotopic ossification (HO) is a frequent pathological phenomenon after total hip arthroplasty. Incidence of HO after the total hip arthroplasty is in average 43%. Most often classification from Brooker and co-authors has been used to assess the HO. Overall 47% of all studies published until the 1999 have used Brooker’s system, but there has been reported a “fair” reproducibility (Cohen’s kappa 0.5) of this system.
The aim of the present study was to estimate the influence of used classification system to the evidence of HO, to assess the reliability of the more often used classification systems, to determine the sources of errors in the assessment-process of HO and, to compose a new classification system with higher reliability.
Four investigators assessed HO in 111 patients applying most often used classification systems and the new system. Six investigators measured dimensionality of HO in 28 patients applying method of digital planimetry. Kappa statistics of all the compared classification systems were calculated. Main sources of errors were detected by dispersion model.
Average evidence of HO differed up to 1.4 times if the different systems were applied to assess HO. Therefore, using literature data, always the criteria of a system used should be taken into consideration.
Most important source of errors in the HO assessment was the error of diagnosing process. This source consisted of two components: inter-observer variation that formed 25.5% (+/−8.0%; p=0.0015) of total error and intra-observer variation that formed 60.9% (+/−7.3%; p< 0.0001). Technical performing error had less contribution in total error, namely 8,0% (+/−0.6%; p< 0.0001) and subspecialisation of the investigators did not cause any systematic bias having a proportion of 5.7% (+/−4.9%; p=0.2457).
Reliability of the Brooker’s system was lowest among the compared systems. Combining the Della Valle’s system which had high reliability with the Brooker’s system, we composed a new classification preserving high reliability. The results obtained using the new classification allow comparison with the results obtained using each of the parent classifications.
Various scoring systems are in use to assess the outcome of total hip replacement. Since its introduction in 1996, Oxford hip score (OHS) has been validated in several studies. Total hip replacement has been shown to improve the OHS in several studies but we could not find any studies on effect of the surgical approach on OHS.
Overall of all petients who underwent surgery, 71% had improved pain control, 53% regained mobility, 64% improved by at least one Frankel grade or maintained normal neurology and 39% regained normal urinary sphincter function. While 18% were bed bound preoperatively, only 5% were still in bed postoperatively. Perioperative mortality rate was 5.8% and morbidity was 21%. The median survival for the cohort was 352 days (11.7 months). The radical surgery group had a median survival of 438 days and the palliative group 112 days (P = 0.003).
In spinal stenosis with degenerative spondylolisthesis, decompression and fusion is widely recommended. However, the main drawback of fusion remains pain at the bone donor site. A novel dynamic transpedicular system (Dynesys™) was introduced to stabilize the spine without adding bone graft for fusion. Two years results reported earlier were excellent.
Residual kyphotic deformity is considered the main factor for the increased risk of new fractures after an osteoporotic vertebral fracture. We hypothesized that even in the absence of kyphotic deformity, the altered pressure profile of the disc after a fracture will increase the risk for subsequent fractures.
In the intact specimens, nucleus pressure gradually increased during flexion. This can more evenly distribute the load during flexion to the entire surface of the endplate and avoid excessive load concentration to the anterior portion. After an endplate fracture, the nucleus pressure gradually decreased during flexion, meaning that the anterior annulus was forced to bear more load. This uneven load transfer to the anterior part of the VB resulted in doubling the strain at the VB adjacent to the fractured end plate. All adjacent factures were observed at the vertebra next to the damaged endplate. The altered mechanical behavior of the nucleus can be ascribed to the increased available space after the endplate depression.
Our objective is to perform a prospective study on the efficiency and durability of pain reduction through percutaneous PMMA vertebroplasty in patients with vertebral osteoporotic fractures.
We started in March 2002, and up to January 2005 we have performed this technique in 43 patients, 42 female and 1 male, with osteoporotic vertebral fractures. We performed a total of 56 vertebroplasties, 36 lumbar and 20 thoracic. The majority is for the thoracolumbar junction. Patient age went from 56 to 85, with an average of 70,7 years.
Cryteria for inclusion in this study have been the following:patients with osteoporosis, preferably with one or two collapsed vertebral bodies, with intractable pain for over 3 months. Exclusion cryteria have been: infection, blood coagulation deficits and mieloradicular compression. Relative exclusion criteria are Fractures over 70% body collapse, Posterior wall fragmentation and Young patient fracture with no prior disease.
We perform our PV under local anesthaesia with sedation and in a lateral decubitus position. We preferably use a parapedicular approach for both thoracic and lumbar fractured vertebrae.
The material we prefer are the LP2 system or the LCO and we chose Exolent spine for PMMA.
We follow a protocol that consists in:bed rest for 2 hours, allowing the patient to sit and have small walks afterwards;Dismissal the following day, with a mild analgesic for the effects of the skin incision;Maintain drug treatment for osteoporosis;Revision on the 2nd and 7th day;New revision at 3, 6 and 12 months.
Evaluation of the results was made by defining a pain score: Score 1 corresponds to minor or no improvement in pain.
Score 2 corresponds to a medium improvement in pain, with 25 to 50% less drugs required.
Score 3 corresponds to a better improvement in pain, with 75 % less drugs required.
Score 4 corresponds to complete relief of pain. In our revision, we had a minimum follow-up of 12 months, maximum of 44, and an average of 28 months. We have observed the following results:
- 2 patients with score 1 - 4 patients with score 2 - 32 patients with score 3 - 5 patients with score 4
We can resume this by stating that 90 % of the patients had a relief in pain, and a good result was observed in 75 %.
We have had some complications, which consisted in:
- PMMA leakage into the disc in 1 case - Transitory radicular pain in 1 case - Hiperthermia in 1 case - Cannula breakage in 1 case, which was resolved through a small incision. None of these has altered the final result. - Venous leakage in 1 case, which we have considered as the only serious complication..
In conclusion, and up to now, we have obtained pain reduction in 90% of the cases; we have prevented collapse of the treated vertebrae, and we have not had collapse of any adjacent vertebrae.
It is a technique that may have complications, but results depend on a correct selection of patients.
The circulatory effects of multilevel balloon kyphoplasty (BK) are not adequately addressed, neither the effectiveness of egg shell cementoplasty in preventing anticipated cement leakage in difficult cases. The purpose of this study was to evaluate
the effect of multilevel BK to blood pressure and arterial blood gasses; the incidence of methylmethacrylate cement leakage using routine postoperative computer tomography scan and the effectiveness of egg shell cementoplasty to prevent cement leaks.
In the last years dynamic devices represent an alternative for the more invasive decompression surgery.
Currently a registry is maintained to collect data on patients implanted with the X STOP.
The results showed a clinical significant change for the domains SS and PF for both 1-year follow-up and 2-year follow-up. For the domain PS the mean score is 1.81 (very satisfied = 1, somewhat satisfied = 2).
The clinically significant success rate based on clinically improvement in 2 of the 3 domains is 71.9% and 65.0 % after respectively 1-year and 2-year follow-up.
Recently we reported that the degree of cauda equina constriction at the most constricted level in the lumbar spine directly was related to typical preoperative symptoms like walking distance, radiating pain but also quality of life. The aim of this study was to relate the degree of preoperative constriction to the results one year postoperatively.
Results: Results: The average CSA for the most constricted lumbar level was 58.0 SD 23 mm2. For those with a CSA < 68 mm2 parameters like walking ability, pain intensity in the leg and back, health related QoL was improved in a statistically significant way. For those with a preoperative CSA > 68 mm2 no signifcant improvement was found one year postoperatively.
Conclusion: Subjects operated for central spinal stenosis having a pronounced cauda equina constriction (CSA) also had the best outcome one year postoperatively.
A total of 10 (11%) of 91 patients developed symptomatic next segment desease at a previously asymptomatic level. Date were obtained in patients with next – segment failure based on X-rays studies, neurological assessment and sequential follow-up examinations. The aforementioned patients had a mean age of 42.8 years and the mean follow up period was 8.7 years after surgery. 7 cases were isthmic, 2 degenerative and 1 dysplastic spondylolisthesis.
Fusion in every case entailed the use of autologinous bone grafts, and with the PLIF technique cages, in 3 cases, dowels, in 6 cases, and autofibula in 1 case were used. The mean follow-up period between original surgery and next-segment failure was 3.8 years.
All patients with instability in cranial adjacent segment underwent successfully additional surgery by using 360° fusion with instrumentation (ALIF).
The cause of instability could also be overloading of the spine, damage to the stability of ligament and bone structures sustained during the operation, or a combination of the above.
1) younger age, particularly age between 36 and 45 years, 2) experience of less than 10 years, 3) having a PhD degree, and 4) working in an academic or teaching setting.
The majority of the respondents (65%) were aware of the Journal’s evidence-based medicine section, and 20% used the Journal’s evidence-based medicine abstracts in clinical decision-making. This increased awareness in evidence-based medicine was also reflected in a frequent use of Cochrane reviews in clinical decision-making (27%). Surgeons who used the Journal’s evidence-based medicine abstracts and Cochrane reviews had significantly higher competence scores.
Every country has its own criteria for consent. In most, a written consent form is used to reflect patient understanding and permision for the procedure to happen.
While oral consent has as much legal sway as the written consent form, the presence of a signature acts as proof of discussion. All European hospitals should have a 100% compliance with patient’s signing consent forms, but their completion is often incomplete and inaccurate, have errors of omission and have lead to litigation, poor patient understanding and recall.
We (along witht the BOA) introduce an computer programme of procedure specific orthopaedic consent forms. They have been created for most common elective and trauma operations. The forms follow the UK Department of Health guidelines on consent and contain a brief explanation of the procedure, offer alternative therapies/consequences of not having the procedure (where appropriate), the serious risks and commonly occurring complications. They are written in layman’s English (aimed at a reading age of 14 years). Preliminary trials have also shown the time taken to print and complete a pre-designed form is much less than that of the current handwritten form, reducing errors of omission whilst still allowing discussion with the patient.
The forms are currently available as word documents from an easily navigable website. With a view towards European usage, the forms can be easily translated to other languages at minimal cost.
With support from the British Orthopaedic Association (BOA), the BOA medico-legal committee, the specialist societies and consultant users (via the website) we hope that the project will continue to evolve with a greater selection of procedural consent forms becoming available.
It is believed, from the evidence available, that this approach should decrease the incidence of patient misunderstanding, and the potential risk of successful litigation, while encouraging better communication between patients and surgeons.
The International classification of adult weight according to BMI was used to categorise patients. Obesity is defined as a BMI greater than 30 and is graded in severity. Class I is a BMI of 30.0 – 34.9, Class II is 35.0 – 39.9 and Class III is greater than 40.0
There were 14 patients in obese class I. 5 patients increased their BMI, 4 patients remained the same and 5 patients decreased their BMI. There was an average increase in BMI of 0.36. 13 patients had an improvement in walking distance and in 1 patient it remained unchanged.
There were 16 patients in obese class II. 6 patients increased their BMI, 5 patients remained the same and 5 patients decreased their BMI. There was an average increase in BMI of 0.62. 14 patients had an improvement in walking distance and in 2 patients it remained unchanged.
There were 7 patients in obese class III. 1 patient increased their BMI, 1 patient remained the same and 5 patients decreased their BMI. There was an average decrease in BMI of 1.3. 5 patients had an improvement in walking distance and in 2 patients it remained unchanged.
There was an average increase of BMI of 0.19 in all patients. All patients reported an improvement in activity levels and a reduction in the use of walking aids.
Gestational age was 1st trimester (3 cases), 2nd trimester (5 cases), 3rd trimester (5 cases). 10 women were treated surgically, 8 before finishing gestation. Gestation ended as and induced abortion (3 cases, 1 due to fetal death and 2 due to teratogenic risk), and birth (10 cases, all alive, 50% eutocic). Only 3 babies needed type II or type III neonatal reanimation.
We present a retrospective study of comparision between two types of aritifical boen graft substitues. There is an overwhelming marketting drive on part of companies to sell alternative bone grafts/BMP. We in this study compae two such producsts and their cost effectiveness
This is an interventional, retrospective, non consecutive, non randamised case series study of 27 patients. Type I bone graft is Mini MIIG which is surgical grade calciun sulphate which is osteoconductive. Type II bone graft is Allomatrix which conatins bone marrow aspirate, bone morphogenic protein, concellous bone chips and surgical grade calciun sulphate which is osteogenic, osteoinductive and osteoconductive. In this study 14 cases were treated with Mini MIIG and 18 with Allomatrix. There were 24 primary fractures with bone defect, 2 non union and 1 delayed union. Complete bony union were seen in all 27 patients. Average time to heal since bone grafting is 3 months. Complications are extrubent callus formation, bone formatiom in soft tissue, but no patient required secondary procedure to trim the bone. Cost for Allomatrix is £ 356.00 and Mini MIIG is £348.00. Use of such artificial bone grafting avoids the complication of autografting which includes bone graft side morbidity like pain, bleeding and neurvascular damage. For fresh fractures useage of such artificial bone grafts doesnt shorten the healing time, doesnt prevent collapse at fracture site and it is not cost effective. For non union and delyaed unions it avoids the cost for artifical bone grafting. But autograft also incurs the cost of removing, theatre timing. human resources cost and hospital inpatient costs. There is no difference between one type of bone graft over the other and for fresh fracture both of them has no advantage over using no bone grafts.
Our study concludes artifical bone graft is of no advantage for fresh fractures and for non union and delayed unions it is too small a number to come to any conclusion.
Fracture repair is a wound healing process that in young healthy patients usually proceeds to uncomplicated union. However, the healing cascade is delayed with increasing age, medication and certain diseases such as rheumatoid arthritis.
Recently the important role of the immune system in fracture repair has become apparent within the emerging subject of Osteoimmunology. Patients with rheumatoid arthritis have an altered immune system and therefore we have investigated the hypothesis that patients with rheumatoid arthritis have a higher incidence of non-union after a fracture compared to patients without rheumatoid arthritis.
Patients with rheumatoid arthritis who progressed to non-union were on the following medication, Gold (1), Indomethacin (1), Non steroidal anti-inflammatories (4), Combination analgesia (2), Antihypertensives (2), Omeprazole (1) and Thyroxine (1).
Satisfactory healing of soft tissue wounds and bone fracture requires activation and response of the immune system. Our previously reported laboratory observations revealed that proper healing of the long bone fractures corresponds with an increased mass of lymph nodes (LNs) draining the site of injury when compared with contralateral limb, whereas delayed fracture healing is characterized by decreased mass of the regional LNs. Aim of the study was to investigate whether an image of LNs may be an indicator of the kinetics of fracture healing.
The quantitative measurement is required for fracture healing evaluation in clinical studies approaching toward Evidence Based Medicine. Early detection of fracture healing impairment is demanded to introduce as early as possible the optimal treatment leading to recovery. Clinically validated and tested methods usually utilize X-ray and CT data. The aim of this study was to improve assessment of fracture healing progress or impairment examined with X-ray and computed tomography (CT) and to determine the usefulness of quantitative methods based on newly developed 3D image analyzing software. An original software “3D Reconstructor” was developed. The application operates on medical image data stored in DICOM format. 3D Reconstructor v.2.0 allows 2D reconstruction in custom surface directs through data block and 3D reconstruction as well. The usefulness of the application was evaluated for long bone fracture healing with three-dimensional presentation of fracture callus. Twenty otherwise healthy fracture patients (average age 43 years) with fractures of the tibial shaft, humerus, forearm, and clavicle were enrolled and underwent chronological series X-ray imaging and spiral CT scanning when it was clinically justified and necessary. Patients were preselected for CT study because of healing impairment suspicion. Computer Tomography examination was performed 14 to 56 weeks after injury (GE Pro Speed SX, slice 2–3 mm, image reconstruction 1 – 1,5 mm, 120 kV, 100 mAs). Qualitative assessment included fracture line/margins, fracture gap, external callus appearance, callus-to-cortex ratio, bridging, and radiologic union. Quantitative assessment of CT density changes (Hounsfield units [HU]) in the fracture gap was performed in patients using 3D Reconstructor multimodality image analysis software. Regions of interest (ROI) were analyzed in details by quantitative and qualitative assessment. Complete bone union was confirmed in 2 cases, delayed union in 8 cases and nonunions in 10 cases. The use of 3D Reconstructor enhanced quantitative evaluation of fracture callus in all evaluated cases. Low union rate observed in computed tomography derives from patient’s preselection based on clinical observations. Reliable fracture healing assessment can be enhanced with computed tomography and Computer Aided Diagnostic methods that supplement quantitative analysis of CT images. CAD quantitative assessment of the fracture gap and callus was successfully performed using 3D Reconstructor software in clinical cases. Higher accuracy of pseudoarthrosis and delayed union diagnosis was achieved. The reliable diagnosis in fracture cases may be supported with Computer Aided Diagnostic Methods. Still ongoing project, “3D Reconstructor” seems to be more accurate over not “armed” evaluation of original CT DICOM files of fracture healing in selected cases.
The mean age in the study group was 24 years and in the control group – 26 years. There was good acceptance of the study in patients of the study group. Only 2 of them insisted on the xrays and were excluded from the study. Rest 30 patients were followed as described.
In patients with an ankle fracture initial delay to operation because of time constraints is often prolonged because swelling precludes surgery for some days. We made use of a year long prospective audit of 2000 trauma patients to analyse the effect of delay to surgery on length of stay in ankle fracture patients.
One hundred and fifty patients were admitted with an ankle fracture. One hundred and twenty nine were operated on. The median (inter quartile range) time to surgery was 3 (2–5) days. Twenty six patients got to theatre within 24 hours. For those who didn’t get to theatre within 24 hours the median time to surgery was 4 days.
For the group as a whole there was a poor correlation between wait for surgery and length of stay (Pearson = 0.6). For the 98 patients under the age of 60 there was a significant relationship (Pearson co-efficient = 0.85). Fifty per cent of those under 60 were discharged within 48 hours of their surgery. The number of co-morbidities was different between the under and over 60s. The over 60s had a median (inter quartile range) of 2 (1–5) co-morbidities, compared to 0 (0–1) in those under 60.
Patients under 60 with an ankle fracture are generally medically fit. If 90% of such patients had their fractures fixed within 24 hours the median post operative length of stay for all ankle fractures in this population would fall from 7 to 3 days and the number of bed days saved would be 400 a year. The length of stay in patients over the age of 60 is more related to their associated co-morbidities than their time to surgery.
Patients were mobilized with an AirCast®e brace and cranes for six weeks, then the syndesmotic screw was removed and patients started full weight bearing. Follow-Up was 21.7 weeks mean after removal of the syndesmotic screw.
Using the x-rays of the ankle after and the CT of both ankles before removal of the syndesmotic screw we evaluated the radiologic results: the syndesmotic interval in the fontal and axial cuts, the Espace claire de Chaput (total clear space, TCS) und the medial clear space (MCS). The functional results were evaluated by the scores of Phillips, Olerud/Molander and Weber.
Average functional scores were: Phillips 118.53 (range 53 – 135), Olerud/Molander 93 (range 60 – 100) and Weber 2.33 (range 0 – 12).
Plain radiographs remain important diagnostic tools in the initial assessment of patients with suspected fractures or dislocations of the foot. Analysis of foot radiograph is a difficult task even in the hands of experts, which is misinterpreted in 2.1% cases. Human visual system is more sensitive to horizontal and vertical stimuli & cardinal orientations (Vertical and Horizontal) perceived more accurately than others. Any absolute judgement task is subject to two types of error: Systematic error and random error. Hence a system of assessment with very high random error of measurement is unlikely to be a reliable assessment method. We tried to find out the influence of experience and orientation on interpretation of foot radiograph.
AP and lateral radiograph from 25 patients who had some form of foot injury were included in this study. The radiographs were first analysed by an experienced foot surgeons for fractures with clinical details to facilitate the identification of the fracture & then presented in two different orientations (vertical and horizontal) to 38 orthopaedics surgeons of different grades and blinded about the nature of the study. We used Kappa analysis & logistic regression to find out the influence of orientation and experience on interpretation skills.
Overall agreement between the foot surgeon and other observers was 0.4. Overall agreement between the observers and the foot surgeon, in the vertical orientation, was.43 and in the horizontal orientation was.32. When experience was taken into consideration agreement between orthopaedics surgeons and the foot surgeon was.416 and agreement between registrar and foot surgeon was.367 and the SHO and foot surgeon was.369. We found that the regression coefficient for horizontal orientation was −.302 and the regression coefficient for the experience was 0.067. Hence horizontal orientation increases the chance of misinterpreting a foot radiograph by 30.2% and with increasing experience the chance of correctly identifying the fracture increases by 6.7%. From this study it is evident with all the other variables like experience, quality and adequacy of radiographs optimised, orientation of the foot radiograph alone can significantly affect the interpretation skills of the observer.
A further study was undertaken to verify the results on composite material with biomechanical properties similar to human bone.
In one case, the technique was purely bifocal arthroscopy, 26 patients had bone grafts (25 autografts, 1 allograft). Indications therefore were 7 failed talar arthroplasties, 6 ankle pseudarthrodesis with side-effects in the sub-talar joint, 5 primitive bifocal arthosis, 5 complex traumatisms in the hinde foot, 4 neurological varus equinus feet, 3 side-effects of talar laxity, 1 diabetic osteo-arthropathy and one pseudarthrosis of the leg with subjacent talo-crural arthrosis. The average follow-up is of 38 months (12–90).
298 patients were operated within 48 hours of admission (early surgery group), and 136 patients after 48 hours (delayed surgery group). The mean hospital stay in the early operation group was mean 5.3 days (SD±4.9) and in the delayed surgery group it was 12.2 days (SD±8.4). The patients who were operated early had shorter total hospital stay (p< 0.001) and also had shorter post-operative stay (p< 0.05). Increasing age and female gender appeared to predispose to longer hospital stay but this was not statistically significant. Mean age, gender and ASA grade, fracture class and operating surgeon’s grade distribution were not significantly different in the early and late surgery groups.
Each patient in delayed surgery group spent an extra 6.9 days in hospital stay compared to the early surgery group, translating into an extra 937 hospital bed days. The average extra cost of hospital stay per case in the delayed surgery group (£1414) exceeds the average expense of surgery per case in that group. The delayed surgery group resulted in added expenditure of £192085 to the trauma division solely for extra hospital stay.
Conclusion: Timing of surgery in ankle fracture appears to be the most significant determinant affecting the hospital stay. This has a significant resource implication, financially and in freeing up of hospital resources, as well as impacting on the lives of this large group of patients.
This study identifies variations in presentation and demographics between structural and non-structural (muscle patterning) shoulder instability.
We analysed 1020 unstable shoulders (855 patients) from our institution database. Demographic details, direction and aetiology were obtained from medical records. Anterior dislocations comprised 67%, posterior 31% and inferior 2% of all directions of instability and 75 shoulders had multidirectional instability.
Structural causes were dominant in anterior instability (traumatic 39% and atraumatic 38%) and muscle patterning in posterior (81%) and inferior (90%) instability. Males accounted for 64% of all patients (73% of all structural patients and 53% of muscle patterning patients. Mean age at presentation was 25 years old (structural patients 28 years and muscle patterning patients 21 years old). There were 690 unilaterally unstable shoulders (57% right- and 43% left-sided); the dominant arm was affected in 58% overall, in 42% of all left-handers and only 33% of left-handers with muscle patterning. Bilateral shoulder instability occurred in 19% of all patients (12% of patients with structural instability and 28% of those with muscle patterning instability). For muscle patterning, the mean age at onset of symptoms was 14 years, and mean length of symptoms before presentation was 8 years. There was a trimodal distribution of age at onset of symptoms corresponding to peaks at 6, 14 and 20 years. In the group with onset of muscle patterning under 10 years old, there was a higher proportion of females (71% vs 47%), laxity (63% vs 29%) and bilaterality (54% vs 42%), and fewer presenting with pain (17% vs 50%).
Muscle patterning instability is associated with a demographic and presentation profile which may help distinguish it from structural forms of instability. As age at presentation increased, pain increased and joint laxity decreased. Bilaterality did not appear to be associated with gender, the presence of laxity or pain.
A total of 186 patients with posttraumatic anterior instability could be clinically re-examined within 1 to 5 years after initial surgery, among which 147 patients underwent an open and 39 patients an arthroscopic Bankart procedure. The median age of this sample was 27 years (interquartile range 21 – 37 years) at initial surgery, 21% of these patients were female.
ROM showed no difference between open and arthroscopic Bankart procedure for abduction and a mild difference for external rotation. 21 of 115 (18%) patients had an external rotation lag of 20° or more after open surgery versus 1 of 34 (3%) after arthroscopic treatment (Fisher p=0,027). The Rowe score demonstrated “good” or “excellent” functional results in 102 of 117 (87%) patients versus 28 of 35 (80%) patients after open versus arthroscopic treatment (Fisher p=0,285).
We will present the results of our different studies from 1979 till now. Between 1979 and 1984 we tested 1120 consecutive patients with distorsion trauma by stress x-rays, taking only the anterior drawer sign. 237 patients (21, 2 %) were treated operatively because of pathological instability. The correlation: operative findings/positive anterior drawer sign was 85 %. Because of our prospective study in 19 84: arthrography versus x-ray in 52 patients we abandoned the invasive arthrography because it did not give better information about the instability of the ankle. After an investigation of 42 patients with instable ankle joints in our and in the university hospital of Kuopio treated by Evans operation in 1983 with the outcome 42% anteriorly instable, 26% pain at the insertion point at metatarsus V, we looked for a better reconstruction method.
We chose our own method, anatomical reinsertion of FTA and FC, and augmentation of FTA with half of syndesmosis anterior.20 patients, who were treated with this anatomical reconstruction technique(group A), and 20 patients, who underwent primary repair (group B), were controlled 2–4 years after operation. We reviewed 15 patients from group A and 17 from group B. Functional scores were good in both groups without significant difference and no difference in the mean talar translation between the two groups. In a second investigation -92–93 with 43 primary ligament repairs and 31 reconstructions, 89% were active athletes. The outcome after 2–4years was 2, 3% of primary repaired ankles were still painful vs. 22,6 of ankles in delayed reconstruction group. Improvement of anterior stress radiography 3,9mm of those with ligament repair and 1,5 mm of those with reconstructive procedures. This difference between these two groups was significant.
Should we operate primarily or treat the patients adequately-air cast, active rehabilitation and only persisting instability by operation with an anatomic reconstruction??
Arthroscopic capsulolabral stabilization for the treatment of recurrent anterior shoulder instability repair using absorbable Knotless offers reliable results with respect to failure rate, range of motion, and shoulder function also at 4 years follow-up.
The percentage of rate for instability is 6,7% and is in accord with the International Literature on non resorbable anchors.
Fracture of the volar rim of the distal radius could be an isolated fracture or part of a complex type of fracture. Frequently it is displaced and rotated because of the attachment of the volar radio-carpal ligaments. Fixation of this fragment is mandatory to preserve integrity of radio-carpal and distal radio-ulnar joints. Given the difficulty of manipulation of this osteochondral fragment we studied the efficiency of a wire-loop as a method of fixation of this fragment.
Eleven patients were examined (8 male, 3 female) mean age 42,6 years (21–72 years) who had various type of fractures of the distal radius but had in common the presence of an osteochondral fracture of the volar radial rim in the ulnar side (7 patients), in the radial side (3 patients) or on both sides (1 patient). Distal radius fracture was type B3.1 (1 patient), B3.3 (4 patients), C3.1 (3 patients), C1.3 (1 patient) and radiocarpal fracture-dislocation in 2 cases. All patients were treated operatively. Eight of them had early (1 – 10 days post-injury) and three had delayed treatment (1 month post-injury). The rim fragment was found displaced in all patients and rotated 45°-180° in 5 patients. Different types of fixation of the distal radius fractures were used, while in all patients the rim fragment was fixed using a wire loop.
Results were estimated after a mean follow-up of 1 year (6 months- 4 years) using clinical (pain, function, range of motion, grip strength) (Cooney 1987) and radiological (articular congruence, arthritis) criteria. Results were evaluated as excellent (4 patients), good (5 patients) fair (1 patient) and poor (1 patient), while in two cases there was loss of fragment reduction.
In conclusion, although intraarticular fractures are often associated with injury of the interosseous ligaments, probably they have no effect on the integrity of the volar radiocarpal ligaments, the origins of which could influence the volar rim fracture displacement. Wire loop is a valid method for fixation of osteochondral fracture of the volar radial rim, giving stability and avoiding comminution and necrosis of the fragment.
Review of the literature involving the use of viscoseal in shoulder surgery revealed no direct comparison with diamorphine, but only to bupivacaine alone.
Many methods of post-arthroscopic pain relief are available. In our hospital diamorphine with bupivacaine is standard, at £2.57 per treatment. In the present study nausea was significantly lower in the Vicoseal group, but no significant intervention was required and oral anti-emetics sufficed. Pain was not significantly different, and there were no significant differences in supplementary analgesia or in early discharge. In our opinion, the significant improvement in nausea alone is not enough to justify the high price of £52.88 per Vicoseal treatment. We believe that the benefits for routine use have not been demonstrated.
Pain, mobility and radiograhs were evaluated and also strength (isokinetics), functionality (DASH score) and, finally, the return to work at 3, 6 and 12 months.
Conservative treatment is not always possibile because it needs anatomic reduction of the fractures and to prevent the functional difficulties. There’s inherent tendency loss of reduction after non-operative treatment. According to criteria of instability of Cooney et al. as dorsal angulation > 20° degrees, loss radial length> 10 mm, intraarticular extension, etc. or if we had fractures A3, B, C of A.O. classification, open, bilateral fractures in polytrauma, will be useful to operate with internal or external fixation. We need to respect the morphology of three columns. We compare two different types of devices usually used in the last ten years in our hospital as the external fixation with Pennig and the plates and screws in internal fixation, underlining the advantages and the disadvantages. Between January 1997 and December 2006 215 patients with comminuted and unstable fractures complicated with different clinical aspects of exposure or vasculopathy or neurological acute entrapment or lesion, of severe displacement were treated by external fixator of Pennig. They were evaluated according to Gartland e Werley system, Sarmiento modified. Pain, disability and functional disease of articulation, radiological criteria of instability. To follow up average 12,4 months (range 5 to 24 months) the patients were distinguished as excellent, good, in 76% and fair good and bad in 24%. Complications of treatment were 3 osteitis and trombosis. In the same period we applied 142 plates the most in the volar side as DCP, LCP in association when it needs with graft, pinning and platelet gel after centrifugation of blood of the patient useful to bone healing. These patients were evaluated regarding to anatomy and function after reduction as strength of punch by Jamar dynamometer, pain, range of motion. After three months the patients operated with plates showed a ROM and a strength of punch better than those operated by external fixator. On the contrary after six months, more and more after twelve months the clinical and radiological results that is anatomical and functional outcomes were the same. At one year the Dash score was the same in the both of groups and there was not a difference between them. So we are authorized to use the external fixator of Pennig in unstable fracture A3 of wrist after failure of closed reduction, higher energy fractures and dislocations, unstable articular methaepiphiseal and comminuted fractures, exposed fractures, bilateral and complicated in politrauma. We applied volar plate and screws when there are extraarticular displaced fractures (A3.3), articular displaced fracture (B, C), corrected osteotomies, particularly in fracture type B (internal osteosintesis with plate + eventual volar graft), type C (internal osteosintesis volar plate associated with dorsal approach and pinning) + possible graft.
They were assessed in terms of early complications following mua and k-wiring and their final clinical outcome.
.3(6%)Had symptoms suggesting superficial radial nerve damage of which 2 recovered completely after pin removal. One had residual symptom which got better before planned exploration.
9 Patients (18%)had stiffness of which only 3(6%)had residual stiffness at the end of 6 months. Crps was noted in 1 patient(2%)who recovered after good physio.
There wer nocases of deep infection, osteomyelitis, tendon rupture, pin migration or significant loss of position.
There is no rationale in giving antibiotic coverage for all the pintract discharges unless swab positive.
MRI scan for the knee joint has often been regarded to be the non invasive alternative to a diagnostic arthroscopy. MRI scan is routinely used to support the diagnosis for meniscal or ACL injuries prior to recommending arthroscopic examination and surgery. Identification of meniscal tears can be difficult to interpret and can be observer dependent as well as dependent upon the sensitivity of the scanner. Similar difficulties may exists in clinical examination as well.
Our aim was to compare and correlate clinical, MRI and arthroscopic findings in the diagnosis of meniscal and Anterior Cruciate Ligament (ACL) Injuries.
This was an observational study of 131 patients over 36 months who had both MRI and arthroscopic surgery.
Our study showed clinical examination had better sensitivity (0.86 vs 0.76)and specificity(0.73 v/s 0.52) in comparing to MRI in diagnosis of medial menisceal injuries. similarly +predictive value and −predictive value were higher for clinical examination. whereas for lateral menisceal and ACL injuries there were marginal differences in sensitivity, specificity and predictive values
We conclude that carefully performed clinically examination can give equally or better diagnosis of meniscal and ACL injuries in comparison to MRI scan.
MRI scan may be used to rule out such injuries rather than to diagnose them. MRI scan has much better negative predictive value than positive predictive value in both meniscal and ACL injuries diagnosis. When clinical signs and symptoms are inconclusive, performing MRI scan is likely to be more beneficial in avoiding unnecessary arthroscopic surgery.
When clinical diagnosis is in favour of either meniscal or ACL injuries, performing MRI scan prior to Arthroscopic examination is unlikely to be of significance. MRI scan should not be used as a primary diagnostic tool in meniscal and ACL injuries
Samples of the 13 previously frozen menisci were classified as grade III in 8 cases (61,54 %), and grade II in 5 cases (38.46 %). They averaged 4.846 points. The control groups were classified as grade I in 6 cases (46.154%) and grade II in 7 cases (53.85 %). The frozen menisci averaged 4.85 points whereas the control group did so 2.46 (p< 0.001)
The meniscus of the human knee joint has an outstanding function for stability, shock absorption and power transmission of the thigh on the shank. After a meniscus trauma so far often only the partial or complete removal of the meniscus has to be performed. Only with injuries in the outside third a primary suture of a tear leads to the healing due to the existing vascularisation in a high number of cases in younger patients. After partial or total meniscektomie cartilage degeneration and resulting osteoarthrosis of the knee joint often is the consequence.
A goal of our investigations was the establishment of meniscus cell cultures as well as their characterisation regarding the expression of different growth factors, cytokines and proteins and the influence by adding different recombinant growth factors. We are able to cultivate human fibrochondrocytes, which originate from menisci of the knee from patient undergoing total knee replacement. Investigations were performed by immune-histochemistry and RT PCR. We could show the expression of collagen I, II, III and VI, the matrix-metalloproteinases 1, -2, -3 and -8 in the human meniscus. In Addition the expression of TGFβ1, BMP II, AS.02, Thy 1, TGFβ1, iNOS and interleukin (IL) -1, -6 and -18, ECGF and VEGF was proved. PDGF-1 and collagen X could not be found in the meniscus investigated. Same expression analysis was performed in same patients’ synovial cells and chondrocytes from knee joint. Differences were found in the collagen expression. Synovial cells do not synthesise collagen II but collagen I. Investigated chon-drocytes show a high level of collagen I an II expression, but fibrochondrocytes a low level of collagen II and high of collagen I, too. After stimulation of meniscus cells with IL-1, TGFβ1 and TNF-α no difference was found in the expression of TGFβ1, BMP II and IL-18, but a total inhibition of IL-6. TGFβ1 suppressed IL-1 expression totally compared to not stimulated fibrochondrocytes.
We were able to cultivate, characterize and stimulate human fibrochondrocytes from meniscus of the knee. We could show that meniscus cells express a huge amount of different growth factors, cytokines and proteins and can be distinguished from synovial cells and joint chondrocytes by the low level expression of collagen II. We also investigated first time the reaction of human meniscus cells after stimulation by recombinant growth factors. These results are a basis for the tissue engineering of meniscus tissue.
Subacromial corticosteroid injection has been shown to be effective in treating impingement syndrome. The exact mechanism of action is not clear but it may be due to its anti-inflammatory properties. However, there are potential side effects of steroid injection including tendon weakening, dermal atrophy and infection. NSAIDs may offer similar anti-inflammatory properties but without the side effects of corticosteroids. Tenoxicam is a long-acting water soluble NSAID and is available without irritant preservatives. Studies have shown that peri-articular Tenocixam injection was useful in treating painful shoulders and local tolerability was good.
The aim of this study is to carry out a blinded ran-domised controlled study comparing subacromial Tenoxicam injection (NSAID) against methylprednisolone (steroid) injection in patients with clinical subacromial impingement syndrome.
The study protocol was approved by local research ethics committee. Patients over 18 with a clinical diagnosis of subacromial impingement syndrome were considered eligible to this study. Patients with other known causes of shoulder pain, contraindication or sensitivity to NSAID and pregnant patients were excluded.
Three functional outcome measures were used – Constant-Murley Shoulder Score, DASH and the Oxford Shoulder Score. The patients completed all three outcome measures before and 2, 4 and 6 weeks after the subacromial injection. Simple randomisation method was used and blinded to both researcher and the patient.
58 patients randomised into two groups were reviewed at the end of six weeks. Patients treated with subacromial steroid injection had a much better outcome compared to patients treated with subacromial tenoxicam injection and this difference was highly significant (p< .003)
In conclusion, patients with subacromial impingement syndrome have a better clinical outcome when treated with subacromial steroid injection than NSAID injection.
The animals were sacrificed after 4 months. The implants and joint surfaces were evaluated on a macroscopic (Implant Gross Assessment Score; Gross Assessment of Joints Score) and histological level.
Seventy five (75) knees also had an associated osteotomy, and eleven (11) had a ligament reconstruction. The clinical outcome using pain and functional knee scores and failure rate of all transplants was evaluated at a mean 10.2 years (2–16 years) postoperatively.
Twenty patients (16.6%) underwent a total knee replacement at a mean interval of 9.3 years after the meniscal transplant.
Patients with isolated meniscal transplantation had the most improved clinical outcome.
Patients with concomitant knee osteotomy and knee ligament reconstruction procedures also had improved knee function without an increase the rate of complications.
1) shoulder pain more than 6 months with no response for conservative treatment, 2) no previous shoulder surgery of the same shoulder or surgery of the contralateral shoulder, 3) clinically and radiologically diagnosed subacromial impingement or rotator cuff tear.
The minimum of the follow-up was 2 years (range 24 to 32 months), and 76 patients (82%) participated to the evaluation at this point. In the outpatient group were 37 patients (24 subacromial impingements, 13 rotator cuff tears), and in the hospitalized group 39 patients (23 subacromial impingements, 16 rotator cuff tears). Evaluation methods were clinical examination, radiographic evaluation, isometric elevation strength measurements, as well as the University of California Los Angeles (UCLA) and Constant shoulder scores. All operations were done by one experienced orthopaedic surgeon, and all evaluations at the follow-up by one independent examiner.
The aim of this prospective study was to report the mid-term results of arthroscopic repair of full thickness rotator cuff tears.
One hundred and four shoulders in 102 consecutive patients were operated within a two-year period. There were 52 female and 50 male patients with a mean age of 64 years (range 41 to 79). Standard arthroscopic techniques of cuff repair were used, under regional inter-scalene block and balanced anaesthesia. The mean size of the cuff tear was 3 cm (range 1 to 6 cm). Patients were discharged within 24 hours and followed a specific rehabilitation protocol. An assessment was performed pre-operatively and at a mean follow-up of 7 months (range 3 to 24 months). Outcome measures included pain, activities of daily living, shoulder power and function and level of patient satisfaction.
Satisfactory pain relief was achieved in 98 patients (94%) with significant pain relief in 87 patients (83.6 %) and good in 12 patients (11.5 %). Ninety -six patients (92.3%) reported a satisfactory improvement in activities of daily living, with significant improvement in 89 (85.6%) and good in 7 (6.7%). Shoulder power was markedly improved in 95 patients (93%). High levels of patient satisfaction were noted in 93 patients. Seven patients were moderately satisfied and two patients were not satisfied.
The mean shoulder score improved from 29 pre-op to 82 post-op, and the shoulder function score from 32 pre-op to 84 post–op. Similar results were found when the subgroup of 65 patients over the age of sixty was compared to the group of 37 patients under the age of sixty. No difference in outcome was also noted in relation to the size of the tear, length of follow –up or sex of the patient.
We believe that this study has shown that the arthroscopic repair of the rotator cuff can consistently achieve a satisfactory outcome. It may therefore be considered as an alternative to the traditional open techniques.
The aim of the study is to evaluate the results obtained in patients older than 70 years who were treated with open surgical repair for massive ruptures of the rotator cuff and the functional outcome.
This is a retrospective analysis of a consecutive series of 280 patients who underwent open repair of a massive rotator cuff tear between 1999 and 2003. The inclusion criteria were: age 65 or over, symptomatic with pain, deficit of elevation, not responsive to the physiotherapy, tear size > = 5 cm, minimum follow-up of 2 y since surgery. All were assessed preoperatively with plain radiographs (anteroposterior and axillary views) and nmr of the shoulder. Patients were assessed with the Costant score, Simple Shoulder test, UCLA score before and after surgery. Pain was assessed by use of a visual analog scale. The mean age of patients was 75b years (range 65–91). There were 41 men and 28 women. The mean duration of symptoms before repair was 18 months (range 1–58). The dominant arm was affected in 54 patients (78%). The change in UCLA scores, SST, Costant score and their subcomponents were analyzed with the paired Student’s test, assuming a normal distribution of the total score. In an exploratory analysis trying to identify preoperative variables that could be associated with a good surgical outcome, a multivariate logistic regression analysis was performed including the following variables: age equal or more than 80 years, sex history, shoulder different affected, UCLA score, SST, costant score and use of formal physical therapy. Satisfactory results were achieved in 250 patients: the mean preoperative UCLA score was 9.3, Costant score 45, and the mean score after surgery was 16.9 and 65 rispectively. The mean preoperative function score was 2.4, after surgery was 8.1. The UCLA preoperative score for active forward flexion averaged 1.3 (30°–90°), and postoperative rating increased to 4.5 points (p=0,0001)corresponding to an active forward flexion between 120° and 150°.
While significant component malalignment in the frontal and sagittal plane may lead to early loosening and pain, even small errors in the rotational component alignment are not tolerated due to its complex impact on knee joint kinematics and especially the patella tracking. It is accepted that navigated implantation of total knee arthroplasties improves accuracy in the frontal plane but it is yet unclear weather navigation leads to a more precise rotational component alignment. The study evaluated the influence of navigated implantation on femoral and tibial component alignment.
In a prospective randomized study 32 navigated and 28 conventionally implanted total knee arthroplasties were evaluated through a postoperative CT scan. In all cases the femoral component was referenced to the surgical epicondylar axis and the tibial component was referenced to the medial third of the tibial tuberosity. The angles between these bone landmarks and the components were measured on the CT scans and compared between both study groups.
The rotational malalignment of the femoral component in the conventional operating technique was 0.1° ± 2.2° (range 3.3° of internal rotation and 5.0° of external rotation). Navigated implanted femoral components showed a malalignment of 0.3° ± 1.4° (range 4.7° of internal rotation and 2.2° of external rotation), the difference was not significant. The rotational malalignment of the tibial component in the conventional technique was 7.5° ± 6.0° (range 27.1° of internal rotation and 15° of external rotation). Navigated implanted tibial components showed a malalignment of 6.9° ± 4.7° (range 21.2° internal rotation and 11.0° external rotation), the difference was not significant.
In conclusion the use of a navigation system did not improve the rotational alignment of the tibial or femoral component if only one bone landmark was used. Taking the relatively small errors of a navigation machine into account the error is attributable to the surgeon, who seems to be unable to precisely define bone landmarks. More than one landmark (e.g. additionally Whiteside’s line, posterior condyles, flexion gap for the femur and ankle joint for the tibia) should be used to define the component rotations. Consideration of different rotational landmarks is best done with a navigation system that, in contrast to the manual technique, has the possibility to show the degree of deviation of the components from each landmark.
Navigation-assisted surgery in total knee arthroplasty (TKA) is aimed at improving the accuracy with which prosthesis components are implanted in the bones, according to anatomical plane orientations. Traditional surgical techniques based on the identification of transepicondylar and intramedullary axes are replaced with those based on segmental anatomical frame definitions following anatomical landmark identification. These frames are offered on the screen to the surgeon to target in real time the alignment goal by adjusting position and orientation of the bone saw guides. However, immediately after sawing, final bone, and in case cement, preparation and component implantation is necessarily a series of actions performed manually by the surgeon. In the current study, we wanted to compare intra-operatively the final component alignments with the corresponding at the original resection planes.
In this series, 50 Scorpio PS TKAs were analyzed. The navigation system used was the Stryker Knee Navigation System (Stryker-Navigation, Kalamazoo, USA). An ‘anatomical survey’ defined anatomical frames for the femur and tibia, based on relevant anatomical landmark identification, and provided target orientations for all the relevant bone cuts. These references were targeted in all three anatomical planes, and bone cuts were made accordingly. Corresponding alignments of the bone resection planes in the frontal, sagittal and transverse planes for the femur and in the frontal and sagittal planes for the tibia were recorded, with a 0.5° resolution. Then, component implantation was performed and alignments were measured again by means of an instrumented probe. Because of the shape of the prosthesis components, only the alignments in the frontal plane for the femur and in the frontal and sagittal planes for the tibia were recorded.
The difference between the alignment of the bone cuts and the alignment of the prosthesis components, in the frontal plane of the femur, and in the frontal and sagittal planes of the tibia was larger than 2° respectively in 8%, 6%, 10% of the patients.
The present study offers a figure for the different alignment between resection planes and final implanted components, necessarily the effect of the manual procedures implied in TKA for the final implantation of the components. Considering that 1° is the claimed achievable accuracy of the navigation systems, and that the correct alignment goal was achieved at the resection planes, these figures reveal that in up to 10% of the patients the benefit obtained by navigation can be lost by the manual procedures implied in component implantation. These differences in alignment put also concerns in the postoperative statistical comparison between conventional and navigated TKAs.
Methods: A total of 50 patients were treated with a navigated (OrthoPilot 4.2) Columbus knee prosthesis (BBraun Aesculap, Germany). In 25 patients either a standard or a minimally invasive (mini-mid-vastus) approach was carried out. In both groups the same exclusion criteria for MIS were adopted. Initially during surgery (Nav1a) and finally after implantation of the original components (Nav1b) the mechanical leg axis, passive range of motion and stability were measured by navigation according to the common workflow of the system. After restarting the software the same parameters were evaluated once more in a second procedure (Nav2) by reacquisition of joint centers both kinematically and by anatomical landmark palpation with the original prosthesis already implanted. Nav2 was conducted independantly from the initial surgical procedure. To validate the intraoperative measurements additional pre- and postoperative long-leg-standing radiographs were made. During the the first 10 days postoperatively daily range of motion (ROM) and pain (VAS) were measured. Perioperative blood loss and complications were documented. Results were analyzed by student’s t-test.
Results: Both groups were comparable with regard to preoperative demografic, radiologic and intraoperative data (Nav1a). There were no significant differences between the groups concerning intraoperative measurements of mechanical leg axis, passive range of motion and stability by Nav1b and Nav2. Additionally no differences were found for the alignment in the postoperative radiographs. The length of the skin incisions were significantly shorter in the minimally invasive group. Postoperative ROM was significantly higher and pain was significantly less intensive in the MIS group. Blood loss and complication rates were comparable.
Discussion: If the exclusion criteria for MIS were accepted no differences regarding the quality of alignment, passive range of motion and ligament stability could be demonstrated between conventional and MIS navigated TKA. Patients with MIS navigated TKA performed superior in terms of early p.o. function and pain. From the authors point of view the technically demanding minimally invasive implantation of knee prostheses should be exclusively performed with support of navigation.
Post-operatively we measured the mean MFT angle in groups A, B and C. In group A, the mean MFT angle was −0.38° varus (−4° to 2°), group B was −0.41° varus(−5° to 2°), and group C was −0.02° varus(−3° to 5°). P=0.7 using the Kruskal-Wallis test. These results show that the post-operative kinematics are similar between the three different populations.
Our study compared the functional outcome following knee arthroplasty using CAKA or conventional instrumentation, and investigated whether the theoretical advantage of improved prosthesis alignment with CAKA resulted in improved functional outcome.
Functional outcome was measured using the Oxford Knee Score (OKS).
A power analysis was performed with alpha of 0.05 and power of 80%. In order to detect a difference of 4 points in the OKS, 126 patients were required. This number was exceeded in our study at one year.
At two years follow up the mean OKS was 25.39 (range 13 – 53, s.d. 10.3) for the CAKA group and 24.14 (range 12–43, s.d. 9.1) for the control group (p = 0.33). The results for the two year follow up group should be treated with caution as further patient numbers are awaited to obtain adequate power.
Soft tissue management is a critical factor in total knee arthroplasty especially in valgus knees. The stepwise release has been based upon surgeon’s experience until now. Computer assisted surgery gained increasing scientific interest in recent times and allows the intraoperative measurement of leg axis and gap size in extension and flexion.
We therefore aimed to analyse the effect of the sequential lateral soft tissue release and the resulting change in the a.p. limb axis on the one hand and the tibiofemoral gaps on the other hand as well in extension as in flexion in 8 cadaveric knees. Measurements were obtained using a CT-free navigation system.
In extension the highest increase compared to the previous release step was found for the first (iliotibial band, p=0.002), second (popliteus muscle, p=0.0003), third (LCL, 0.007) and the sixth (entire PCL, p=0.001) release step. In 90° flexion all differences of the lateral release steps were statistically significant (p< 0.004). Massive progression of the lateral gap in flexion was found after the second (popliteus muscle, p=0.004) and third (LCL, 0.007) release step.
Computer assisted surgery allows to measure the effect of each release step of the sequential lateral release sequence and helps the surgeon to asses the result better.
One previous study has suggested that the computer-assisted technique may reduce blood loss in comparison to traditional methods. This study (
Our study uses a more accurate method of assessing blood loss, and the sample size is larger (n=136; 68 standard TKR versus 68 computer assisted TKR).
Total body blood volume was calculated using the formula of
Our study found that overall blood loss was less for both groups, when compared to the findings of Kalairajah Y et al. We suspect that this difference was due to our departmental policy that all patients receive tranexamic acid at the start of joint replacement procedure.
Pre- and post-operatively, the surgeon applied a varus and valgus stress at maximum extension, recording the mechanical femorotibial (MFT) angle. There were no patellar resurfacings. We compared the kinematics of each varus knee. Based upon the kinematics and the surgeon’s experience the following medial releases were performed as usual and divided into three categories:
No release (limited medial approach). Moderate release (postero-medial release including the semimembranosis). Proximal (extensive) release.
With the following medial releases, these kinematics were found:
No release – MFT angle not less than −12° with varus stress, greater than 2° with valgus stress, and/or if extension deficit was not greater than 5°. Moderate release – MFT angle less than −12° with varus stress, between −5° and 2° with valgus stress, and/or extension deficit not greater than 5°. Proximal release – MFT angle less than −12° with varus stress, less than −5° with valgus stress, and/or extension deficit greater than 5°.
The results show that post-operatively, the mean MFT angle is maintained within a narrow range (−1° to −7° with varus stress, 4° to −3° with valgus stress). 5/57(9%) patients had a mean MFT angle of 6.4°(0° to 7°) with valgus stress, and were considered to have been over-corrected. There were no extension deficits.
Increasing age and a higher level of mobility lead to an increasing incidence in revision arthroplasty after total knee replacement and tumor surgery. So far, the reconstruction of large defects in bony and soft tissue environments can be accomplished by the modern modular components of revision implants. The consecutive reconstruction of the extensor mechanism in extended revision has its own drawbacks and is often associated with significant functional limitations for the patient. Specially designed implants and methods are required to generate good functional
Results: The modular knee revision system MML provides specific modifications of the tibial component for reconstruction of the extensor mechanism. Combined with artificial strips, an excellent functional outcome could be achieved. In this study, 70 patients were operated with the MML endoprosthesis in knee revision or tumor surgery. An excellent functional outcome could be determined. At 7 years after surgery, an average of 32±13 points was achieved on the Oxford Knee Score. The outcome measurement using the functional scoring system of the American Knee Society (AKS score) showed similarly good results with 71±25 points out of 100. A minor deficit of only 2° in active extension could be observed after reconstruction of the extensor mechanism. In conclusion, we have demonstrated that the MML modular revision system is appropriate for reconstruction of segmental bone defects.
Fresh frozen allograft bone was used to fill defects during revision total knee replacements in 21 patients (21 knees) using radial impaction grafting technique. Radial Impaction grafting technique produces a very rigid bone cement construct to allow for immediate weight bearing without any reinforcements. The strength of the graft substitute with stems allowed us to avoid metal augments in both type II and type III defects in majority of cases. At a minimum of 12 months follow up (12 to 60 months follow up, average 28 months), 19 of the knees showed radiological incorporation of the graft and no evidence of lysis of bone graft. Radiological incorporation of the graft was seen as early as six months and remodelling was continuing at three years. There were no cases of non-union. There were no cases of collapse of the graft or migration of the implant. There was one cases of osteolysis due to deep infection, which needed re-operation. There was one case of traumatic peri-prosthetic fracture, which was treated conservatively.
Oxford knee scores improved from an average of 45 (35 to 53) to 17.4 (12 to 22) at an average follow up of 27.4 months. American Knee Society scores improved from an average of 39.8 (31 to 53) to 87.8 (30 to 70). Knee Society Function scores improved from an average of 45 (30 to 70) to 85 (65 to 100) at last follow-up.
We recommend use of radial impaction grafting technique to fill defects of type II and type III in Tibias during revision knee arthroplasty.
The non-invasive diagnosis of musculoskeletal infections remains a challenge. Recent studies have indicated that fluorine-18 fluorodeoxyglucosepositron emission tomography (FDG-PET) is a highly accurate imaging technique in selected patient groups with infected total hip replacement. The present study analyses the diagnostic accuracy in a consecutive series of patients with suspected musculoskeletal infections.
We propose that ASEPSIS provides the most accurate and reproducible results and also provides more information with the grading of wound infection. The overall rate of orthopaedic wound infection using the ASEPSIS method is 3%. If all hospitals used this scoring method, more accurate comparisons of infection rates could be made.
78 patients (41 male and 37 female) with a revision total knee or hip arthroplasty were enrolled in this prospective study to evaluate the role of new laboratory markers in the diagnostic of deep implant infection.
The average age at the time of surgery was 64 years. Based on intraoperative cultures, 21 patients had a septic and 57 patients had an aseptic revision total joint arthroplasty. White blood cell counts, erythrocyte sedimentation rate, C-reactive protein levels, interleukin-6, procalcito-nin and TNF-alpha were measured in preoperative blood samples. Diagnostic cut of values were determined by Receiver Operating Characteristic curve analysis.
If patients with rheumatoid arthritis and other concomitant infections are excluded the C-reactive protein (> 3.2md/dl) and interleukin 6 (> 12 pg/ml) have the highest sensitivity (0.95). Interleukin 6 is less specific than the C-reactive protein (0.87 versus 0.96). Combining C-reactive protein and interleukin identifies all patients with deep implant infection. Procalcitonin (> 0.3 ng/ml) and TNF-alpha (> 40 ng/ml) are very specific (0.98 versus 0.94)) but have a low sensitivity (0.33 versus 0.43).
The combination of C-reactive protein and interleu-kin 6 is an excellent screening tests for deep implant infection. Highly specific marker like procalcitoninn as well as preoperative joint aspiration might be useful to identify patients with true positive CRP and/or interleu-kin 6 levels.
A significant portion of prosthetic joint infections with biofilm-embedded bacteria may not be adequately sampled by standard periprosthetic tissue collection techniques. The aim of the present study was to combine ultrasonication sampling procedures with standard in-traoperative sampling and cultural techniques.
A total of 69 patients with implants to be removed were included in this study; a prosthetic joint infection was diagnosed or rejected according to a standardized clinical score. Intra-operative tissue specimens were cultured using standard techniques; implants were subjected to ultrasonication and sonicates used for inoculation of cultures and broad-range eubacterial PCR.
According to the clinical score, a prosthetic joint infection was present in 14 of the 69 patients. 11/14 had positive cultures for tissue samples, 13/14 had positive cultures when considering in addition the results from sonicate cultures. Sonicate PCR was positive in 12/13, and negative in 1/13 (excluding one infection due to Candida albicans). Ultrasonication improved sensitivity of culture from 78.6% to 92.9%; sensitivity and specificity of PCR from sonicates was 92,3% and 100%, respectively.
Combined with serially sampled periprosthetic tissue, ultrasonication of implants may help to increase the sensitivity of laboratory investigations based on cultural procedures. PCR analyses did not improve sensitivity although implementation of PCR may aid in improving the specificity of cultural detection.
All patients presented with symptomatic back pain, with or without neurological compromise.
All patients had appropriate pre and post treatment imaging. 100 had microbiological and/or histological confirmation of TB. The disease was predominantly in the thoraco-lumbar spine, although cervical involvement was seen in 5%. All patients presented with anterior column involvement, with psoas abscesses in 30%.
Combination chemotherapy, according to British Thoracic Society guidelines, was the main modality of treatment. Surgery was performed for certain indications: deteriorating neurology, instability and post tubercular kyphosis. 15% of the 107 patients treated required surgical intervention.
DISCUSSION: We recommend 8 additional auxillary staff to cover 2 wards. This will enable nurse cohorting and cost £120 000 per year. Our department should have a positive pressure dressing room which cost £20 000 to build. This will ensure wounds are inspected in a clean controlled environment. A PCR rapid MRSA detection device plus staffing and culture media cost £149 000 per year. This should be used on emergency admissions. A cheaper detection kit can be used on elective patients which cost £12 000 per year. Hence total running cost will be £301 000 a year and subsequent years will cost £261 000. Compare that to £384 000 bearing in mind it was extrapolated from 3 months study on 14 newly identified MRSA positive orthopaedic patients who developed wound infection. Apart from that, we also recommend a holding bay for suspected cases whilst awaiting PCR results. Colonisers should be treated with Aquacept or Bactroban. At induction, teicoplanin and gentamicin iv should be used. MRSA patients should be nursed in side rooms. Beds should also be ring fenced.
The purpose of our study is to analyze retrospectively our patients, who had received conservative treatment or either posterior or combined approach.
The diagnosed was based on clinical examination, cultures, bone histology, X-rays, bone scan and MRI with gadolinium. The location of the infection was in 13 (8%) patients the cervical spine, in 62 (38%) the thorachic, in 10 (6%) the thoracolumbar junction and in 78 (48%) the lumbo-sacral spine. In 95 cases, concomitant diseases were present.
In 67 (41%) patients was not able to detect any microorganism. From the remaining patients, 53 (33%) were infected by staph.aureus and 22 (13%) by mycob tuberculosis.
The patients according to the treatment provided, were divided in three groups:
Group A: 70 patients, which had conservative treatment with antibiotics and bracing. Group B: 56 patients, which, sustained posterior decompression alone Group C: 37 patients, which had anterior debridemant and posterior decompression and stabilizations or anterior stabilization.
The group A patients had not neurological symptoms. In group B, 11 had altered neurology and the operation was beneficial for 5 of them (45.5%), 4 remained unchanged and in 2 was deteriorate. In group C, 11 patients had altered neurology, from which 9 (81.8%) were improved and 2 remained unchanged.
The in-hospital complications were: 2 pulmonary embolism, 2 post operative haematomas, 1 persistent anaimia, 1 diafragm paralysis, 2 atelectasia and 1 cerebral thrombosis. In addition 3 patients had residual psoas abscess, 2 pancreas abscess, 1 cerebelum abscess and 3 lung infection.
The in-hospital mortality was 3 patients, other 17 patients died during the follow up
The conservative management in selected patients is effective up to 89%. From the operations performed the decompression alone had unacceptable high re-operation rate and also, it wasn’t so beneficial regarding the neurological improvement. If it is combined with anterior reconstruction and posterior stabilization provides better results.
The influence of ESW on the effectiveness of antibiotics was examined using Gentamicin whose stability under influence of ESW was proven infrared-spectrometrically earlier.
S. aureus in specific broth (CAMHB) was treated with 4000 impulses at 0.59 mJ/mm2. Then the MIC against Gentamicin was compared with the MIC of an untreated control group.
For the examination of synergistic effects between antibiotics and ESW, bacteria were treated with ESW (4000 impulses, 0.59 mJ/mm2) in a solution of CAMHB and varying Gentamicin concentrations (0.25 – 4 μ g/ml).
The vital bacteria were quantified and compared to the control group which was exposed to either ESW or Gentamicin. Bacterium colonies were quantified according to the guidelines of the NCCLS, the statistical evaluation was done with the Man-Whitney-U- test.
Despite the germicidal effect of the ESWT neither a change of the bacterium cell permeability nor a damage to the DNA could be proved. Synergistic effects between Gentamicin and ESW were not found. No loss of effectivity of the Gentamicins at a simultaneous application of the ESW (P > 0.05) could be seen either.
It could be shown that the applied total energy is responsible for the germicidal effect rather than single paramters as EFD and impulse quantity. A synergistic effect of antibiotics applied in addition to the ESW could not be proved. When ESW was carried out in presence of Gentamicin, the antibacterial effect of Gentamicin was influenced neither positively nore negatively.
The simultaneous application of ESW and systemically or locally applied antibiotics could represent a new therapy approach against tissue and bone infections. To prove this, further in-vivo studies are needed.
110 had MRSA infection in their surgical wound. 83 of 110 (75.5%) patients were non-elective admissions, of which 49 (60%) were proximal femur fractures. 20% of proximal femur fractures admitted from nursing home and 7.8% from their own homes developed SSI with MRSA. This cohort of SSI with MRSA had an average of 5.7(1–18) previous admissions. 25 (23%) had been previously colonised with MRSA. Majority of them (76%) were between 70–90 years old and were ASA grade 3–4.
Long-term clinical study to explore the curative effect and mechanism of the treatment of adult chronic osteomyelitis by implant Osteoset T.
The study object were 65 case adult chronic osteomyelitis patient from November 1977 to April 2003 in a University-based hospital. Age ranged from 18 to 69 years old. 40 cases were treated by general debridement (Method I); 25 cases were treated by general debridement and implant Osteoset T in dead space (Methods II). Stage IA(The UTMB Staging System) osteomyelitis 39 cases; The Organism was Staphylococcus Aureus 28 cases. In all cases (group A), 40 cases were treated with Method I (group AI), 25 cases were treated with Method II (group AII). The majority of the patients, 39 resulted as Stage IA (group B); 22 were treated with Method I (group BI) and 17 cases were treated with Method II (groupBII). Finally, 28 patients were chronic Staph Aureus osteomyelitis (Group C); 13 were treated with Method I (group CI) and 15 cases with Method II (group CII); Followed from 36 to 334 months, mean 75.0 months. Then respectively evaluate and analysis analyze the success rate of different method with standard.
The success rate of group BI was 59.09%, group BII was 94.12%, contrast the success rate there was significant difference (p< 0.05). The success rate of group AI was 60.00%, group AII was 80.00%. The success rate of group CI was 46.15%, group CII was 80.00%.
The use of Osteoset T has demostrated better healing rate than left the empty cavity there after debridement and irrigation. Osteoset T can local delivery antibiotic, filler of the dead space, It can be mixed with different antibiotics, reduces the hospitalization time, reduces the number of operation. Unfortunately, Osteoset dos not help with the bone growth.
A number of series report limb length discrepancy in long bone chronic osteomyelitis, however in most cases, it is shortening of the affected bone. This is thought to be due to damage in the affected growth plate leading to early growth arrest. However, it is known that the inflammatory state of chronic osteomyelitis results in an increased blood supply and, as in other conditions such as rheumatoid arthritis, the increased blood supply results in overgrowth of the affected bone.
In order to study the effect of long bone chronic osteomyelitis on limb length, we designed a prospective trial of 42 consecutive patients presenting to our unit with chronic osteomyelitis of a long bone. The inclusion criteria were all patients presenting with a long bone osteomyelitis. There were no exclusion criteria. The mean age at presentation was 10.3 years. The mean duration of symptoms of 18.2 months prior to presentation. For 37 (88%) of patients the cause of osteomyelitis was haematogenous. On examination, 3 (7%) patients had shortening of the long bone compared to the unaffected side (of an average of 2.5cm), whilst 13 (31%) patients had overgrowth of the affected bone (average overgrowth 2.2cm). The most common bone affected was the tibia (20/42, 48%), followed by the femur (8/42, 19%) and the humerus (6/42, 14%).
All patients underwent radiographic analysis, and the average percentage of long bone affected was 59%. 8/42 (12%) of patients had at least one physis affected (2 of these patients had undergrowth and 1 had overgrowth).
This large prospective series of patients is the first in the world literature to show the effect of osteomyelitis on the growth of long bones, in particular an overgrowth rate of 31%. We suggest that the mechanism for this is related to the duration of symptoms. In areas of the world where there is poor access to health care, there is consequently a prolonged period of increased blood supply as a result of inflammation. This increased blood supply may make limb length discrepancy is more likely to be due to overgrowth rather than undergrowth.
The amount of bone formed under each condition was assessed by solubilising the mineral content in hydrochloric acid overnight and then measuring the change in colour induced by Calcium exposed to a commercial reagent. The amount of calcium detected was then determined using a standard curve.
This experiment was repeated in cells from 3 patients.
There was a statistically significant impairment in osteogenesis at a concentration of tobramycin of 400 microg/ml and above.
The search for the ideal bearing surfaces to be used in Total Hip Replacement continues. The current “best” materials are felt to be various combinations of metal, ceramics and cross-linked polyethylene. Laboratory studies suggest that ceramic-on-metal articulations may provide distinct advantages. This study aims to identify the best combination with the lowest side effect profile.
In February 2004 a prospective randomised trial on different bearing surfaces was started. The combinations selected were ceramic-on-cross-linked polyethylene, ceramic-on-ceramic, metal-on-metal and ceramic-on-metal. Institutional ethics clearance was obtained. In all patients uncemented femoral stems are used, with an uncemented porocoated acetabular shell. A uniform 28mm femoral head size was selected. Blood samples have been taken to measure the metal ion concentrations in all patients. These are measured pre operatively, and repeated at follow up visits at 3 months and 1 year, with further follow up at 3,5 and 10 years post operatively. Whole blood ion levels are measured using a graphite furnace atomic absorption spectrometer.
Between February 2004 and April 2006 one hundred and ten hips have undergone total hip replacement. There are 105 patients (5 bilateral). 40% are males and 60% female. The average age at operation is 52 years (17 to 72). 49% hips are left and 51% right. Follow up includes blood samples and the Harris Hip Score. Complications to date have been surgeon related, with three femoral components needing early revision for technical reasons. This has not affected the bearing surfaces. Radiological and clinical assessment shows no difference between the different bearing surface groups.
Post operative whole blood metal ion levels are compared to the patient’s pre operative level. To date there is no increase in the metal ion levels for the ceramic-on-cross linked polyethylene and ceramic-on-ceramic articulations. The ceramic-on-metal group is providing moderately raised metal ion levels, and the highest metal ion levels are in the metal-on-metal articulation group. At one year, the ceramic-on-metal group demonstrates a drop to close to pre-operative levels and these are still significantly lower than the metal-on-metal group. This confirms laboratory studies on the ceramic-on-metal articulation, which demonstrate significantly lower wear than comparable metal-on-metal articulations. The high level of metal ions in the latter groups has always been of concern.
This study demonstrates a lower blood level of metal ions in the ceramic-on-metal group. If the in vivo wear rate in this group continues to replicate the laboratory wear studies, this articulation becomes a very attractive bearing surface in younger active patients, and may well become a bearing surface of choice in the future.
Antibiotic concentration in infected bone is a major determinant of clinical response. As glycopeptides and fluoroquinolones are widely used for the treatment of bone infections, aim of our study was to assess their diffusion in infected human bone. Patients with a posttraumatic septic pseudoarthrosis undergoing debridement of infected tissue, who received a glycopeptide or a fluoroquinolone for > 1 week, were studied. Plasma and bone specimens were collected intraoperatively for phamacokinetic and microbiologic assays at a mean of 4.1h after antibiotic administration. Bone samples were crushed and concentrations were measured by HPLC-UV method. Overall plasma exposure was also determined with daily sampling. 16 patients were studied. 6 patients received iv vancomycin 1 g bid over a 1-hr infusion Bone cultures grew E. faecalis, MRSA and MRSE (MIC < 2 mg/L). Mean plasma concentration of vancomycin at time of osteotomy was 19.8 mg/L. Mean bone concentrations were 2.4 mg/L in cortical and 7.1 mg/L in cancellous bone, with a mean bone extraction of 12 % and 36 %, respectively. 4 patients were treated with iv teicoplanin 10/mg/Kg for MRSA infection (MIC < 2 mg/L). Mean bone concentrations were 8.9 mg/L and 37 mg/l respectively for cortical and cancellous bone, respectively corresponding to 6% and 25% of plasma levels. Six patients were treated with a fluoroquinolone. 3 patients received iv ciprofloxacin 400mg bid and E. coli grew from bone samples(MIC = 0.5 mg/L). Mean Plasma concentration of ciprofloxacin at the time of osteotomy was 3.6 mcg/mL. Mean bone concentrations were 1.7 mg/L in cortical bone and 30.2 mg/L in cancellous and newly formed bone, with respective bone/ plasma ratios of 0.5 and 8.4. 3 patients were administered iv levofloxacin 500mg qd and Enterobacter spp. were isolated (MIC = 1 mg/L). Mean plasma concentration at the time of surgery was 2.5 mcg/mL. Mean bone concentrations were 0.3 and 2.69 mcg/mL in cortical and cancellous bone, respectively. To our knowledge this is the first study that compares different antibiotic’s concentration in infected bone with the same dosing procedure. Both vancomycin and teicoplanin provided mean bone concentrations exceeding the susceptibility breakpoint of the infecting agents. Higher and constant glycopeptides plasma levels may be required for preventing recurrencies in bone infections. Only ciprofloxacin provided cortical bone concentrations higher than the susceptibility breakpoint of the infecting agent, and similar to those reported in non-infected bone. Ciprofloxacin concentration in cancellous bone and in bony callus were far higher than those detected in plasma, which may be related to an augmented vascularization and/or selective accumulation of fluoroquinolones into regenerating bone, as observed in children’s cartilage growth plate. Ciprofloxacin may be therefore preferred to levofloxacin.
The aspirates were examined with a commercially available assay using a Multiplex Reader. The interleukins Il-1 beta, -2, -5, -6, -10, -12, -13, -15,-17 and IL-1 receptor antagonist (Il-1ra) were measured. Further G-CSF, GM-CSF, IFN gamma, MIP 1 beta, MIP alpha, MCP 1, and TNF alpha were assayed.
We therefore analyzed the effects of CoCr particles on T cells & B cells. We also analyzed it effects on dendritic cells, which are the key antigen presenting cells to T helper cells.
Dendritic cells (DCs) were harvested from mouse bone marrow & cultured in medium supplemented with GM-CSF for 6 days, generating DCs typically 80–90% CD11c+. These were incubated with CoCr in concentrations of 25, 10 & 2.5 μg/ml, for 24 hours, or lipopolysaccharide 1 μg/ml as a positive control. Following incubation, activation status of CD11c+ DCs was characterized by MHC Class II, CD40, CD80 & CD86 expression by FACS analysis.
T-Lymphocytes were harvested from mouse lymph nodes & cultured in medium without phenol red. These were incubated at 5 ×105 cells/well with either CoCr, conA (positive control) or CoCr + conA & repeated using 2.5 ×105 cells/well. Other positive controls (CD3 & CD 28) were studied in repeating the experiment. At 48 hours Almar Blue was added & further incubation for 24 hrs. Light absorbance at 570nm & 600nm was then used to determine T cell proliferation
B-Lymphocytes were harvested from the lymph nodes of mice which were only able to mount a B-cell reaction to Hen egg Lysozyme (HEL). These were incubated with medium with CoCr, HEL (positive control) or CoCr+ HEL. The concentration of the CoCr was varied between 25, 10 & 2.5 μg/ml. FACS analysis for markers of B cell regulation was performed after 48 hours incubation..
cell proliferation assays (3H-thymidine incorporation) and cytokines secretion (ELISA) following exposure to antigen challenge using Tetanus Toxoid and polyclonal mitogen phytohaemoagglutinin (PHA).
The long term results (mean follow up period 110 months) are presented in this study.
Two acetabular and one femoral component had to be revised due to aseptic loosening without showing macroscopic evidence of metallosis and no histological evidence of excessive metal wear. One patient hat to be revised by a complete change of the total hip (acetabular component and stem) showing histologic evidence of a metal induced hyperergic immunologic reaction. One patient presented with a broken neck of the stem and had to be revised by stem exchange.
As a none device related orthopedic complication one acetabular component required revision surgery due to a periprosthetic fracture.
We reviewed retrospectively the results of total hip arthroplasties that were performed at one institution in young patients who had different types of sickle-cell Haemoglobinopathies to ascertain whether this form of therapy for Osteonecrosis of the hip was appropriate.
Usually 4–5 blood units are needed perioperatively. Prophylatic antibiotic therapy and anticoagulation treatment always is used.
Thirty-six hips re-evaluated and according the Harris Hip Score in 17 the result was excellent, in 15 good and in 4 fair.
The main problem, during the operation, was the difficulty to open the femoral canal, which was very narrow and in some cases completely closed and the bone cortex very dense.
One patient had a revision procedure in two stages for septic loosening seven years after the primary THR. Four patients had a revision procedure for aseptic loosening between one and ten years after the primary operation.
The more serious complications during the surgical intervention were fracture of the greater trochanter in four cases and fracture of the diaphysis of the femur in four, also, cases.
Hip arthrodesis is still a major option for the painful arthritic hip in the third world, where total hip prostheses are seldom available or too expensive for the patient. Various procedures for hip fusion have been described in the literature; they are often complex, frequently need a long period of post-operative immobilisation and are coupled with a considerable failure rate.
A new simple technique for hip arthrodesis is described without dislocating the hip preoperatively in order to maintain the oxygen concentration in the femoral head, using a self devised plate and requiring no post-operative immobilisation.
During a three year period the procedure was performed in 22 patients by the same surgeon. In all cases the indication for hip fusion was hip osteo-arthritis. The cause of osteo-arthritis was in 46% hip destruction by tuberculosis, in 23% aseptic osteonecrosis of the femoral head, mostly linked to sickle cell anaemia, in 8% complications of trauma of the hip, in 8% slipped upper femoral epiphysis and in 15% primary arthritis. Two had concurrent femoral osteotomy for correcting malposition of the limb and one had during the same procedure a femoral diaphysis osteotomy with placement of a Wagner elongating device in order to proceed with a callotasis. Mean follow up was 15.4 months. All hips, except one, achieved a solid fusion by radiographic and clinical criteria between 6 and 12 months after surgery. The failure of fusion was in the oldest patient (63 years) who presented loosening of plate and screws due to an advanced degree of osteoporosis. One superficial infection occurred that resolved under antibiotics.
Ten out of 32 hips required revision; 9 acetabular components were revised because of aseptic loosening (3), osteolysis/excessive wear (4), instability (1) and infection (1) with a total revision rate of 28%. Eight patients needed acetabular revision alone, one femoral revision alone and one revision of both components. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (p> 0.05).
Outcome measures included rate of complications: infection, DVT, PE, length of hospital stay and Harris Hip Score (HHS).
Statistical analysis was undertaken to determine any correlation between smoking and these outcome measures using chi-squared tests, t-tests and multiple regression adjusting for confounding factors.
268 patients (15%) were smokers, 582 patients (33%) were ex-smokers and 917 patients (52%) had never smoked. As there was little data available on when the ex-smokers had stopped smoking we studied current smokers compared to patients that had never smoked
There were no significant differences in complications such as DVT, PE, Deep infection and Superficial infection, these were all rare events. Neither was there any significant difference in hospital stay times. After adjusting for pre-operative HHS, age, sex and ASA status current smokers had significantly lower HHS at 6 months (p< 0.001, 95% confidence interval for effect size 1.6 to 5.3), and also showed a lower HHS at 18 months, 3 years and 5 years although not significantly so.
We plan to further analysis the data to try and ascertain why this is the case.
Femoral head osteonecrosis is a progressive disease that affects patients in the third to the fifth decades. It is probably a multifactorial disease since many patients that have the known risk factors never develop it and others develop the disease without any risk factors.
There isn’t any totally effective treatment that can stop the disease and prevents bone collapse, but it is known that operative treatment gives better results than conservative treatment in Ficat stages I and II.
The authors began in October of 2003 the surgical treatment of pre-collapse patients (Ficat stage I and II) with the tantalum hip screw hopping that it could prevent progression to collapse.
The tantalum is an innovating new metal with an excellent bio-integration and with mechanic properties very close to normal bone. The tantalum hip screw gives structural support to the necrotic bone segment, permits immediate charging of the affected hip and pretends to be a substitute to peroneal graft.
There isn’t any published clinical result of the use of the tantalum hip screw in the literature to date.
Between the October of 2003 and November of 2004 we made 10 such procedures in 8 patients with mean age of 44 years. The patients were Ficat grade I and II and we could identify that most of the patients had been taking corticosteroid medication. There was one hip with less than 15% of extension and 9 with a severe extension (more than 30% of the femoral head from the University of Pennsylvania system of classification and staging).
There was rapid radiographic progression of the disease in all patients but one with bilateral involvement. There was progression for femoral head collapse in 70% of the patients despite the femoral hip screw. In 3 patients the collapse led to screw protrusion on the acetabulum and needed hip arthroplasty, on average, 12 months after screw implantation.
The harris hip score of the 5 patients (7 hips) than weren’t submitted to hip arthroplasty gave a good result in 1 patient and a fair result in 3 patients (4 hips). There was a poor result in the other patient.
The tantalum hip screw made it more difficult to do a hip arthroplasty but it didn’t make it impossible.
This study shows that the tantalum hip screw didn’t prevent the progression of the femoral neck osteonecrosis in all but one patient with an initial Ficat grade IIa.
The fact that 9 in 10 patients had a severe extension of the disease (> 30% of the femoral head diameter) could have prevented the success of the tantalum hip screw because the area of sustention of the screw was limited and the disease continued to progress around the screw.
To assess the referral system, clinical notes and radiographs of patients presenting with metastatic disease of long bones in a regional oncology unit.
Thirty questionnaires were sent to oncologists asking about reasons for referral to orthopaedics and use of scoring system to assess risk of pathological fracture.
Ninety three percent of oncologists did not use a reliable scoring system to assess risk of pathological fracture. The majority referred in respect to pain on mobilising and the presence of a lytic lesion. Sixty percent felt an improvement in communication between the departments was required.
The notes and radiographs were reviewed of thirty-seven patients presenting with femoral metastatic lesions to the oncology department.
Sixteen patients had a Mirels score of greater than eight. Four patients were referred for an Orthopaedic opinion. All patients underwent prophylactic fixation. Twelve patients with a score of greater than eight were not referred. Seven of theses patients suffered a pathological fracture within three months.
Five patients had a Mirels score of 8. One patient had prophylactic fixation. No fractures occurred.
Sixteen patients had a Mirels score of less than 8. None of these patients were referred for an orthopaedic opinion. None of these patients had a pathological fracture within three months.
In conclusion, we presently do not offer a multidisciplinary approach to metastatic disease affecting the appendicular skeleton.
The majority of patients’ who score eight or above in the Mirels scoring system are at risk of fracture and do require prophylactic surgery.
In keeping with the BOA guidelines, “Metastatic Bone Disease: A Guide to Good Practice”, we would recommend that the introduction of a multidisciplinary approach and the use of a recognised scoring system is essential to improve patient care.
Many pateints showed an extented survival despite disseminated disease with a high and quality of life. Radical resection as tried in a few patients did not proof to be beneficial regarding the prognsotic effect.
The pain-related disability was evaluated for every single daily living activity using visual analog scale (VAS) over 10 points. (pain at rest, walking, sitting–standing, taking a shower and wearing clothes). (This evaluation is performed to every patient with degenerative disorders of the spine upon admission to our clinic.) Overall VAS scores were evaluated over 50 points (0 minimum, 50 maximum) preoperatively, at postoperative six weeks, six months and at one year prior to taking analgesics.
The amount of analgesic use was recorded. Data was analyzed statistically using variance analysis, Friedman’s multiple comparison test and Student’s t test.
Results: The mean overall pain score in the kyphoplasty group decreased from a preoperative value of 36 to 12.13 at the sixth postoperative week, to 8.63 at the sixth month and to 9.72 at one year. (p< 0.001).
The mean overall pain score in the vertebroplasty group decreased from a preoperative value of 37.83 to 15.33 at the sixth postoperative week, to 12.17 at sixth months and to 13.47 at one year. (p< 0.001).
Student’s t test was used to analyze the percentage of differences in overall pain score. Difference between groups was not statistically significant at the sixth week (p=0.106) but was statistically significant both at the sixth month (p=0.024) and at one year (p=0.027) in favor of kyphoplasty group.
No secondary collapse was observed in adjacent levels in both groups. There were no intrapostoperative neurologic/pulmonary complications in both groups. Analgesics usage significantly decreased in both groups.
Since high levels of urokinase-type plasminogen activation system have been associated with cancer metastasis, purpose of this study was to investigate its expression in patients with giant cell tumor and the relationship with outcome.
We reviewed the treatment and clinical outcome of 32 consecutive patients with Ewing’s sarcoma who presented with or developed pathological fracture after biopsy between 1984 and 2004. The minimum follow-up was 18 months. The mean age at diagnosis was 20 years (5 – 51). There were 18 males and 14 females. All patients were newly diagnosed and had localized disease at the time of diagnosis. 21 patients presented with pathological fracture while 11 patients developed fracture during the course of chemotherapy. The femur was the most common location in 15 patients.
All the patients had chemotherapy according to the protocol current at the time of treatment. 6 patients had radiotherapy alone while 26 patients underwent surgical excision and reconstruction. Of the patients who had surgery, 7 patients had adjuvant radiotherapy. Fracture healing was the norm after pre-operative chemotherapy. Surgical margins were wide in 17 patients, marginal in 4 and intralesional in 3 patients.
Local recurrence developed in one patient (3%). Metastases occurred in 12 patients (37%). At the time of review 16 patients were free of disease, 3 were alive with disease and 13 patients had died of disease. The cumulative 5 year metastases free and overall survival in all the patients was 58% and 61 % respectively and similar to patients with Ewing’s sarcoma without fracture treated at our centre. The prognosis of patients who presented with fracture was exactly similar to those who developed fracture in the course of treatment.
We conclude that limb preserving surgery is perfectly safe in patients with Ewing’s sarcoma who have associated pathological fracture and survival is not in any way compromised. Survival of patients who present with fracture is similar to those who develop fracture in the course of treatment. The exact role of adjuvant radiotherapy in these patients needs to be clarified.
Five patients with isolated Madelung’s deformity were reviewed with an average follow-up of 34 years after surgery. All the patients were female and their average age at surgery was 12.7 years, whereas average age at follow-up was 53 years. The deformity was bilateral in 4 patients and unilateral in 1.
At diagnosis deformity, pain and limitations of the range of motion were present in all the wrists except 2, which were painless but presented marked functional impairment. In all the patients the typical radial deviation of the hand, was observed, with dorsal prominence of the distal end of the ulna. The x-rays showed, in anteroposterior view, the V-shaped arrangement of the first carpal row, with the lunate at the apex of the V and the marked obliquity of the articular surface of the radius toward the ulnar side. In the lateral view, the articular surface of the radius was markedly angulated anteriorly, the ulna was subluxated posteriorly and carpal bones were translated anteriorly. In no patient did we observe growth disturbance of the other bones or deformities typical of osteochondrodysplasias. In some cases the deformity progressed rapidly, whereas in the others the progression was slow. Surgical correction was sought by both the family and the patients mainly for functional reasons, although cosmetic improvement was also expected.
The operation consisted of closing-wedge osteotomy of the distal radial metaphysis and either shortening osteotomy or resection of the distal ulna. At the operation all the patients had passed the adolescence growth spurt, although in 5 out of the 9 wrists growth plates were still open.
At follow- up, all the patients were satisfied with the results of the operations and the range of motion of the wrists was improved. Some residual radiographic abnormalities were present in 4 wrists, but all patients were mostly pleased with the absence of pain and improvement of wrist cosmesis. No radiographic osteoarthritis was present in any of the operated wrists, although 4 of the 5 patients were over 55 years of age.
Kyphoplasty is an efficient tool in the treatment of primary tumours (plasmocytoma) and osteolytic metastasis. Especially in plasmocytoma the current chemotherapy has increased life expectancy significantly. Therefore minimal-invasive stabilisation is not only a palliative treatment but really increases quality of life in those cases.
Kyphoplasty offers several special tools and techniques to lower the leakage rate which is especially high with other cementoplasty techniques in the osteolytic spine.
In our institution there has been concern regarding MRSA surgical site infection and possible cross contamination of elective and emergency patients. There would be implications for implant related infections if this were to occur. This had prompted the unit to consider adopting a screening programme to identify and treat MRSA carriers. This would aim to minimise risk of post operative infection and cross infection. As little was actually known about the MRSA colonisation rates of admissions to our hospital we undertook the following project to assess the feasibility and effectiveness of implementing such a screening programme.
There were three superficial surgical site infections postoperatively, all in individuals who were clear on their admission screening. Of these two were due to MRSA and one was due to MSSA. There were no cases of deep infection requiring further surgery.
Of the 120 fractures (in 117 patients), 16 were excluded from our study (10 patients were followed in other institutions and 6 died of non-related causes).
From the total of 104 fractures reviewed 77% had been submitted to rigid internal fixation with extramedular devices (95 Blade plates, DCS, Condylar plates, etc) although in the last few years (since 2000) the use of intramedular retrograde nailing has became the standard form of treatment (16 type A and 8 type C, including 2 C3).
In our experience the application of retrograde nails in type A fractures and the combination of multiple screws fixation and retrograde nails in type C fractures provide the best results.
Ring frames have the advantage of allowing progressive correction. However, the available frames for complex deformities are heavy and bulky leading to poor compliance by patients. Also, the mounting procedure requires considerable expertise and skill. On the other hand, a unilateral external fixator has the advantages of less bulk and a lighter weight. Thus, it causes less disability and can achieve better patient compliance even with bilateral application. However, previous unilateral fixators have had various limitations with respect to deformity correction, such as restricted placement of hinges, restricted correction planes, and a limited range of correction angles. In addition, it was impossible to achieve progressive correction while fixation was maintained. To overcome these disadvantages of existing unilateral fixators, we developed a new fixator for gradual correction of multi-plane deformities including translational and rotation deformities. This unilateral external fixator is equipped with a universal bar link system. The link is constructed from three dials and two splines that are connecting the dials. The pin clamps are able to vary the direction of a pin cluster in the three dimensional planes. The system allows us to correct angulation, translation, rotation, and the combination of the above. In addition, open or closed hinge technique is available because the correction hinge can be placed right on the center of rotational angulation (CORA), or at any desired location, by adjusting the length of the link spline. By increasing the spline length, the virtual hinge can also be set far from the fixator. Gradual correction can be performed by rotating the three dials using a worm gear goniometer that is temporarily attached. A 3D reconstructed image of the bone is generated preoperatively. Preoperative planning can be done using this image. Mounting parameters are determined by postoperative AP and lateral computed radiography images. These postoperative images are matched with the pre-operative 3D CT image by 2D and 3D image registration. Then, the fixator can be virtually fixed to the bone. By performing virtual correction, it is possible to plan the correction procedure. The fixator is manipulated by rotating each of the three dials to the predetermined angles calculated by the software. Static load testing disclosed that the fixator could bear a load of 1700 N. No breakage or deformation of the fixator itself was recognized. Mechanical testing demonstrated that this new fixator has sufficient strength for full weight bearing, as well as sufficient fatigue resistance for repeated or prolonged use. The results of clinical application in patients with multi-plane femoral deformities were excellent, and correction with very small residual deformity was achieved in each plane.
Goodfellow & Bullough (1968) first described the pattern of articular cartilage wear in the elbow. More recent post mortem studies have shown that advanced degenerative changes can develop in the radio-capitellar (lateral) compartment of elbow joints of elderly subjects in which the humero-ulnar (medial) compartment remains remarkably well preserved. The significance of this post-mortem findings,in an elderly population, with unknown elbow symptom logy, who died from diverse causes, is unknown. There has been no clinically based,in vivo,study of this subject. Our study would support these observations, but indicates that symptomatic degenerative change occurs at a much earlier age than had previously been thought.
We have reviewed the findings in a consecutive series of 117 elbow arthroscopies performed on patients with elbow pain resistant to conservative treatments (age range 21–80 years: mean age 51 years). We documented established degenerative changes involving articular cartilage in 68 patients (59%). In this group we found that in 60 patients (88%) the degenerative changes were confined to the lateral compartment and contrasted with normal appearances of the articular cartilage of the medial compartment.
The findings presented in this work are in full agreement with previous work on the articular wear and biomechanics of the elbow joint. Previous studies which have been on cadaveric specimens, with findings of uncertain symptomatic relevance. To our knowledge, this finding has not previously been demonstrated in a symptomatic, young population. Unicompartmental lateral degeneration of the elbow is therefore a real clinical entity rather than a interesting post mortem finding. As such, it demands consideration in terms of investigation, diagnosis and treatment. It is likely that in the past, many patients have been misdiagnosed as having chronic lateral epicondylitis.
We consider that lateral compartment degenerative change is a distinct clinical entity. It begins in relatively young patients in whom the x ray appearance may be normal or near normal and is often diagnosed as lateral epicondylitis. Our observations taken together with the reported post mortem studies indicate that primary osteoarthritis of the elbow begins in the lateral compartment of the joint and may remain confined to the lateral compartment throughout life. We believe that new treatment strategies need to be developed specifically for patients with primary osteoarthritis as opposed to degenerative joint disease due to other causes.
We will report the clinical and radiographical results of a comparison between conservative and surgical treatment of Perthes disease after an average period of 25 years. All the children were observed at Orthopaedic and Traumatologic Center (CTO) of Florence between 1962 and 1989.
A slipped capital femoral epiphysis (SCFE) can be fixed in-situ with K-wires or screws. For the latter is said that one disadvantage is the lack of femoral neck growth. Assumed reasons for this is despite an injury of the physis by the often too long thread the missing lubrication of the screw in the bone.
The following study evaluates the amount of remaining bony growth and method-depending complications in screw fixation of SCFE.
In 20 patients we tried to remove the screws after completed growth. This was possible in 30% minimal invasively and in 30% with open surgery. In 40% parts of the screws or even the whole screw remained in situ. Time of surgery for bilateral screw pinning was 51 minutes, for removal 91 minutes in average (34–278).
The aim of the study is to evaluate the prognostic value of Herring’s classification for treatment planning of Perthes Disease and predicting the final outcome of the disease.
We analysed 45 patients treated in our department in the period of 1992 – 2005. The analysis consisted of determining the lateral pillar collapse in fragmentation stage and the containment of the femoral head in the residual stage. We did retrospective analysis of the x-rays in fragmentation stage and classified the patients according to Herring’s classification. Group A included 10 patients, group B – 20 patients and group C included 15 patients. We used Hayman – Herndon Acetabulum – Head Index (AHI) to analyse the x- rays in the residual stage. The statistical analysis of the results included the analysis of the differences between the lateral pillar collapse among the groups and the differences between affected hip and the contralateral control hip. Correlation between the degree of lateral pillar collapse and the AHI in the residual stage was also analyzed. Correlation between the age of onset of the disease and AHI was determined for each group, too.
The results show significant differences between the lateral pillar collapse in Herring groups, and among the affected and control hips. Differences of AHI values were also significant between the groups. Correlation between the AHI and lateral pillar collapse for each group shows moderate connection just as the one between AHI and age.
Herring’s classification is reliable in classifying patients with Perthes disease. It enables good prediction of the natural course of the disease and thus influences the treatment decision-making
Ten patients were studied using an ambulatory gait device (Physilog®). Each participant was asked to perform two walking trials of 30m long at 3 different speeds and to complete an EQ-5D questionnaire, a WOMAC and Knee Society Score. Lower limbs rotations were measured by four miniature angular rate sensors mounted respectively, on each shank and thigh. The outcomes of the eight patients undergoing total knee arthroplasty, recorded pre-operatively and post-operatively at 6 weeks, 3 months, 6 months and 1 year were compared to 2 age-matched healthy subjects.
Due to these major complications further investigations on additional patients have been stopped.
When surgical treatment of dysplastic hip and hip joint incongruence in adolescence is necessary, triple pelvic osteotomy is preferable to other types of pelvic osteotomies (even when they are associated with femoral ones). We evaluated our ten years long experience with the mentioned method.
We treated 78 hips (67 patients) with Tonnis-Vladimirov triple pelvic osteotomy between 1996 and 2005. Average age of our patients was 15 years and 6 months. The patients were followed for mean 39 (17–133) months. In 2 hips triple pelvic osteotomy was associated with femoral corective osteotomy, in one hip with femoral corective osteotomy and open reduction, and in 7 with the translocation of the greater trochanter.
Treatment results were evaluated, both anatomically and functionally. Anatomic improvement was detected by measuring CE angle of Wiberg. It improved from an average of 16,1 – to 43,1 degrees – the difference has proven to be statistically highly significant. Functional improvement (absence of waddling gate or limp; as well as better range of motion) was noticed in almost all the cases. The improvement was accompanied by spatial reorientation and correction. Major complications included asymptomatic pubic and/or ischial osteotomy nonunions in seven patients.
We found good radiographic correction of deformities and improvement of hip function with an acceptable complication rate. With appropriate patient selection, this procedure is the most physiological treatment of acetabular dysplasia and hip joint incongruence in patients older than 8–10 years. It may prevent and postpone the development of secondary osteoarthrosis.
The results of a functional, clinical and radiological study of 30 children (60 hips) with whole body cerebral palsy are presented with a mean follow-up of ten years.
Bilateral simultaneous combined soft-tissue and bony surgery was performed at a mean age of 7.7 years (3.1–12.2).
Evaluation involved interviews with patient/carers and clinical examination.
Plain radiographs of the pelvis assessed migration percentage and centre-edge angle.
Twenty two patients were recalled. Five had died of unrelated causes and three were lost to follow-up.
Pain was uncommon, present in 1 patient (4.5%). Improved handling was reported in 18 of 22 patients (82%). Carer handling problems were attributed to growth of the patients. All patients/carers considered the procedure worthwhile.
The range of hip movements improved, with a mean windsweep index of 36 (50 pre-operatively)
Radiological containment improved, with mean migration percentage of 20 degrees (50 preoperatively) and mean centre-edge angle of 29 degrees (−5 preoperatively) No statistical difference was noted between the three year and ten year follow-up results demonstrating maintained clinical and radiological outcome improvement.
In conclusion, we consider that bilateral simultaneous combined hip reconstruction in whole body cerebral palsy provides painless, mobile and anatomically competent hips in the long term.
The aim of the study is to compare the postoperative pain relief provided by continuous perfusion of wound by bupivacaine and fentanyl with that of patient controlled analgesia using morphine in elective shoulder surgery. This retrospective case control study included 76 consecutive patients who had elective shoulder surgery. 39 patients had patient controlled analgesic system (PCA) with morphine and 37 patients had a continuous wound perfusion(intra bursal) with bupivacaine and fentanyl via a disposable Silicone Balloon Infuser. Patients were also given additional oral NSAIDs or morphine if needed. The pain score measured postoperatively based on a 10 point Visual Analogue Scale (VAS) at 1, 2, 3 and 18 hours was noted. The use of antiemetics and additional painkillers was recorded. The complications of both methods were also noted.
We found that the analgesia provided by continuous perfusion of wound by bupivacaine and fentanyl was constant and comparable to that provided by the patient controlled analgesic system using morphine. PCA with morphine was associated with significantly high incidence of nausea and vomiting (p < 0.001).We conclude that continuous perfusion of the wound by bupivacaine and fentanyl appears to be a simple, effective and safe method of providing analgesia following elective shoulder surgery.
Patients overestimate pain following hip and knee replacement.
Ninety two patients awaiting hip or knee replacement were asked at their pre-operative assessment to estimate the level of pain they expected following their surgery on a 10cm visual analogue scale. Note was made of their age, gender, previous surgeries, Amsterdam anxiety score as regards the anaesthetic and surgery and an information score relating to their anaesthetic and surgery. Seventy nine patients had pain scores collected on a daily basis post surgery.
Mean (std dev) age of the group was 68 (11) years and with a female to male ratio of 1.57. Females were significantly more anxious about the surgery than males (t-test, p< 0.007). Patients were more anxious about the anaesthetic and the surgery with hip replacement compared to knee replacement although this did not reach significance (t-test p=0.07). The mean (std dev) pain score pre-operatively was 7.5 (1.6). The mean (std dev) pain score expected was 7.0 (2.2) on the first post operative day and 4.3 (2.2) on the sixth post operative day. Forty four per cent of patients expected to have pain greater than their arthritis pain on the day following surgery.
The level of pain experienced post-operatively was significantly lower than expected. Mean (std dev) pain score was 5.1 (2.7) on day 1 post op and 3.3 (2.4) on day 6 (t-test, p< 0.05 for both). There was no correlation between age, gender, number of previous surgeries, anxiety or information scores and the expected level of pain.
The majority of patients, whatever their age, gender or level of anxiety over estimate their level of post-operative pain after joint replacement. Studies are needed to assess whether educating patients about pain post surgery will be of benefit, particularly in their early rehabilitation.
In the Leiden University Medical Center (LUMC), the non-augmented direct repair method as described by Duquennoy for treatment of chronic lateral ankle instability, is used since the early eighties. To our knowledge, this procedure has not been described in English literature before. We performed a retrospective study, to assess the long-term outcome of non-augmented anatomical direct repair procedures, as originally described by Duquennoy. The procedure reassures ankle stability by retightening and reinsertion of the original talofibular and calcaneofibular ligament, without dissecting the ligamental tissue. The purpose of this study is to determine the long-term effects of the procedure in terms of postoperative quality of life, joint function and development of osteoarthritis.
Twenty-three patients who were treated in our institution between 1985 and 2002 completed the Short Form-36 Health Survey (SF-36) for assessment of postoperative quality of life and the Olerud Molander Ankle Score (OMAS) for subjective symptom evaluation. Clinical reevaluation, including physical examination of the ankle and the completion of the Ankle Society ankle-hindfoot scale (AOFAS) questionnaire, was conducted for twenty-one patients after a mean follow-up of 13±7 (range 3–22.2 years) years. At final follow-up radiographs were taken to assess the development of osteoarthritis. The mean total postoperative SF-36 and OMAS scores were 79.6 (SD ±14.6) points and 81.7 points (N= 23 patients) respectively. The mean total postoperative AOFAS score was 89.7 points (N= 21 patients). We found a significant postoperative reduction in talar tilt and anterior drawer sign. According to the AOFAS, the long-term functional outcome of the procedure was excellent in 10 patients (48%), good in 7 patients (33%), fair in 4 patients (19%) and poor in none of the treated patients. The results in terms of ankle function and stability do not seem to deteriorate in time. The procedure is seldom causing restriction in range of motion, neither a higher chance of degenerative changes in the ankle joint on the long term. We conclude that the procedure as originally described by Duquennoy is simple and effective, with a very low complication rate and does not provoke restriction in range of motion of the ankle joint.
Approximately 40 to 50% of the civilized population may expect feet disorders, and in 90% localized in the forefoot. Hallux valgus (H.V.) deformity is not a single malformation, but a complex problem affecting the first ray of foot, frequently accompanied by deformities and symptoms of the lesser toes. Proximal osteotomy and soft tissue release of I metatarso-phalangeal joint (MTP) provides adequate correction of intermetatarsal angle and joint alignment.
The hallux rigidus, first described by Nicoladoni in 1881 (1), is the painful and decreased motion, especially dorsiflexion at the metatarsophalangeal joint, of the great toe. The purposes of this report were to evaluate the mid-term results of the Sliding osteotomy technique(2,3,4).
Thirty nine (46 feet) consecutive patients (mean age 38 years) with hallux rigidus of I and II grade were followed over a five-year period.
All patients were evaluated clinically and radiographically preoperatively and post operatively.
At the time of final follow-up, the mean AOFAS score was significantly improved: excellent 26 (56,5%); good 12 (26%); fair 6 (13%); poor 2 (4,5%).
This clinical review suggest that this procedure as a safe, effective measure to treat in patients with hallux rigidus of I and II grade.
Implantation of metatarso-phalangeal prostheses or spacers has been widely indicated for the replacement of the articular surfaces in severe hallux rigidus.
A reabsorbable device in poly(D-L-lactic acid) (PDLLA) which is dome-shaped with a stem for implantation into the first metatarsal, avoiding any resection of the base of the proximal phalanx, is proposed.
The rationale of the reabsorbable spacer is to maintain the distance between the articular surfaces and provide a sliding surface suitable for articulation. It is then reabsorbed and replaced by fibrous tissue, which allows motion and removes pain.
37 reabsorbable spacers have been inserted for severe hallux rigidus in 33 patients aged from 26 and 76 years (average 58). Patients were reviewed with a follow-up ranging between 36 and 96 months (average 59.5).
The results were assessed using the American Orthopaedic Foot and Ankle Society (A.O.F.A.S), hallux-metatatarsophalangeal-interphalangeal scale.
Anteroposterior and lateral weight-bearing X-rays were made preoperatively and at follow-up, evaluating the dimensions of the articular space and the length of the first metatarsal.
The chronology of device reabsorption was studied in 10 patients with M.R.I., assessing complete reabsorption within 4 months of the operation.
Excellent and good results were obtained in 91% of patients. The A.O.F.A.S. score was 43.7+/−20.6 pre-operatively and 82+/10.3 post-operatively.
The reabsorbable spacer confirmed the expectations of its protagonists. This procedure would appear to be an alternative to arthrodesis of the first metatarso-phalangeal joint or traditional permanent implants, and represents an intermediate technique between an implant and resection arthroplasty.
The purpose of this study was to determine whether there is a significant difference in femoral component alignment when the posterior and direct lateral approaches are compared.
1. AP radiograph A Tip of stem to outer medial cortex. B Tip of stem to outer lateral cortex. 2. Lateral radiograph C Tip of stem to anterior outer cortex D Tip of stem to posterior outer cortex.
Component alignment was defined as A – B and C – D.
Total hip arthroplasty is a challenging problem in case of high hip dislocation. In order to reduce the hip, a femoral shortening osteotomy is necessary to prevent damage to the neurovascular structures. In this study we present the mid-term results of a simple technique of simultaneous derotating and shortening osteotomy of the femur without the necessity of additional osteosynthesis.
In this retrospective study we included 28 patients with high hip dislocation. In these patients 30 consecutive cementless primary total hip arthroplasties with femoral shortening osteotomy were performed. 20 cases were previously operated. All patients were clinically and radiologically followed up after a mean of 4.5 years (range 2 – 5.7 years). Time point of consolidation was determined on consecutive radiographs for each patient.
The average operative time was 116 minutes (range 65 to 150 minutes). There were no intraoperative complications. Postoperatively no femur fractures, no pseudarthroses and no pareses were observed. The mean consolidation time of the osteotomy was 4.4 months. At the time of follow-up, one aseptic loosening had been verified. In this case a very small stem (size 03) had been used. The mean Merle d’Aubigne score for the unrevised hips improved from 8.2 points preoperatively to 15.1 points at follow-up.
In conclusion the presented technique allowed an easy and fast implantation of total hip arthroplasty in patients with high hip dislocation. The Zweymueller stem design with its rectangular cross-section seems responsible for the sufficient stability of the osteotomy resulting in a short consolidation time. Any additional osteosynthesis is obsolete. This leads to additional advantages including a short duration of surgery and a low complication rate. The good clinical results are attributable to the fact, that by shortening the femur, the physiological hip joint biomechanics could be approximated. The mid-term results of the described technique are very promising.
The neck is the firmer structure of the proximal femur designed to spread the stresses both in compression and tension towards the metadiaphisys and the greater trochanter. Therefore femural neck preserving in total hip arthroplasty allows an optimized stresses’ distribution to obtain both an optimal integration and a subsequent better bone remodelling. The solidity of the structure and the geometric architecture with a femural neck angle of 125° guarantee the maximum primary stability, especially torsional of the stem. At last femural neck retaining allows, when requested, the revision with a richer bone-stock. For the aforementioned reasons since 1979 I proposed the femural neck preservation making a short cementless stem named Biodinamica. From 1983 to 1996 I personally implanted 498 Biodinamica prostheses with very satisfactory results showing a long term survival of the 98% (f.up 13 to 17 years). In 1996 with Ing. Keller it has been created the C.F.P. stem with the T.O.P. acetabular cup as evolution of Biodinamica system. The improvements are critical: materials have changed (from Cr-Co-Mb to Ti alloy), coating and design too. We report clinical and radiographical results of 10 years of C.F.P. implants that showed a further improvement, not only about the prosthesis’ survival, but especially regarding their quality with a 91% excellent clinical outcome. In conclusion we report the 25 years experience retaining the femural neck in hip arthroplasty with Biodinamica (498) and after C.F.P. (445) of a complessive cases of 943 arthroplasty.
There was no vertebral artery injury and no cerebrospinal fluid leak. Three patients developed post operative occipital neuralgia. This neuralgia was transient in one of the patients having settled at 6-week follow up. In the other 2 patients the neuralgia was unresolved at the time of latest follow up but was adequately controlled with appropriate pain management. Post operatively no patient had radiographic evidence of construct failure and all demostrated excellent sagittal alignment.
We aimed to establish if radiological parameters, dual energy x-ray absorbtiometry (DEXA) and quantitative CT (qCT) could predict the risk of sustaining a femoral neck fracture following hip resurfacing. 21 unilateral fresh frozen femurs were used. Each femur had a plain AP radiograph, DEXA scan and quantitative CT scan. Femurs were then prepared for a Birmingham Hip Resurfacing femoral component with the stem shaft angle equal to the native neck shaft angle. The femoral component was then cemented onto the prepared femoral head. No notching of the femoral neck occurred in any specimens. A repeat radiograph was performed to confirm the stem shaft angle. The femurs were then potted in a position of single leg stance and tested in the axial direction to failure using an Instron mechanical tester. The load to failure was then analysed with the radiological, DEXA and qCT parameters using multiple regression. The strongest correlation with the load to failure values was the total mineral content of the femoral neck at the head/neck junction using qCT r= 0.74 (p< 0.001). This improved to r=0.76 (p< 0.001) when neck width was included in the analysis. The total bone mineral density measurement from the DEXA scan showed a correlation with the load to failure of r=0.69 (p< 0.001). Radiological parameters only moderately correlated with the load to failure values; neck width (r=0.55), head diameter (r= 0.49) and femoral off-set (r=0.3). This study suggests that a patient’s risk of femoral neck fracture following hip resurfacing is most strongly correlated with total mineral content at the head/neck junction and bone mineral density. This biomechanical data suggests that the risk of post-operative femoral neck fracture may be most accurately identified with a pre-operative quantitative CT scan through the head/neck junction combined with the femoral neck width.
Radiographic evidence of migration of the femoral stem component after THA is the most important diagnostic sign of femoral implant loosening. Early detection of stem subsidence may help in deciding to perform revision surgery before severe bone destruction has occurred, at a moment when standard clinical and radiological follow-up may still be reassuring.
The aim of this study was to identify the most appropriate bone and prosthetic landmarks to study subsidence and to determine the accuracy of the Imagika® method as compared to the ‘gold standard’ EBRA-FCA® software.
256 THA in 242 patients (102 men, 140 women) with a median age of 63.8 years (range: 36–85) received 4 different cementless or cemented prosthetic stem designs. They were followed for 10.6 years (range: 6–16). CLS® stems were used in 56 patients, MS-30® in 76, Elite® in 50 and Osteal® in 74.
4 specific analysis models were created in the Imagika® software in order to evaluate several possible landmarks on the proximal femur and on the stem, and to evaluate the possibility of using a correction factor to improve the comparability of successive x-rays taken under non standardised conditions. The most accurate prosthetic landmarks were the prosthesis shoulder in CLS® and MS-30® stems and the lateral aspect of the collar in Elite® and Osteal® stems. The best bone landmark was the top of the greater trochanter in all cases.
For the whole series, the annual linear subsidence rates were 0.049+/−0.014 mm with EBRA-FCA® and 0.052+/−0.012 mm with Imagika® respectively (P = 9E-7). Migration values in the 4 different groups were respectively 0.06 +/− 0.01 mm/yr and 0.05 +/− 0.01 mm/yr in the CLS® group (P = 4.6E-6), 0.02 +/− 0.002 mm/yr and 0.06 +/− 0.09 mm/yr in the MS-30® group (P = 6.8E-4), 0.06 +/− 0.002 mm/yr and 0.04 +/− 0.003 mm/yr in the Elite® group (P = 4.2E-5), and 0.05 +/− 0.005 mm/yr and 0.06 +/− 0.004 mm/yr in the Osteal® group (P = 7.4E-7). The different prosthetic designs did not show significant differences concerning migration values when studied according both methods.
Thanks to a correction factor, the Imagika® method uses all the radiographs when EBRA-FCA® rejects incomparable radiographs.
The Imagika® method is more users friendly and provides excellent reliability thanks to an automatic edge detection device.
Since no significant difference was observed between EBRA-FCA® and Imagika® methods whatever the prosthetic stem design studied, our results authorise us to apply these analysis models within the Imagika® software to all THAs to follow their radiographic evolution and to possibly predict the clinical evolution.
Patients after ALIF and PLF had an even complication rate (5/39 vs. 26/296, p = 0,41). The types of complications in the ALIF group were less severe (sensory and motoric disturbance vs. implant failure and implant malposition). All five patients needing reintervention belonged to the PLF group. Three quarters of all patients underwent rehabilitation. The proportion of patients with outpatient rehabilitation was higher in the ALIF group (14/39 vs. 50/296 patients, p = 0,05).
Posterolateral spinal fusion is considered one of the most challenging condition for bone graft substitutes since using autogenous bone graft pseudarthrosis have been reported in 30% of cases.
1) the cell-biomaterial constructs which per se were highly efficient in previous animal studies, used in different absolute quantities but identical ratios were not efficient in the direct preclinical model. 2) Radiography alone is misleading. 3) Once efficient cell and material preparations are obtained, additional consideration must be given to specific circumstances of the pre-clinical and clinical application such as mobility of the graft and its component and vascularization of the graft bed.
A 980 nm Diode (Biolitec AG) Laser energy introduced via a 21G needle under C-arm or CT-Scan guidance and local anesthesia, vaporizes a small amount of nucleous polposus with a disc shrinkage and a relief of pressure on nerve root. The procedure in the disc herniation treatment over the years had several changes, not only related to the different types of lasers (Ho:YAG, Nd: YAG, Er:YAG), but also in the types of optical fibers employed and in the neuronavigation systems. In our department starting under C-arm, realized that the only way to visualize the nerve root and increase the total energy delivered in several points of disc herniation, was to use a CT-Scan guidance (Aquilion 64 Slices Toshiba).
In conclusion, CT-Scan guidance appear to be the best way to practice PLDD not only in terms of resolution, treating succesfully non contained disc herniation, but also because the visualization of the nerve root permits a safe application of the laser energy and the effectiveness of the procedure give a faster return to normal life.
It is the aim of this study to investigate the influence of the age of vertebral fractures on the clinical and radiological outcome of balloon kyphoplasty. All data were recorded prospectively at each visit (admission, postoperatively, discharge) and no patient was lost. 92 Patients (27 male, 65 female, mean age 67,2 years, mean body mass index 26,4) with 102 vertebral fractures (84 patients had one fracture, six had two and two had three fractures) were included in this study. All fractures were type A of the AO-classification (29 were A1.1, 34 were A1.2, 36 were A1.3, 2 were A3.1 and one was A2.3). Radiologically verebral body height, kyphosis angle, kyphosis index, compression index and bone cement application were evaluated. Clinically pain intensity (VAS 0-10), pain medication consumption (WHO 1-3) and surgical specific data were documented. The age of the vertebral body fracture was less than one week in 23 patients, between 7 and 14 days in 22 patients and more than 14 days in 57 patients. The mean surgical time was 43 minutes with a mean cement volume of 3,3 ml. A significant reduction of the kyphosis angle and index and an increase of the verebral body height could be documented. Pain medication consumption was reduced from 1,8±0,9 preoperatively to 1,2±1,1 at discharge. A significat reduction of pain intensity was observed (8,2±1 preoperatively vs. 3,9±2,5 at discharge). The most intense pain reduction at discharge was seen in fresh fractures (ifracture age < 7 days 2,4±0,5, 7–14 days 4,0±0,6, > 14 days 4,4±0,3; p< 0,005). Balloon kyphoplasty is a reliable method to reduce vertebral body fractures. A pain reduction can be achieved in all cases, but pain is mot effectively reduced in fresh treated fractures.
CaSO4 and CaCO3 3% alginate hydrogels were injected into the NP cavity of a bovine tail. After 90 minutes the tail was dissected to reveal the gel. NP cells released from pooled bovine NP tissue were dispersed into the CaSO4 and CaCO3 alginate gels (10x106 cells.mL-1) with and without hylan (Synvisc®) and cultured for 21 days.
Injectable alginate suspensions formed solid viscoelastic gels, filling the exact shape of the NP cavity. NP DNA and ECM synthesis was significantly greater in the CaCO3 alginate gel than in the CaSO4 alginate gel (p<
0.05). Synvisc® significantly increased sulphated GAG (p<
0.01) and collagen (p<
0.05) production. These effects were supported histologically and immunohistologically where cells in the CaCO3 and Synvisc® gels stained more intensely for proteoglycan and collagen type II.
We removed 23 Charité artificial discs in 19 patients due to severe back-and legpain and performed an anterior as well posterior fusion. Mean interval between insertion and retrieval is 8,4 years (3,0–16,0 years). The mean age at retrieval is 49,4 years (40–72 years). The cause of persistent or recurrent pain was one or more of several problems thought to be related to the pain: subsidence, migration, wear with or without breakage of the metal marker ring, facetjoint or adjacent degeneration. In all cases wear of the polyethylene core was seen in major or minor degree. The wear was related to posterior impingement possibly due to hyperlordosis and extension instability and was subsequently more pronounced in the peripheral rim than in the central dome. Also a relationship was noted to in vivo oxidation of the polyethylene, especially in the rim. In the periprosthetic tissue an inflammatory reaction was found, more in the severe wear cases. Polyethylene loaded macrophages were seen, also polyethylene particles lying freely in the tissue. The macrophages proved positive for Interleukin 6. The wear pattern and the inflammatory reaction resembles the pattern seen in total hips and knees. Probably a substantial number of patients will exhibit these wear changes some years after insertion. It is questionable whether changes in sterilization and packaging and better insertion and sizing techniques will prevent wear development in the future.
Results: The concentrations of cobalt and chromium ions in the serum amounted on average to 4.75μg/l (standard deviation 2,71) for cobalt and 1.10μg/l (standard deviation 1,24) for chromium. Compared to the control group, both the chromium and cobalt levels in the serum showed significant increases (Mann-Whitney Rank Sum Test, p=0.0120). At follow-up the Oswestry Disability Score was on average significantly decreased by 24.4 points (L5/S1) (t-test, p < 0.05) and by 26.8 points (L4-S1)(t-test, p < 0.05). The improved clinical situation is also represented by a significant decrease of the Visual Analog Pain Scale of 42,2points after the follow-up (t-test, p< 0,05).
Based on the complexity of the anatomical structures and the nearly unknown loading conditions at the moment only contradictory knowledge exists about the kinematics after TDA and in particular the location of the center of rotation in the human lumbar spine [
The objective of our study was to evaluate the kinematics of the human lumbar spine and the ability of TDA to restore the native conditions in regard to range of motion (ROM), neutral zone (NZ) and center of rotation (COR).
Therefore a spinal simulator has been customized, applying pure moments for flexion/extension, lateral bending and axial rotation (+/−7.5Nm) and axial preload (FP=400N) with a defined velocity (1°/s). The instantaneous COR has been calculated based on the velocity pole method using a 3D ultrasonic motion analysis system, measuring the twelve components of motion.
After insertion of the lumbar artificial disc the instability can be reduced to the native grade of motion and the COR is located again in the main axis of the spinal column in the upper third of the inferior vertebra.
Between 11/2005, and 9/2006 a first series of patients has undergone transpedicular instrumentation with 3D robotic assistance in the lumbar spine at our Orthopaedic Department. This technology must not be confused with standard spine navigation and will be presented in detail.
16 patients (12m, 4f, avg. age 55 yrs.) were randomly selected from our clientele for lumbar fusion or dynamic stabilization via transpedicular instrumentation. After informed consent they obtained thin slice CT scans of the operating field prior to surgery.
The Mazor computer system then imported the scans, allowing 3-D planning of screw placement. A fixation device was then attached to the patient and the system was calibrated in connection with a standard fluoro-scope. On the device a robotic device with a working arm was mounted. Automatic matching algorithms then moved the robot, pointing its arm towards the designated pedicle screw portals. The screws could then be placed through the working arm, either cannulated (ICON) via K-wires, or solid (XIA) via standard awls. Percutaneous MIS insertion was also feasible. Instrumentation was then set forth after removal of the robot as usual. The CT accuracy of screw placement in all robot-assisted patients was scored according to Mattes et al. postoperatively.
1 patient had to be instrumented manually for reasons unrelated to the system. In 2 early obese patients the system denied robotic access due to insufficient imaging, thus enforcing standard manual technique. In the remaining patients a total of 58 screws had to be placed. No clinical complication related to the Mazor system occurred. A total of 6 screws could not be placed by the system due to steep lumbosacral angles. Additional time of surgery could be reduced to 40 minutes per case during the series.
None of the robotic screws was misplaced in the final CT. 1 of the 6 non-robotic screws was misplaced at the S1 level and needed replacement due to apparent nerve contact without palsy. The robotic screws reached an average Mattes score of 1.5 which can be considered superior to sole fluoroscopic techniques (2.5). Additional decompression did not impede the system which does not rely on surface matching. On the basis of the clinical application, additional features were developed, e.g. robot mounting wedges for hyperlordosis, and oblique fluoro view acquisition. The planning software also avoids “supercharging” of the pedicle due to screw oversize. In one case this inevitably would have happened in conventional technique.
This is the first report worldwide about the beginning of robotic assisted pedicle screw placement in Europe in daily routine. The Mazor System now has proven its usefulness and potential. Additional most recent data will be available at time of presentation as the system is further evolving and under continuous use.
In order to evaluate the short- and long-term clinical and radiological results of MIS in TKA, a prospective randomized trial was designed in our department. All patients admitted to the department under the care of one surgeon specializing in Joint Replacement surgery were assigned to participate in the study, signed a concern form, and randomly allocated into two groups. For patients of group A, a TKA was performed using the mini mid-vastus approach; for patients of group B the surgery was performed using a conventional medial parapatellar incision. The Genesis II prosthesis and MIS instrumentation were used for all patients.
Pre and postoperative clinical and radiological data were collected for all patients at regular time intervals (pre, 1st d, 3rd d, 6th d, 3rd w, 6th w, 3rd m, 6th m, 9th m, 1st y, and every year thereafter). Early postoperative pain was also evaluated using a VAS scale and the ability of early SLR was also recorded.
Until now 80 patients (40 MIS, 40 Controls) have entered the study with a follow-up of more than 6 months. In 5 patients (12.5%) of group A the MIS surgery was abandoned in favor of conventional surgery due to technical problems.
Patients in MIS group A had knees with greater range of motion at 3 w, 6 w and 3 months, better function at 3 and 6 months, and less blood loss. In contrast, the same patients experienced greater pain during the first 3 postoperative days. Surgery lasted 16 minutes more on average for the MIS group A. On radiological evaluation technical errors were observed in 5 patients of MIS group A.
Long term quadriceps strength defictis have been reported after a TKA performed with a quadriceps splitting approach. Will an MIS-TKA performed with a mini midvastus approach significantly improve long term quadriceps strength retention?
147 subjects were chosen in a retrospective manner for this study. 52 MIS-TKA, 48 quadriceps splitting TKA, and 47 controls with normal knees and no prior surgery. All groups were age and gender matched. All knees were tested more than 1 year after the index operation on a Cybex isokinetic dynamometer. All surgeries were performed by the author.
The average Knee Society knee score for the MIS-TKA group was 94.3 and the average age was 71. The quadriceps splitting group had an average knee score of 95.7 and an average age of 72. The control group had an average age of 70. All groups averaged 38% male and 62% female. At 30 degrees from full extension the MIS-TKA group retained 96.6% of the control group strength and the quadriceps splitting group 94.5%. At 15 degrees from full extension the MIS-TKA group improved to 99.7% while the quadriceps splitting group fell to 85% of the control group strength.
MIS TKA with a mini midvastus approach preserves terminal quadriceps strength better than a standard quadriceps splitting approach.
The following data were assembled by a skin incision blinded study nurse: VAS, use of morphine pump, range of motion, straight leg raising, time to independent ambulation, time to discharge, wound problems and complications up to 6 weeks postoperative.
Generation of the tibial cyst is multifactorial. Implantation techniques can increase poly imminence impingement by the femoral notch thus increasing forces on poly during gait. Lowering the notch on the NKII improves patella contact but can lead to impingement if the surgeon flexes the femur or places too much slope on the tibia. Hydraulic action is also postulated, joint fluid is being forced down the screw channel carrying with it small poly particles. The tight peripheral tolerances of the insert into the baseplate may create such a tight fit that the insert acts like a piston with each step. Lab testing is currently being done to test this hypothesis and evaluate micromotion and wear patterns. We are recommending polyexchanges for stg 3 & 4 pts to the highly crosslinked poly as well as curetting and grafting all cysts. Early results show cyst resolution. Stress fractures may require long stem revision baseplates. Stg 1 & 2 can be followed with serial xrays
TKR backside wear studies have concluded that, compared to rough trays, polished trays decrease total amount of backside wear by 80% to 87%. However, size and volumetric concentration of sub-micron-sized polyethylene particles are critical factors for macrophage-mediated osteolysis. We assessed the size and morphology of polyethylene wear debris from TKR backside wear simulations comparing polyethylene fretting against polished and blasted metal surfaces. A 3-station fretting wear simulator reproduced loads and motions typical of the backside of fixed-bearing inserts of TKRs. 5-million cyclic experiments combined low (50μm) or high (200μm) linear motion with +3o rotational motion. Load profile was double-peak Paul curve (peak 10MPa). Eight 3-station experiments measured polyethylene wear against blasted or polished metal surfaces of Ti6Al4V or CoCr. Polyethylene particles were isolated from serum following gradient separation and filtration on 0.01μm polycarbonate filters. Using SEM analysis, average 200 particles per sample were characterized with Meta-morph™ image analysis software. Concentration of submicron particles in the debris from rough surfaces was 31–32% under 50μm motion, 28–30% under 200μm. Surprisingly, this concentration from polished surfaces was substantially greater: 69–78% (50μm), and 57–63% (200μm). However, total poly wear against rough surfaces was 0.45–1.63mm3/
Mcycles, and 0–0.35mm3/Mcycles against polished. Taking this into account, the volume of submicron particles from polished surfaces is less than 0.1mm3/ Mcycles and from rough surfaces between 0.1 and 0.45mm3/Mcycles.
In conclusion, although polished metal trays produce up to five times less wear than blasted surfaces, they may also lead to an increase in the osteolytic potential of the polyethylene debris.
The New Jersey Low Contact Stress prosthesis was introduced in 1977. LCS mobile bearing prostheses have been implanted in patients in the United States since 1985. The PCL-sacrificing rotating platform design of the LCS® prosthesis was designed to minimally constrain knee kinematics while minimising bone-cement-prosthesis interface stresses and polyethylene wear.
The purpose of the current study was to assess the in vivo rotating platform PE wear of the LCS-RP® and to check if the PE tray mobility is preserved over time.
We investigated 120 total knee replacements in 108 patients (38 men, 70 women) treated by the LCS-RP® prosthesis for osteoarthritis or rheumatoid arthritis. Average age of the patients was 70.4 years (range: 36–81). Average follow-up was 15.3 years (range: 10–18).
PE wear assessment was performed using a specific analysis model created in the Imagika® software on AP radiographs.
Rotating platform mobility was assessed thanks to another analysis model. We used prosthetic landmarks (tip of the prosthetic stem, tibial tray and tantalum markers embedded into the PE) visible on lateral radiographs.
Linear wear rates were 0.012+/−0.007 mm (tibial plate/ PE interface), 0.026+/−0.034 mm (PE/internal condyle interface) and 0.017+/−0.041 mm (PE/external condyle interface). There were no significant differences between wear values of both internal and external sides of the upper surface of the PE insert (P = 0.000054) and of tibial plate PE/external condyle PE interfaces (P = 0.0012), but a P value of 0.063 was observed between the tibial plate PE interface and the internal condyle PE interface.
The PE range of motion was 5.3 +/− 1.2° (range: −2.5 (external) to +3.2 (internal)) at last follow-up as compared to the first radiograph (3 months after operation). All trays preserved there mobility in rotation.
Annual PE wear rates were extremely low as well as at the lower and the upper surfaces of the mobile bearing. Our results suggest that the long term mobility conservation contributed to low PE wear rates despite a high anatomic congruency due to the prosthetic design.
At the end of the interview every person/patient was asked for a statement about their understanding, formulations, difficulties with the ‚pationnaire’, missing questions and general impression.
Work-related musculoskeletal disorders are a persistent and expensive health challenge in all industrial countries including Switzerland. A recent European survey indicates that, among the working population, the three most common work health problems reported are: back pain (30%, increasing), stress (28%), muscular pain in arms or in legs (25%). A relatively small group of patients causes relatively high health services costs and long absenteeism from work and furthermore show a high risk to loose workability.
Significant progresses have been made these last years in the understanding of the disorder occurrence and chronitisation. Despite of this, the management and successful rehabilitation of MSD suffering workers is still difficult. Recent reviews recommend an intervention strategy based on the bio-psycho-social model. Work hardening and work rehabilitation programs seek to achieve a balance between the physical and mental demands of the job and the individual’s abilities. In a pilot project, we developed and tested the needed instruments and protocols for a multi-disciplinary intervention strategy that takes both aspects into account. This involves the application of clinical and occupation medical skills (rheumatology, occupational medicine, work psychology, ergonomics).
work hardening, cognitive training, and psychosocial counseling directly related to the person’s real work conditions and demands, and job analysis and, if necessary, modification of work conditions.
Patients were recruited for participation in the two groups (120 patients in the intervention group and 120 patients in the control group) in collaboration with companies that have a work absence management system. Two research teams – with members from two university centers (Orthopedic Hospital, Lausanne;University Hospital Zurich) and from the two Swiss institutes working in the area of work and health (Center for Organizational and Occupational Sciences (ZOA), Swiss Federal Institute of Technology; Institut universitaire romand de Santé au Travail (IST), University of Lausanne), will conduct the case control study jointly. In addition, a research team at the University of Neuchâtel will conduct a cost-benefit analysis of the multidisciplinary and the standard treatment.
The purpose of this study was to show the feasibility of setting up a computerized register of complications for a whole Department of Orthopaedic Surgery and Traumatology, based on a simple, user-friendly and upto-date scientific approach.
The average age of primary hip replacement patient was 70 years. (male patients 68 years and 71 years in females.) Over the 13 year period, the average age of male patients was noted to decline steadily from 71 in 1993 to 66 in 2003. But the average age of female patients remained constant at around 71 years.
The number of patients below age 60 years undergoing hip replacement procedures was analysed. Only 8% of patients were under 60 years of age in 1993 rising to 23% in 2005. Between 2000 and 2005 this figure was at or above 20%.
Surface hip replacement was started at our hospital in 1999. The number of patients treated with surface hip replacement as a proportion of all primary hip procedures has increased to 32% in 2005. The average age of these patients was 57 years. The sex difference was approximately 1:1 as compared to 1:2 in total hip replacement.
The average age of primary knee replacement patients was 73 years, 72 yrs for males and 73 yrs for females. No change in average age was noted over the period. The proportion of patients under age of 60 years varied between 4 and 9%
In addition this study analysed how compressive, bending and torsional stiffness as suitable tools were related to the torsional load bearing capacity using a common set of bone regenerate samples of 26 sheep treated with distraction osteogenesis.
The most important issue in the assessment of fracture healing is to acquire information on the restoration of mechanical integrity of the bone. To measure bending stiffness at the healing fracture site, we focused on the use of echo tracking (ET) that was a technique measuring minute displacement of bone surface by detecting a wave pattern in a radiofrequency echo signal with an accuracy of 2.6 μ. The purpose of this study was to assure that the ET system could quantitatively assess the progress, retardation or arrest of healing by detecting bending stiffness at the fracture site.
With the ET system, eight tibial fractures in 7 patients with an average age of 37 years (range: 24–69) were measured. Two tibiae in 2 patients were treated conservatively with a cast, and 6 tibiae in 5 patients were treated with internal fixation (intramedullary nailing: 4, plating: 1, screw 1). Patients assumed supine position, and the affected lower leg was held horizontally with the antero-medial aspect faced upwards. The fibula head and the lateral malleolus were supported and held tight by a Vacufix ®. A 7.5 Hz ultrasound probe was placed on each antero-medial aspect of the proximal and distal fragments along its long axis. Each probe was equipped with a multi-ET system with 5 tracking points with each span of 10 mm. A load of 25 N was applied at a rate of 5 N/second using a force gauge parallel to the direction of the probe and these probes detected the bending angle between the proximal and distal fragments. An ET angle was defined as the sum of the inclinations of both fragments. In the patients treated with a cast, the contralateral side was also measured and served as a control. Fracture healing was assessed time sequentially with an interval of 2 or 3 weeks during the treatment.
None of the patients complained of pain, or no other complication related to this measurement occurred. In the patient (patient:M) treated with a cast, the ET angle exponentially decreased as time elapsed (y = 1.4035e-0.1053x, R = 0.9754) and the radiographic appearance showed normal healing. Including this case, in all patients with radiographic normal healing, the ET angle exponentially decreased. However, in patients with retarded healing (patient:N), the decrease of the angle was extremely slow(y = 0.2769e-0.0096x, R = 0.815). In patients with non union (patient:T), the angle stayed at the same level.
With this method, noninvasive assessment of bending stiffness at the healing site was achieved. Bending angle measured by ET diminished over time exponentially in patients with normal healing. On the contrary, in patients with healing arrest, no significant decrease of the bending angle was recognized. It was demonstrated that the echo tracking method could be applicable clinically to evaluate fracture healing as a versatile, quantitative and noninvasive technique.
Shock wave treatment has been shown to induce new bone formation both under physiologic conditions and during fracture repair. Whereas various underlying molecular working mechanisms have been shown in recent studies, no study has assessed the influence of varying energy flux densities (EFD) on the amount of new bone formation in vivo. Therefore, the aim of this study was to investigate whether the effect of shock waves on bone is dependent on the applied EFD and if so, to identify the minimal dose necessary to induce new bone formation in vivo to avoid unwanted side effects of high-energy shock waves.
To this end, 30 New Zealand white rabbits were randomly divided in 5 groups and treated with extracorporeal shock waves at the distal femoral region (1,500 pulses at 1 Hz frequency each):
(a) control (sham treatment), (b) EFD 0.35 mJ/mm2, (c) EFD 0.5 mJ/mm2, (d) EFD 0.9 mJ/mm2 and (e) EFD 1.2 mJ/mm2.
To investigate new bone formation, animals were injected with oxytetracycline at the days 5 to 9 after shock wave application and sacrificed on day 10. Histological sections of treated and untreated femora of all animals were examined using broad-band epifluorescent illumination and contact microradiography. The amount of new periosteal and endosteal bone was measured and signs of periosteal detachment, cortical fractures, and fragmented trabecular bone with callus were recorded.
Application of shock waves showed new bone formation beginning with 0.5 mJ/mm2 EFD and increasing with 0.9 mJ/mm2 and 1.2 mJ/mm2. The latter EFD resulted in new bone formation also on the opposite cortical bone and cortical fractures and periosteal detachment occurred. EFD of 0.35 mJ/mm2 did not lead to any new bone formation. Here for the first time a threshold level is presented for new bone formation after applying shock waves to intact bone in vivo.
We conclude that the results presented here have significant impact on further clinical applications of shock waves on bone tissue. In the present study, it is clearly demonstrated that the amount of new bone formation is directly dependent on the applied EFD. If the applied EFD is to low, no significant new bone formation will occur. If it is too high, unwanted side effects, like the formation of bone spurs in the shoulder or nerve entrapment syndromes in the elbow or feet by bony overgrowth may result.
A conventional implant/bone construct typically involves a plate fixed to a fracture bone via set of screws aligned vertically to the plate/bone interface. In this study new configurations of plate/bone constructs with varied screw angulations were tested. The conventional screw configurations a parallel set of screws aligned vertical to interface were tested against two new configurations, called the divergent configuration and the convergent configuration. A total of four construct systems were prepared for tests. The samples used in the experiments are listed. Sample A, named conventional construct, used a set of parallel screws drilled vertical to the interface plane. Sample B, named convergent construct, used screw holes drilled such that their axes converged. Samples C and D, named divergent construct, used screw holes with diverging axes. The difference between Samples C and D is in the angle of alignment between their screw axes and the normal to the interfacial plane, the former drilled at 150 and the latter at 300. The load displacement curves for the four samples are shown. The failure loads, along with the mode of failure for each sample are read from the load-displacement curves. At a first glance, it is observed that the sample with highest pullout strength in terms of failure load is the conventional construct (A). This is followed by the divergent constructs (C and D), and the sample with the lowest strength is the convergent construct. It takes a more careful investigation, however, to note that similar results will not apply when one takes the average pullout stiffness as a criterion. Here, we define the average pullout stiffness of the structure as It is immediately noticed that samples producing the highest stiffness are those prepared as divergent constructs (C and D), followed by the convergent construct (B), and finally, Sample A produced the lowest stiffness. Also note that the initial portion of the load-displacement curve for Sample D (300 screws) is highly nonlinear, although the curve then assumes a linear shape. The stiffness obtained in the linear region of Sample D, and that of Sample C are quite close in comparison.
This initial deviation in the curve of 300 divergent screws may be explained by a self-aligning motion of the screws as the load is applied, during which the angle of alignment tends to decrease towards a smaller angle. As the angle gets closer to that of Sample C and the curve becomes linear, the stiffness produced by Sample D, approaches to that of Sample C.
As a result, we have found the divergent constructs to be a promising alternative to the conventional set of screws, used in treating fracture involving bones with osteoporosis. Moreover, research needs to be focused on determination of an optimal angle of alignment, the number of screws to be used and the optimal distance between each screw for the divergent construct.
We hypothesized that topical bisphosphonate (Pamidronate, Mayne Pharma) in combination with rhBMP2 (InductOs, Wyeth) would give increased mechanical implant fixation and increased new bone formation without excessive allograft resorption. We looked at both porous-coated Ti implants and HA-coated implants.
allograft alone (control) allograft + rhBMP2 allograft + pamidronate allograft + rhBMP2 + pamidronate (combination)
The observation time was 4 weeks.
The HA implants had less fibrous tissue and more new bone compared to the Ti implants. The fractions of allograft were the same.
The rhBMP2 group had more new bone and much less fibrous tissue than the mechanically superior control group. However, there was almost no allograft left in the rhBMP2 group due to extreme resorption.
The addition of pamidronate seemed to freeze bone metabolism around the implants. Neither in the pamidronate group nor in the combination group was there anything but minor new bone growth. The allograft was preserved. In the pamidronate group there was a dense, thick fibrous capsule around the implants. This was not the case in the combined rhBMP2-pamidronate group, and is most likely a positive effect of the rhBMP2.
The negative results with rhBMP2 may be due to over dosage, which warrants further preclinical testing. Despite the limitations of this animal study with non-loaded implants, the results encourage extreme caution in adjuvant therapies of arthroplastic surgery.
Aims: Compare video conferencing to patient and surgeon ‘face to face’ consultation in counselling of patients prior to surgery.
The assessment was done for all four scenarios both in person and over a video conference link (AHMS). The order of each case was varied to minimise ‘rehearsal’ of the consent. The consent process was scored on a number of points followed by rating. SHOs acted as their own controls removing bias of differing levels of knowledge.
The development of iron oxide nanoparticles, which are taken up and endosomally stored by stem cells, allows the evaluation of cellular behaviour in the muscle with the use of magnetic resonance imaging (MRI). Previous work has shown that labelling does not affect the proliferation and neurogenic differentiation capacity of embryonic stem cells. In the present study we are currently investigating the in vivo distribution and migration of locally transplanted MSC after blunt muscle trauma in a rat model.
We present the results of a simple method of stabilisation using intramedullary K-wires without violating the articular surface.
We present in this work our experience with the sural fasciocutaneous flap to treat coverage defects following a lower limb posttraumatic lesion. This work is a review of the fasciocutaneous sural flaps carried out in different centres between 2000 and 2005. The series consist of 14 patients, 12 men and 2 women with an average age of 38 years (23–54) and with a medium follow-up time of 2 years (12–48 months). In all of the cases, aetiology was a lower limb injury being the most frequent the distal tibial fracture (eight patients), followed by sequelae from Achilles tendon reconstruction (two patients), fracture of the calcaneus (two patients) and osteomyelitis of the distal tibia (two patients) secondary to an open fracture. Associated risk factors in the patients for performing a fasciocutaneous flap were diabetes (1 case) and cigarette smoking (4 cases).
The technique is based on the use of a reverse-flow island sural flap with the superficial sural artery dependent on perforators of the peroneal arterial system. The anatomical structures which constitute the pedicle are the superficial and deep fascia, the sural nerve, external saphenous vein, superficial sural artery together with an islet of subcutaneous cellular tissue and skin.
The flap was viable in 13 of 14 patients. Only in one case, a diabetic patient, the graft failed. No patient showed signs of infection. Slight venous congestion of the flap occurred in two cases. No further surgical intervention of the donor site was required because of morbidity. In two cases partial necrosis of the skin edges occurred which resolved satisfactorily with conservative treatment.
The sural fasciocutaneous flap is useful for the treatment of complex injuries of the lower limbs. Its technical advantages are: easy dissection with preservation of more important vascular structures in the limb, complete coverage of the soft tissue defect in just one operation without the need of microsurgical anastomosis. All of that results in a well vascularised cutaneous islet and thus a reliable flap
A total absence of acute compartment syndrome (ACS) was noted in 966 tibial fractures in African patients of diverse ethnic groups, reviewed retrospectively at our institution. According to general incidences reported in the literature, we should have experienced between 22 and 86 cases of acute compartment syndrome. The purpose of this prospective study was to confirm these findings and at the same time to try to find an explanation for this phenomenon.
During a period of 1 year and 4 months, 257 tibial fractures were prospectively analyzed for clinical signs and late sequelae of acute compartment syndrome. In 156 of these patients, presenting 158 fractures of the tibia, the pressure in the anterior compartment was systematically measured. Not a single case, nor late sequel of ACS was diagnosed.
The hypothesis we forward for this total absence of ACS is the effect of chronic high temperature surroundings in preventing ACS by safeguarding the arteriovenous gradient and lowering the vascular resistance. We propose that further investigation should be carried out to study this hypothesis.
The records of these 28 patients were reviewed. Twenty three were male. Ages ranged from 19 to 83 years old. Eight patients had open fractures and 20 had closed fractures. Seven patients (25%) had difficulties with communication which could have impeded or delayed the diagnosis of a compartment syndrome.
However, due to the ease of use and the low cost involved, we recommend that all patients with tibial fracture should have continuous compartment pressure monitoring performed.
Surgical treatment of complex wounds of the lower extremities has greatly evolved in the last years, leading to a higher percentage of limb salvage and good functional recovery.
Microsurgery surely is a good weapon when facing extensive tissue losses and infections.
From 1994 to 2004, 25 patients have been treated in our department for complex traumas of the lower limb.
These cases include 4 acute complex injuries with extensive soft tissue loss (Gustilo III open fractures) which were treated with 3 Latissimus Dorsi and 1 Gracilis Muscle Flaps; 10 delayed referrals with exposed bone or bony/soft tissue loss (1 Fibula Flap for the distal femur, 1 Fibula Flap for the lower leg, 3 cases of amputation stump coverage, 2 Parascapular Flaps, 2 Gracilis Flaps, 1 Latissimus Dorsi Flap, 1 Serratus Flap with a rib, 1 Iliac Crest Flap); and 11 late reconstructions of chronic osteomyelitis: 1 distal femur infection (Double-barrel Fibula Flap), 10 infections of the middle or distal third of the lower leg (3 Fibula Flaps, 4 Latissimus Dorsi Flaps, 3 Gracilis Muscle Flaps).
In the last few years, the approach to bony tissue losses has been changing: on one hand, elongation techniques for the lower extremity give good results; on the other, microsurgery may allow a single-stage reconstruction of bone, muscle and skin defects, leading to much shorter hospitalization time, and improvement of the patients’ quality of life because of a faster recovery.
Over 90% of the flaps survived, leading to a good recovery of the patients. The two failures were due to the necrosis of a Gracilis Flap in the coverage of an amputation stump and that of a Latissimus Dorsi Flap used for an extensive soft tissue loss in a leg which subsequently had to be amputated.
In 78.5% of the cases of osteomyelitis recovery was obtained after a single operation, and in only 12.3% of the cases the flaps had to be partially revised.
In 2 cases, after the bony resection and coverage by means of a Gracilis Muscle Flap, a homolateral fibular transfer with the Ilizarov technique was performed.
The length of bone resections treated by fibular flaps was 8–12 cm (mean 9).
In the present study, the clinical efficacy and safety of intra-articular injections of ACS were compared to intra-articular hyaluronan (HA), and placebo (saline) in patients with confirmed knee OA.
So far, the efficacy of ACS is defined through improvement in clinical signs and symptoms, particularly pain. It remains to be determined whether there are disease-modifying, chondroprotective, or even chondroregenerative, sequelae.
To compare the onset, extent and duration of pain relief (pain during activity, at rest and at night) in the affected knee between 2 dose groups of ITB and placebo by using a visual analogue scale (VAS). To compare ITB and placebo for safety and the efficacy variables: Western Ontario McMaster Universities OA index (WOMAC), and time until need of rescue medication.
Statistical analysis included the Chi-square test, differences in means, Wilcoxon-test, the trapezoid rule and Kaplan-Meier curves, using analysis of variance without and with covariates (ANOVA, ANCOVA).
After 3 injections, long-lasting reduction in pain up to 12 weeks after start of treatment could be observed in all treatment groups. Onset of pain relief by _ 10 units was fast and had been reported already 4 hours after start of injection. Both ITB groups consistently demonstrated greater effects on pain when compared to the placebo group; however, there was no difference between the 500 μg and 2000 μg dose groups.
DASH score results were excellent in all bar one of those returned.
These results are comparable to the best results of arthroscopic ACJ Excision.
There were one hundred and three children with two part clavicle fracture (95.3%) and one required surgical fixation (1%). There were only five children with three or more fracture fragments (4.7%) and one required surgical fixation (20%). All five children who had three or more fracture fragments were found to have vertical fragment on x-ray. The average time for discharge was 27.48 days for two part fractures and 49 days for three part fractures.
There were seventy-five (55.5%) adults with two part fractures and ten of them required surgical fixation (13.3%). There were fifty-nine (44.0%) with three or more fragments and eleven of them required surgical fixation (18.6%). Out of the fifty-nine fractures, which had three or more fragments, forty-eight had vertical fragment on x-ray (81.3%). Among the three part fractures, there were ten fractures with vertical fragment that required surgical fixation (20.8%).
The average time for discharge was 52.07 days for two part fractures and 93.56 days for fractures with three or more fragments. There was no difference in the discharge time for non operated three part fractures with or without vertical fragment.
The presence of vertical fragment predicts higher rate of surgical intervention required due to either delayed/non union or localised skin tenting. We recommend that we should have a lower threshold to fix the 3 or more part clavicle fractures with vertical fragment.
Distal clavicle excision (DCE) is the treatment of choice for A–C joint arthritis. Isolated DCE., as an open procedure has been considered to be a safe procedure, and it is the gold standard for comparison for arthroscopic distal clavicle excision. This study attempts to define the incidence of complications after isolated, open DCE.
The clinical results following open reduction and internal fixation via a modified dorsal two-portal-approach in dislocated scapular neck and glenoid fractures should be evaluated.
The approach with two dorsal portals to the glenoid, one cranially and one caudally of the infraspinatus muscle, is described.
From 1.7.1992 until 30.06.2006, 37 patients (27 men, 10 women, mean age 53 years), 31 patients with glenoid fractures and 6 patients with unstable scapular neck fractures were operated on via the two-portal-approach.
The reduction was controlled radiographically, the clinical results were analysed using the Constant-score.
The mean follow-up was 68 (6–168) months. In 22 out of the 31 glenoid fractures the reduction was anatomically. The mean Constant-score revealed 81,1 (35–100) points.
In one case an early postoperative wound infection could be cured by local revision and one patient developed an arthritis of the acromioclavicular joint after two years.
The dorsal two-portal-apporach allows a good visualisation to the dorsal scapular neck and the glenoid area fascilitating reduction and a safe internal fixation of dislocated scapular neck and glenoid farctures.
- scapulas can be classified into two groups regarding the angle between the glenoid surface and the upper posterior column of the scapula with significant differences between them. - two different lengths of the neck of the inferior glenoid body have also been differentiated in the anterior as well as in the posterior faces of the scapula. - the base of the coracoid process is not in line with the posterior column of the scapula. - three-dimensional computed tomography of the scapula constitutes and important tool when planning reversed prostheses implantation.
The accuracy of the physical examination for biceps pathology remains controversial. The goal of this study was to investigate the validity and clinical usefulness of various physical tests used for diagnosing partial tears of the biceps tendon.
The suture material used in all three groups was identical and consisted of an ultra high molecular weight poly-ethylene suture (Ultrabraid). To simulate the direction of pull of the subscapularis, the testing block was tilted 45 degrees while a vertically applied distraction force was applied. A custom made jig was used to measure the amount of displacement in response to a gradually applied load. All specimens were tested to failure. The mode of failure of each fixational construct was recorded.
Seven specimens were used for mechanical analysis. A humeral osteotomy was performed distal to the insertion of pectoralis major, leaving intact the biceps sheath and the muscle belly of long head of biceps. The proximal humerus was attached to a custom-designed jig and the muscle belly of biceps grasped in cryogenic grips. Specimens were loaded on an MTS 858 Bionix mechanical testing machine (MTS Systems, MN) in uniaxial tension at a rate of 1 mm/sec until failure was observed.
Histological examination of the biceps sheath revealed membranous tissue consisting of loose soft tissue with fat and blood vessels. Synovial tissue was also identified. The sheath was seen to loosely attach to the biceps tendon, with a more intimate attachment to the periosteum.
The mean force to pull the long head of biceps tendon out of the sheath 102.7 N (range 17.4 N–227.6 N)
The purpose of this study was to investigate the effect of the degree of abduction on shoulder abduction strength.
Thirty healthy volunteers with no history of shoulder complaint participated in this study. A modified Nottingham Mecmesin Myometer was used. The modification allowed the Myometer to be attached to a clinic table at different angles in order to be at 90°to the arm in varying degrees of abduction. Abduction strength of both shoulders was measured on four occasions at two-week intervals. On each occasion, a different abduction position was adopted at 90°, 60°, 30°and 0°.
The results showed that shoulder abduction strength varies according to the degree of abduction. In comparison with that at 90° of abduction, shoulder abduction strength showed an increase by 12.5% and of 31.3% at 60° and 30° of abduction respectively. However, it was decreased by 18.8% at 0° of abduction. The Student’s T-test showed significant difference between shoulder abduction strength at 90° abduction and all other three abduction positions.
Two modules with 3 miniature capacitive gyroscopes and 3 miniature accelerometers were fixed by a patch on the dorsal side of the distal humerus, and one module with 3 gyroscopes and 3 accelerometers were fixed on the thorax. The subject wore the system during one day (8 hours), at home or wherever he/she went. We used a technique based on the 3D acceleration and the 3D angular velocities from the modules attached on the humerus.
1) an intact joint with a radius of curvature of 24mm for the humeral head and 26mm for the glenoid; 2) an eroded joint with a radius of curvature of 40mm for the humeral head and 42mm for the glenoid.
Movements of external rotation (0–45°) and abduction (0–150°) were performed by muscles’ activation. Contact forces caused by muscles wrapping on bony surfaces were accounted for. Joints forces, glenohumeral contact point locations and humeral head translations were calculated for the intact and eroded joint.
All treatment emergent adverse events (AEs) were recorded. The primary efficacy endpoint was change from baseline (at final injection) in the Ankle OA Pain VAS at 3 months after the final injection. Secondary endpoints were Ankle OA Pain VAS scores at all other time-points, total Ankle OA Scale, Patient and Physician Global OA Assessment (VAS), and health-related quality of life (SF-36).
In TG hydroxyprolin followed the same trend showing a significant decrease after the six month treatment (18±3,2 mg/l vs 13±3,6 mg/l p< 0,05).
At the same time B-ALP reduction was almost significant (36±4,8% vs 23±3,9% p=0,06)
DEXA demonstrated an improvement in total foot mineralization in the TG(0,18±0,06 g/cm2 vs 0,24±0,08 g/cm2 p< 0,05) and in the distal phalanxes (0,194 g/cm2 vs 0,242 g/cm2 p< 0,01) (fig. 3). Only the TG showed a significant decrease of IGF-1 throughout the trial (142,8±24 vs 123,5±41 ng/ml p< 0,05).
Abduction strength forms an important component of shoulder function assessment tools such as the Constant-Murley score. However, there is no consistency in literature with regards to the method used for its assessment. An extensive review of the literature failed to reveal any evidence to support any particular method. The purpose of this study was to compare the reliability of a single measurement with that of the maximum and average of three consecutive measurements. Sixty healthy volunteers participated in this study. Three measurements of shoulder abduction strength were taken on two occasions separated by 2 weeks. For each shoulder, two single (first) measurement values, two average values and two maximum values were obtained. For each method, 95 % limits of agreement were calculated. Both methods average and maximum have higher reliability than a single measurement. Furthermore, the reliability of the maximum is slightly higher than that of the average.
Objective: To assess the effect size and safety of ESWT compared to placebo in the treatment of chronic painful heel syndrome with a new electromagnetic device and an optimized protocol.
We retrospectively reviewed 27 patients who underwent an uncemented total Moje ceramic arthroplasty of hallux rigidus.
Out of 33 patients who had the above procedure, 27 were available for review. Clinical and functional outcome were assessed using the American orthopaedic foot and ankle society (AOFAS) fore-foot score, and the SF-36 health assessment score. All patients had an antero-posterior and a lateral weight bearing radiograph
The primary pathology was oesteo-arthritis (Hallux Rigidus). All procedures were performed by the senior author or under his supervision.
All patients were female with an average age at surgery of 52.6 years (range 45.8–64.7). The average follow up was 39.5 months (range 14–46).
The average post-operative AOFAS forefoot score was 80/100 (range 40–100). The average subscore for pain was 29.39/40 (range 10–40). Twenty five patients 92.5% were satisfied with the outcome, and 22 (81%) were able to wear high heel foot wear.
The functional outcome as assessed using the SF-36 health score was compatible with an age matched population.
The alignments of component were measured in relation to the shaft of the metatarsal and to the proximal phalange. There was no statistical correlation between the alignment and the functional scores.
Although, arthrodesis remains the gold standard procedure, total ceramic first MTP joint arthroplasty has a place in the management of some cases of advanced but not end stage hallux rigidus. Careful patient selection is essential to achieve a favourite outcome.
An enlarged debridment of the first MTP joint was mandatory before any reconstructive procedure.
The collateral lateral ligament reconstruction has been achieved with a synthetic suture (LigaproÒ or LigasticÒ of 1.5 mm diameter) according to flexible joint with no arthritis (regimen 1 (25 cases), youngpopulation (44 years) with an average varus of −12°).
The first MTP joint arthrodesis was performed for osteoarthritis combined with stiffness. (regimen 2 (40 cases), older (64 years) with an average varus of −16°.
In series 1 (ligament reconstruction),24/25 patients were totally painless with an artificial device well tolerated. The joint motion, the gait and the shoe-wearing were normal in 24/25 of cases. The medium post-operative valgus was of 12°.
In series 2 (MTP arthrodesis), arthrodesis healed in 39 cases with an average time of 60 days. Valgus positionning was always restaured.Degenerative changings occured in the IP joint in 4 cases without any complain. Shoe- wearing was classical in all the cases.
Among the procedures for the first MTP joint preservation, enabled to restore valgus strength, the synthetic reconstruction of the collateral lateral ligament is a reliable and reproducible technique, without any damages for the active tendons nor for the joint function.
After one year 22 patients (73,3%)had complete resolution of symptoms.
There is a place for conservative functional treatment in the acute rupture of the Achilles tendon. But prospective comparison with modern surgical techniques, like minimal invasive suture, is still required, especially in patients with high functional demand.
The validation was performed in two steps: Step 1. Comparison of standard dynamic pedography (three trials, walking, third step, three trials, mid stance force pattern), static pedography in standing position (three trials) and pedography with KIOP in healthy volunteers (three trials, total force 400 N).. Step 2. Comparison between pedography in standing position, pedography with KIOP in awake and anaesthesized patients (three trials, total force 400 N).
A randomized prospective controlled study comparing treatment with and without intraoperative pedography has started on November 1, 2005. The subjects are randomized into two groups,
a) use of intraoperative pedography, versus b) no use of intraoperative pedography.
One-year-follow-up including standard dynamic pedography is planned. The following scores are used: American Orthopaedic Foot and Ankle Society (AOFAS), Visual-Analogue-Scale Foot and Ankle (VAS FA), Short-Form 36 (SF36, standardized to 100-point-maximum). Intraoperative consequences after the use of intraoperative pedography were recorded.
Conclusion: Since no statistical significant differences were found between the measurements of intraoperative pedography in anaesthesized individuals and the standard static pedography, the introduced method can be considered to be valid for intraoperative static pedography.
During the clinical use, in 44% of the cases a modification of the surgical correction were made after intraoperative pedography in the same surgical procedure.
The aim of this study was to review the different surgical modalities for ingrown toenails in the paediatric age group in a hospital setting.
All procedures were carried out under general anaesthetic. The treatment methods practised were:
Nail avulsion with or without nail matrix ablation using phenol. Wedge excision of the nail with or without nail matrix ablation using phenol or thermal ablation.
We also applied the same Fischer’s exact test for rate of infection in all the groups.
During the stage of inflammation, conservative measures in the past have been noted to be successful.
In a hospital setting, most patients present in the second stage (infection). Nail avulsion is still commonly practised as a first line treatment. It provides good symptomatic relief in this stage but has been reported to have high rates of recurrence. We noted similar results (recurrence rate: 55%) in our study.
Then patients present in the next stage with symptoms of chronic ingrowths i.e. previous infection and presence granulation tissue in the nail fold. The aim of treatment here is to remove the ingrown area along with the nail fold. Wedge excision with or without removal of nail matrix is a commonly performed procedure. There are various methods for removing the nail matrix namely surgical matrixectomy, chemical matrixectomy using phenol or sodium hydroxides, diathermic/electric cauterisation, laser. There are reports that show low recurrence rates with use of phenol. In this study we found recurrence and infection to be high when phenol was used as the ablative agent. We achieved cure rate of 97% when using wedge excision alone and 70% when phenol was used for nail matrix ablation.
The 130 feet were divided into 2 groups. Group I was without TMT 1 – compression screw (n= 60) and group II with an additional compression-screw (n=70). Average age of group I was 54-years. The average age of group II was 50-years. The American-Orthopaedic-Foot and Ankle Society (AOFAS) Forefoot-Score, Visual-analog-pain-scale and foot radiographs were assessed preoperatively and after a mean of 23 months for group I and 39 months for group II. All 130 feet were treated immediately postoperative with a postoperative Darco orthowedge ® shoe.
The first metatarsophalangeal (MTP) joint is the key joint of the foot in terms of function during gait. Various replacement toe joint prostheses are commercially available but unlike other replacement joints such as the hip or knee, few simulator based studies have been conducted to evaluate the performance and reliability of these prostheses. Presented are results obtained using a newly developed and validated multi-station MTP joint test-rig that is able to simulate the natural biomechanics of the toe joint. The developed simulator is a multi-station computer controlled electro-pneumatic metataso-phalangeal joint simulator that applies dynamic loading and motions commensurate with the walking gait cycle. This involves the combination of plantar-dorsi flexion range of 32 degrees, 5 degrees of inversion/eversion and toe-off dynamic loading peaking at up to 820 N. Presented are the validation and in vitro test results of MTP joint simulations carried out on silastic and articulating metal and polymer designs of MTP prostheses. Despite being subjected to a reduced loading regime of 300 N peak force, the silastic prostheses were found to perform poorly in the simulator, ultimately failing due to a combination of fatigue crack growth and joint collapse. This behaviour and failure mode was consistent with that of ex vivo origin silastic MTP prostheses examined and provides confidence in the validity of the simulator.
The study of the 184 osteotomies performed (of which 177 Weil osteotomies), made use of clinical, and radiological computerised analysis.
We have noted a significant relationship between the preoperative (in-)stability and the risk of developing transfert metatarsalgia (p-value = 0.03). A metatarso-phalangeal articulation, unstable in the preop setting, has 0.36 times less the risk of leading to this complication than if the operation was performed on a stable articulation preoperatively. A stable articulation would so be an indirect sign of a good tolerance by the adjacent rays.
The clinical examination stays the most essential element. Only the preoperatively symptomatic and unstable metatarsals should probably undergo this osteotomy.
This study aims to assess prospectively whether measurement of peripoperative Troponin T is a useful predictor of potential morbidity and mortality in patients undergoing surgery for fractured neck of femur.
All patients aged 65 years and over presenting with a fractured neck of femur over a 4-month period were initially included. Exclusion criteria were renal failure, polymyositis and conservative fracture management. Troponin T levels were measured on admission, day 1 and 2 post surgery. According to local protocol, a level of > 0.03ng/mL was considered to be raised. Outcome measures adverse were cardiorespiratory events (myocardial infarction, congestive cardiac failure, unstable angina, major arrhythmias requiring treatment and pulmonary embolism), death and length of inpatient stay.
108 patients were recruited after application of the exclusion criteria. 42 (38.9%) showed a rise in Troponin T > 0.03ng/mL in at least one sample. Of these, 25 (59.5%) sustained at least outcome complication, as opposed to 7 (10.6%) from the group with no Troponin T rise (p< 0.001). The mean length of stay was 25.7 days for patients with elevated Troponin T levels, compared with 18.3 days in the normal group (p< 0.012). There were 9 deaths in the raised Troponin group (21.4%), versus 5 (10.6%) in the group with no rise (p< 0.05).
The principle causes of early death after hip fracture surgery are cardiac failure and myocardial infarction. Troponin T is a sensitive enzymatic marker of myocardial injury. The association between raised Troponin and hip fractures has not previously been made. In our series, 38.9% showed a perioperative Troponin rise. This was significantly associated with increased morbidity, mortality and longer hospitalisation. Many hip fracture patients appear to be having silent cardiorespiratory events, contributing significantly to perioperative morbidity. We recommend measurement of Troponin levels in all such patients to identify this risk and initiate appropriate treatment.
Intracapsular dislocated fractures: Screw fixation was used in 48 % of the hips while 46 % of the hips were operated with a hemiarthroplasty, and 4.1 % were operated with a THR. We could not find any difference in mortality between screw fixated patients and patients operated with a hemiarthroplasty.
Does your trust/department have a policy on discontinuing clopidogrel in patients who are due to have emergency trauma surgery such as operative fixation for femoral neck fractures? If yes: how many days prior to surgery is the clopidogrel discontinued? If no: are any precautions undertaken? Clotting function checked: Platelet cover/other blood products: Increased X matching of packed red cells: Other precautions? Any complications as a result of clopidogrel?
As a busy regional Trauma and Orthopaedics Unit of a District General Hospital we are increasingly affected by economic agendas and have noted an increase in the presenting frailty of our fracture hip patients.
Our practice has already changed by the use of an Orthogeriatrics Team (OGT): optimising patient status pre-operatively and ensuring maximum post-operatively continuity. The OGT has significantly reduced time to theatre. With appropriate investigation and lower complication rates it will offset the cost of the team.
We wanted to see if the care of fractured hip patients could be further focused.
On this basis, a four-part clinical stratification system was devised for patients undergoing fractured hip repair:
Complex 0 (C0): Hip repair of a non-complex fracture pattern in an otherwise fit, healthy patient. Complex I (CI): A fit, healthy patient with a complex hip fracture pattern. Complex II (CII): Medically unfit patient with a non-complex hip fracture. Complex III (CIII): Medically unfit patient with a complex hip fracture.
Patients were grouped accordingly and age, length of stay, time to theatre and reason for delay, mental state examination score (MSE) on admission, and number of co-morbidities were also recorded.
Chi-square was performed on co-morbidity, MSE and theatre times with AVOVA used for age and length of stay data.
Two fold increase in stay (2004 paired classes C0+I vs CII+III; P< 0.003).
Chance of more than 2 co-morbidities (C0+I vs CII+III): 52% vs 96% (2004) and 56% vs 92% (2005).
MSE with a positive dementia score: 26% vs 82% (2004; P0.001) and 39% vs 70% (2005; P< 0.05).
Time delays to theatre greater than 24hrs were seen 24% vs 92% (P< 0.001) in 2005. The correlating values in 2004 were 63% vs 87%.
Active treatment delaying theatre in the C0+I group 24% vs 57% (CII+III) in 2004 and 0% vs 78% 2005 (P< 0.001).
Stratifying patients for pre- and postoperative planning, risk counselling, and surgeon selection can identify patient groups likely to incur greater cost during their treatment.
The classifications are easily reproducible and can be applied to larger patient groups via institutional or national joint registries.
In order to define the optimum timing of surgery for a hip fracture, we undertook a systematic review of all previously published studies on this topic. Data from the retrieved studies was extracted by two independent reviews and the methodology of each study assessed. In total, 43 studies involving 265137 patients were identified. Outcomes considered were mortality, post-operative complications, length of hospital stay and return of patients back home.
There were no randomised trials on this topic. Six studies of 8535 patients have the most appropriate methodology, which was prospective collection of data with adjustment for confounding variables. These studies found no effect on mortality for any delays in surgery. One of these studies found fewer complications for those operated on early but this was not found in the other study to report on these outcomes. Two of these studies reported on hospital stay, which was reduced for those operated on early. Six studies of 229418 patients were retrospective reviews of patient administration databases with an attempt at adjusting for confounding factors. They reported a reduce mortality, hospital stay and complications for those operated on early. Thirty-one other studies of variable methodology reported similar findings of reduced complications with early surgery apart from one study of 399 patients, which reported an increased mortality and morbidity for those operated on within 24 hours of admission.
In conclusion those studies with more careful methodology were less likely to report a beneficial effect of early surgery, particularly in relation to mortality. But early surgery (within 48 hours of admission) does seem to reduce complications such as pressure sores and reduces hospital stay.
A prospective audit was carried out to analyse the relationship between time to surgery, number of co-morbidities and length of stay in 357 consecutive patients operated on for a fractured neck of femur.
One hundred and thirty five patients were operated on within 48 hours (group 1), 129 between 48 and 96 hours (group 2) and 93 patients after 96 hours (group 3). The mean (std dev) age was 77.2 (12.5) years in group 1, 79.8 (9.9) years in group 2 and 79.2 (9.4) in group 3. There were 93 (69%) females in group 1, 99 (77%) in group 2 and 67 (72%) in group 3. The number (%) admitted from home was 85 (63) in group 1, 81 (63) in group 2 and 73 (79) in group 3.
In the 30 patients with no co-morbidities there was a strong relationship between wait for surgery and length of stay. In these patients the median length of stay increased from 8.5 days in group 1 to 21 days when in group 3. In the 187 patients with one or two co-morbidities the relationship was present but weaker. The median length of stay increased from 16 days in group 1 to 21 days when in group 3. In the 140 patients with 3 or more co-morbidities there was no relationship between wait for surgery and length of stay. Median length of stay was 23 days in group 1 and 21 days in group 3.
This data from a large consecutive group of patients suggests that the fit patient with a hip fracture benefits from early surgery with a shorter length of stay. Those with multiple co-morbidities have their length of stay determined by their medical condition.
Several studies have evaluated the association between timing of hip fracture surgery and mortality in elderly patients. The evaluation of functional outcome is lacking.
We studied the effect of delayed surgery on the patient’s ability to return to independent living, the incidence of pressure sore and total length of hospital stay. Days of hospital stay included the post-operative period and the rehabilitation admission in the first 4 months following the operation.
Patients older than 50 years of age, admitted to two major hospitals in Stockholm during one year were included in the study (n = 853). To eliminate the effect of time interval between injury and admission, all patients who arrived to the hospital later than 24 hours of the injury (n=75) were excluded. Patients with pathological fracture (n = 30) were also excluded. The time intervals between hospital admission and the operation were evaluated against the patient post-operative independent living at 4 months follow up.
We divided the patients into two groups depending on delay to surgery. We performed a comparison of those patients who operated within 24 hours with those who hade been operated more than 24 hours after the admission. Moreover we repeated the analysis using 36 and 48 hours cut-off points.
After adjustment for age, ASA, walking ability, living with some one, gender and reason for delay, the late operated groups had a significantly decreased OR for return to independent living at 36 and 48 hours cutoff points (OR 0.5 respectively 0.3) but not at 24 hour cut-off point. The incidence of pressure sore in the late operated groups was significantly increased at all 3 cutoff points after adjustment for age, ASA, walking ability, dementia, and duration of surgery (OR 2.2, 3.4 and 4.2 respectively).
The median length of hospital stay was significantly increased in the late operated groups (14 versus 18 days at 24 hours, 15 versus 19 days at 36 hours, and 15 versus 21 days at 48 hours cut-off point). Linear regression analysis with adjustment for age, ASA, walking ability, dementia, gender and place of residence showed that there was a significant relationship between waiting time for operation (hours) and length of hospital stay (days) (B 0.148, P 0.002). Accordingly for every 6.75 hours delay in surgery, the total hospital stays increased by one day.
Our conclusion is that early operation of patients with hip fracture is associated with a significantly improved ability to return to independent living, a reduced incidence of decubitus ulcers and reduction in the length of hospital stay before the 4-month follow up.
We present the use of the Orthopaedic POSSUM Score and Surgical Risk Score (SRS) to identify optimal time for fracture neck of femur surgery. The objective of this study was to identify the physiological status of patients at admission and compare the results of operative physiological condition and differences in predictive and actual operative outcomes.
1238 consecutive hip fractures from Jan 2005 to July 2006 at 3 hospitals were assessed. Collection of demographic, admission and operative POSSUM, and SRS scores, fracture pathology, physiological status, and postoperative outcome were conducted.
In total, 1031 (83.3%) patients had surgery. The median age was 72.6 (range 55–95, mean 68). Majority had significant systemic multiple co-morbidity (78%), an average ASA score of 3.3. POSSUM predicted 18.7% (n= 194) of death at 30 days, where as the surgical risk score predicted 13.8% (n=142 deaths), the actual mortality was 11.7% (n=120).
The difference between admission and operative physiological POSSUM score increased with operative delay (see table 1). Physiological scores greater than 30 had a 67.8% risk of 30-day mortality. 361 patients had an increase in physiological score from admission to operation, resulting in higher analgesic requirements and reduced mobility scores (P< 0.005). These patients had a 12.6% increase in mortality when compared with patients operated earlier with a similar initial score (P< 0.005). Furthermore delayed surgery (> 48 hours) lead to reduced in return mobility, function, increased wound infections and other medical complications.
Possum and SRS over predict operative mortality, but are useful in prioritising their time of surgery. Declining operative physiological POSSUM scores indicate room for improvement in preoperative care, and for specific protocols if surgery has to be delayed to prevent further physiological deterioration, and induce optimal functional outcomes.
Discussion: We are a busy District General Hospital in Scotland and hemiarthroplasty for # ICNOF is one of the routinely performed surgeries with more than 100 patients undergoing this procedure in a year. We have a dedicated Hip audit nurse who is responsible for maintaining a database for all these patients.
With increasing age of the population, # ICNOF in over 80s has evolved into a commonly encountered problem. Early mobilisation and aiming for pre injury functional status is an achievable goal in most. ‘The better they walked before, the better they will walk after’ is the golden rule to predict outcome. We use uncemented Austin Moore prosthesis for all patients but prefer to use a bipolar uncemented HAP coated prosthesis (JRI Furlong prosthesis) for patients who are relatively active and independent, regardless their age. The early results in this second group of patients are predictably better, but it will require further detailed study to determine whether these hold true in long term as well.
In the recent years, the concept of minimally invasive surgery has invaded the orthopaedic field and literature on the subject is spawning. Mini-incision surgery for total hip arthroplasty has been studied without a clear consensus on the efficacy, safety and advantage of that innovative technique. To our knowledge, the efficacy and safety of mini-incisions in hip fracture surgery has not been studied.
This study is a prospective clinical randomized trial which primary objective was to demonstrate the safety and efficacy of a single posterior mini-incision approach compared to a standard posterior approach for hemiarthroplasty in acute femoral neck fractures. The mini-incision was defined as less than 8 cm. To date, 45 patients have been randomized between the two surgery groups has follows: 22 patients in the mini-incision surgery group (MIS) and 23 patients in the standard incision group (STD). Data were collected preoperatively as well as 4 days, 3 and 6 weeks, 3, 6, 12, and 24 months postoperatively. The following validated disease-specific outcome instruments where used: the Jaglal Lower Extremity Measurement (LEM) and the Time Up and Go (TUG). Secondary endpoints of pain, function, and quality of life where assessed by the components of the Harris hip Score and SF-36. Radiograghic outcomes where also evaluated as well as the rates of all reported complications and adverse events during the two years follow-up.
The demographic data where similar between the 2 groups for age, gender, weight, type of anaesthesia used, pre-operative haemoglobin and preoperative comorbidities. There was no significant difference for operative time, blood losses, 72h postoperative haemoglobin and the need for transfusion therapy between the 2 groups. Also, there was no difference between the groups for post-operative morphine use and pain evaluation with the Visual Analog Scale. The functional assessment using the LEM, TUG, Harris Hip score and SF-36 scores did not demonstrate any statistically significant difference between mini and standard incision.
This study demonstrates that the clinical and functional outcomes measured are similar between the two groups, thus limiting the potential benefits of MIS in hip fracture patients.
1133 patients with an intracapsular fractures of femoral neck treated by internal fixation were prospectively studied. All surviving patients were followed up for a minimum of one year from injury. The overall incidence of non-union was 229(20.2%) and the incidence of avascular necrosis was 61(5.4%). Fracture non-union was less common for undisplaced fracture in comparison to displaced fractures [48 out of 565(8.5%) versus 181 out of 568(31.9%)] and in males than females [45 out of 271(16.6%) versus 184 out of 862(21.3%)]. The incidence of non-union progressively increased with age from one out of 17(5.9%) in those aged below 40 years to 84 out of 337(24.9%) in those in their seventies. For those in their eighties the incidence of non-union began to fall, but if those patients who died within one year from injury were excluded, then the incidence was found to continue to increase. For avascular necrosis there was a falling incidence with age from 9 out of 68(13.2%) in those aged less than 50 years to 10 out of 388(2.6%) in those aged over 80 years.
The information from this large series of patients treated by contemporary methods enables to surgeon to use the three factors of age, sex and present of fracture displacement to predict the risk of non-union or avascular necrosis occurring.
Impaction grafting with morsellised allograft is becoming the treatment of choice for revision arthroplasty, especially in the younger patient. The optimum treatment of the graft prior to impaction has not been determined. Some groups wash the graft prior to impaction and others do not. Washing of graft has been shown to enhance bone ingrowth in an animal model, however the reasons for this remain unclear. The aim of this study was to identify any underlying cellular cytotoxicty of fresh frozen allograft bone before and after washing.
Paired samples of washed and unwashed morcellised FFH allograft were taken during revision hip arthroplasties. Washing was performed by 4 consecutive rinses in 300ml warmed saline, the bone being filtered between each exchange of saline. Contact cytotoxicity assays involved culture of cell lines in direct contact with bone samples. Quantitative cytotoxicity assays utilised culture media conditioned with the bone samples and subsequent assessment of cell metabolism and viability using both dimethylthiazol (MTT) and neutral red (NR) assays. Assays were performed with human osteoblastic (MG63) and fibroblastic (HSF) cell lines.
Nine pairs of samples were analysed. Contact assays demonstrated a clear zone of cellular inhibition around the unwashed bone samples. Quantitative assays were performed in triplicate for each cell type and both MTT and NR assays giving 108 paired assay results. 88.9% of pairs (92/108) showed cytotoxicity in the unwashed sample. No washed samples demonstrated cytotoxicity. When grouped by assay and cell type, analysis of means showed statistically significant differences between washed and unwashed samples in MG63-NR (p=0.0025), HSF-NR (p=0.0004) and MG63-MTT (p=0.008). The difference observed in the HSF-MTT assays did not reach statistical significance (p=0.06).
Unwashed FFH allograft can be cytotoxic to human osteoblastic and fibroblastic cell lines in vitro. This suggests that allograft should be washed prior to impaction in order to optimise the biological compatibility.
Bone stock loss is a major challenge to the revision hip surgeon. Impaction grafting is frequently the preferred option for the surgeon when faced with bone stock deficiency. This retrospective study assesses a consecutive series of patients who underwent revision hip replacement with femoral impaction grafting during the period 1994–2001. Radiographic measurement for stem subsidence was carried out by 2 independent observers on pre-operative and post-operative radiographs at 6 months, 1 year, 18 months and 2 years following surgery. Graft incorporation and trabecular remodelling were also subjectively assessed. Irradiated bone allograft was used in all cases.
Sixty-nine hips were reviewed. Radiographic analysis revealed graft incorporation in 38% of cases. However, there was no evidence of trabecular remodelling. Moderate subsidence (5–10 mm) occurred in 10 cases (14.5%), and massive subsidence (> 10 mm) occurred in 5 cases (7.2%). The survivorship with re-revision or need for further surgery as the end point was 92.8% at an average of 28 months.
The results obtained in this study are less favourable than other reported studies of revision of the femoral stem using impaction bone grafting. The absence of the characteristic changes of graft remodelling reported in other series raises concerns that irradiated bone graft may be a significant factor in the post-operative progress.
Fixation of extracapsular proximal femoral fractures with intra/extramedullary device is common operation in any trauma theatre. We audited our results of fixation of 307 similar fractures over the period of Feb’03 to Jan’06. Final analysis was on 252 cases (191 female and 61 male) with mean age of 86.7 years. The fractures were classified by AO classification (A1=116, A2=84, A3=52) and the implants used were DHS (204 cases) and Gamma nail (52 cases). Fixation failure was noted in 38 cases (15.07% failure rate). Failure incidence was higher in female patients and unstable fractures (A3). There was no difference in failure rate of DHS or Gamma nail fixation. The reasons identified for failures were inappropriate implant selection, inadequate reduction (p< 0.007), poor implant placement (screw head in anterior/superior quadrant p< 0.0029, TAD> 25mm p< 0.0037, oblique placement in relation to neck axis in lateral view). Multivariate logistic regression was used to identify the effect of each individual contributing factor. More than one factor was identified in all cases of failure. Out of 38 failures 3 patients died within 6 weeks after primary surgery, conservative treatment was done in 7 cases due to co-morbid conditions, 13 cases were treated by revised fixation, and 15 cases arthroplasty was carried out. The outcome after the second surgery was no different in revision fixation or arthroplasty. We conclude that failure of fixation of these fractures are serious event with disastrous consequences, so every effort should be made to produce a stable construct with any device during primary fixation.
These results provide a biochemical insight into the bone formation and bone resorption processes during allograft incorporation.
Introduction: Revision arthroplasty using the impaction grafting technique is an increasingly popular technique. The lost bone stock is replaced rather than substituted with ever increasing amounts of metal. There have been many advances in the understanding of this technique in recent years. It has recently been shown that washing of the graft improves the biomechanical strength, bony ingrowth and biocompatibility of morsellised allograft bone. The aim of this study was to identify the most efficacious method of washing morsellised allograft in the operating room.
Containment of bone defects is one of the main requisites for using the bone impaction grafting technique. When the proximal femur is absent, circumferential meshes in combination with impacted bone allografts and long stems could be an alternative method. However, the initial stability of this femoral stems has not been evaluated and we were not able to find any series in the literature that includes a group of patients treated with this method.
This study has two purposes: one is to analyze the initial resistance in vitro to axial and rotational forces of a fresh frozen bovine model with a complete loss of the proximal femur reconstructed with a circumferential metal mesh containing impacted bone allografts and a long polished cemented stem. The second is to present the short-term clinical and radiographic evaluation in a group of patients with massive bone loss of the proximal femur that were reconstructed with this method.
Four femurs with an 8 cm proximal bone defect were reconstructed with a circumferential metal mesh, impacted bone grafts and a cemented long stem (group 1). Results were compared with 4 cases presenting an intact proximal femur in which the same stem was implanted (group 2).
Thirteen patients with complete massive proximal femoral bone defects (average 12 cm long) were reconstructed with a circumferential metal mesh, impacted bone allografts and a long cemented stem (average 217 cm long).
Failure mode was characterized by subsidence under axial load in group one at 617 kg and by periprosthetic fracture in control group at 1335 kg. Under rotational load, group 1 femurs failed at the cement interface at an average of 79 kg and the intact femurs presented a fracture at an average of 260 kg.
At 25 months follow-up, 6 patients had to be reoperated. We observed 2 fractures of the metal mesh at 31 and 48 months in cases reconstructed with a Charnley stem that did not by pass the mesh. Three patients presented one dislocation that needed open reduction in 2 cases. Two acute deep infections were treated with debridement, antibiotics and component retention.
This model presented a 50% resistance to axial load and 30% resistance to rotational load compared to an intact femur with the same implant. However, this resistance is by far higher than the physiologic load occurring in a normal femur during gait.
Although the incidence of complications in this patients was high, this was related to the complexity of the cases. Failures of the system were not observed except in the 2 cases presenting technical defects.
This experimental initial stability and early clinical as well as radiographic results encourage the use of circumferential meshes to contain impacted bone allografts combined with long cemented stems in complex revision hip surgery.
We have explored indentation-type scanning force microscopy (IT SFM) that allows for a direct, quantitative inspection of cartilage morphology and biomechanical properties from the millimeter to the nanometer scale ex vivo, and ultimately, in situ (
We employed IT SFM for quality control of engineered cartilage cultured under various conditions. These measurements harbor the prospect to optimize and yield engineered cartilage that exhibits long-term mechanical stability, functionality and biocompatibility for joint arthroplasty. For a more rational understanding of cartilage biology and pathology, we have recently investigated the articular cartilage of mice lacking the β1-integrin in chondrocytes. The β1-integrin gene knock-out mice differed only in stiffness when measured at the nanometer scale, i.e., exhibiting a softer extracellular matrix compared to their wild-type controls. We inspected the changes of aging articular cartilage by employing a mouse model.
Accordingly, the stiffness of the aging cartilage increased concomitant with a decrease of its glycosaminoclycan (GAG) moiety. Frequently, aging articular cartilage takes a pathological turn called osteoarthritis (OA), which usually ends with a complete disappearance of the articular cartilage layer. Towards an early detection of OA in the human body, we inspected the morphological and biomechanical status of articular cartilage biopsies representing different grades of OA according to the ‘Outerbridge scale’. Most significantly, the early changes (grades 0 to 2) were only detectable at the nanometer scale, but not at the micrometer or millimeter scale. Based on such ex vivo indentation testing, we started to move from the bench to the patient, aiming to directly inspect the quality of human articular knee cartilage by an arthroscopic SFM (
In order to avoid recurrence of haemarthrosis in haemophilia, we must act on the syniovium membrane either resecting it (synovectomy) or fibrosing it (synoviorthesis). The intrarticular injection of Rifampicine (r) was introduce by us. Technique consists 250 mgrs. of Rifampicine injected intrarticularly in elbows and ankles and 500 mgrs. in knees with 3 to 10 cc of Lidocaine, depending on the joint size, once a week during five to seven weeks. Patients were only covered with antihaemophilic factor the day of the injection 30% above coagulation level. The evaluation was made by means of a double scale of grading. Subjective, given by the patient and objective by the examiner. Thus, objectively the grading was : EXCELLENT: “Dry joint”, recuperation of function. No haemarthrosis. No synovitis. GOOD: Clinical improvement. Synovitis. Diminution of haemarthrosis. Recuperation of function. FAIR: Synovitis. Diminution of haemarthrosis. No recuperation of function. BAD Synovitis. Recurrence of haemarthrosis. And subjectively the patient graded the results from his point of view from 1 BAD to 10 Excellent. 1,2,3 bad; 4,5,6 fair; 7 and 8 good and 9 and 10 excellent. We report on 38 patients with 39 joints with more that 3 years follow up, mean 1.8 years. on 22 knees, 9 elbows and 8 ankles with subjective excellent results in 21 joints (11 knees, 6 elbows and 4 ankles) good in 15 joints (8 knees, 3 elbows and 4 ankles), fair in 2 knees and bad in 1 knee. Objective results obtained were excellent in 20 joints (11 knees, 6 elbows and 3 ankles); good in 17 (9 knees, 3 elbows and 5 ankles); fair in 1 knee and bad in 1 knee. Since september 2000 we have been usisng OXITET-RACICLINE CLORHYDRATE named EMICINA(r) from PFIZER, comes in bottles with 20 and 100 cc of solution with a dose of 50 mg’s of active material per cc. of product. The dosage developed by us is in knees 4cc. (200mg) plus 6 cc anesthetic and for ankles 1 cc Emicina (50mg plus 1 cc anesthetic) once a week fot 3 weeks. Our experience consists in 43 joints, 21 knees 14 elbows and 8 ankles. All joints Stage I or II of our classification. Evaluation was made according to objective and subjective scale: Pain from 0 (no pain) to 10 (pain requiring medication), Range of Movement: No movement (0) to complete range of movement 10, use of limb from 0 (impossibility to weight bear) to 10 normal use in daily activities. Objective evaluation was made by measuring ROM and diameter of joint. All cases had very satisfactory results with diminution of swelling, absence of haemarthrosis and improvement of ROM and activity of daily life. Subjewctively pain diminished a mean 0.5 (Liker), movility improved 9.0 mean, and the use improved a mean of 9.3. Objectively the mean joint diameter diminished from 31.5 cmts to 30.2 cmts and ROM improved from 102.4 and 158.8 degrees pre to 112.2 and 166.7 post.
The dorsal capsule of the knee joint was opened and the meniscus were mobilised in a way that the pressure foils (Fuji typ super low) could be placed between the undersurface of the meniscus and the tibia plateau in each joint compartment. The measurements were recorded in four different joint positions (0°, 30°, 60° flexion and 0° with removed meniscus).
Each anatomical model was well fixed in a universal testing machine” (Instron, System ID: 5565 H1703). The used axial pressure in all set ups used was 1500N.
We used 4 four different test series:
no pressure, no orthesis no pressure, with orthesis with pressure, no orthesis with pressure, with orthesis
After removing the pressure foils the actual pressure could be estimated by the diameter of the coloured foil. Using the programm Mortphomet it was possible to calculate these pressure areas and give procentual figures.
Without pressure:
Knee → 64,37 % Knee → 55,30 % Knee → 54,43 % Knee → 58,75 % Knee → 44,80 %
Mean value 55%.
With pressure:
Knee → 74,59 % Knee → 74,00 % Knee → 67,91 % Knee → 86,34 % Knee → 49,69 %
mean value 70%.
The Antivalgus Orthesis could reduce the intraarticular joint pressure between 46–74%
Without pressure:
Knee → 79,78 % Knee → 76,22 % Knee → 75,20 % Knee → 62,55 % Knee → 76,49 %
Mean value 74%.
With pressure:
Knee → 42,68 % Knee → 46,24 % Knee → 64,61 % Knee → 40,08 % Knee → 37,20 %
Mean value 46%.
Clinical evaluations show an average score of 78 (acc. to HHS); 82,3 percent of patients are pain free, while slight pain still persists in a 13,7 percent pain in a 3,9 percent.
The radiographic analysis has put into evidence only 1 case of mobilization, and suffering bone in 4 percent of cases; by contrast, 79,5 percent show astonishing endosteal bone formation.
For every case the implants were planned with a total leg x-ray and manufactured (Link). The implants were removed and the knee and hip joint prepared. The approach was performed with two incisions (knee, hip) to reduce the invasivity. The implantation started with the knee implants connected with the intramedullary rod and was finished with the hip implants. Postoperative weight bearing was following pain.
The pain diminuished significant in all patients in the questionnaires and the pain medication could be reduced substantially. All patients gained mobility already three months after the procedure, every patient could walk with crutches. No patients needed to be reoperated in the follow-up period. Every patient could keep the mobility over the the follow-up time. Two patients reported some pain in the knee. Radiologically the defects of the femur were partially consolidated and we could not see further bone loss.
This study describes our experience, comparing peri-operative femoral fractures during stem removal with ETOs in rTHA.
Indication for a TOFEM was fracture in 43%, bone loss in 51% and others in 6 %. Infection occurred at primary intervention in 32%, in connection with revisions in 18% or delayed in 49%.
All of the patients underwent resection the humeral head or retrieval of the arthroplasty with large debridement followed by implantation of an antibiotic impregnated polymethyl methacrylate spacer. After a mean duration of two months of antibiotics and after normalisation of the CRP a delayed reimplantation of a prosthesis was performed in 6 patients. One patient is awaiting arthroplasty, while two patients are satisfied with the functional result obtained with the spacer and do not want further surgery.
20 Vancouver type B periprosthetic femoral fractures were treated in our unit by cementing a revision stem into the pre-existing cement mantle following fracture reduction. The technique was used in elderly, multiply co-morbid patients with the intention of reducing operative time and peri-operative complications.
3 patients died in the first 3 months from reasons not related to surgery, with no recorded evidence of fracture healing and were excluded from the study and 1 was too frail to attend follow up. The remaining 16 cases were followed up for a mean of 3 years. The mean time to radiological union was 5 months (range: 2–11) and the mean time to clinical union was 4.9 months (range: 2–17). The mean Modified Harris Hip Score in these patients was 66.5 (range: 35.2–97). One patient had further surgery for a delayed union and there was one failure of fixation. The mean hospital stay was 10.8 days and the mean time to fully weight bear 38.1 days.
This study suggests that there is a valid role for the use of the in-cement revision technique in Vancouver type B periprosthetic femoral fractures in a highly selected group of elderly patients unsuitable for lengthy reconstructive procedure
Acute periprosthetic infection, acute and chronic course of the infection with unknown spectrum of organism, hardly to treat and loss of mobility due to long lasting immobilization after implant removal are the indications for this special design of a spacer. The management of a bacterial periprosthetic infection by two-stage reimplantation using an implanted applicationspacer for antibiotics maintains mobility and soft tissue balance and ensures simultaneous local delivery of antibiotics.
After a complete synovectomy the implant components and all foreign material are removed. 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. After the applicationspacer for antibioticss has been implanted, the wound is closed.
Daily parenteral doses of antibiotics are delivered through the percutaneous silicone catheters directly into the intramedullary canal at the site of the infection. The applicationspacer 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. The implant beds are debrided to remove the synovial tissue that has developed in the interim. Then the revision implants can be placed in the prepared bone because the same templates are used for both the applicationspacer for antibioticss and the revision implants.
36 patients have been treated with this method since 1993. Two-stage reimplantation of a total knee was performed in 27 cases.. The longest postoperative follow-up period is now 12 years. Till now, no revision surgery has been required on a joint treated in this manner, and no periprosthetic 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 7,1 years. In the hip, values of 10/0/110 degrees were achieved after an average of 7,3 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 aim of this prospective study was to assess safety and effectiveness of Spacer-K, a pre-formed articulating spacer made of gentamicin-impregnated acrylic bone cement. used in two-stage exchange technique for the infected total knee arthroplasty.
32 consecutive patients infected total knee arthroplasty were operated on in two centres. Infection was caused by Coagulase neg. Staphylococcus (21), Staphylococcus aureus (4), and others (4). In 3 case microorganisms were not identified. The mean implantation time of the spacer was 11 weeks (range, 7 to 28 weeks). The rehabilitation program between stages consisted in early range of motion exercises and partial weight-bearing. In one patient removal of the spacer and insertion of a molded cement block with vancomycin was necessary because of insurgence of methicillin-resistant Staphylococcus aureus.
The mean follow-up of 32 knees after removal of the spacer and insertion of the new prosthesis was 40 months (range, 24 to 75 months. The mean Knee Society functional score during spacer management was rated 75 points (range, 41 to 91 points) and was rated 87 points (range, 77 to 97 points) at latest follow-up. Preoperative range of motion improved markedly after removal of the infected prosthesis and insertion of the spacer. Neither breakage nor clinically relevant surface wear were detected. No implant-related complications were observed. Bone stock remained unchanged during the whole management process.
The Spacer-K is safe and effective for the management of the infected total knee arthroplasty.
The treatment protocol consisted of a two stage exchange with removal of infected components via a posterior approach incorporating an extended trochanteric osteotomy, insertion of an interim antibiotic eluting cement spacer and re-implantation of an extensively coated uncemented prosthesis on the femoral side. Systemic antibiotic treatment following each stage consisted of an abridged course of 5 days post operative intravenous administration followed by complete cessation of anti-microbial therapy. The mean interval between implant removal and re-implantation was 111 days.
The mean follow up was 5 years. Patients with rheumatic disease, tumors or patients under immunosuppressive therapy were excluded. Infectious disease consultants supervised the administration of intravenous antibiotics. No antibiotics were added to the irrigating solution.
The objective of the present study was to assess the efficacy and tolerability of antibiotic prophylaxis for THR at S. Corona Hospital Pietra Ligure SV (Italy).
In our hospital the majority of prostethic device infections are due to MRSA, but recently we have described increment of infection due to Pseudomonas spp and other gram-. For this reason we used association of vancomycin plus pefloxacin in primary prophylaxis.
Even though the operations are largely successful, complications after joint replacement surgery occur frequently. Approximately 10% of lower limb arthroplasties need surgical revision, of which 70% are due to loosening. The purpose of this study was to assess the feasibility of 18-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) in detecting septic and aseptic endoprosthetic loosening of hip and knee endoprostheses.
The sensitivity/specificity for infectious loosening in hip replacement arthroplasties was 67%/83%, in the knee 14%/89%.
using a questionnaire to investigate course of disease and health-related quality of life (VAS). 7 patients were treated with and 17 patients without additional application of antibiotics penetrating bacterial biofilms.
In the group of patients treated with additional application of antibiotics penetrating bacterial biofilms 6 of 7 (86%) implants were salvaged and reduced number of revison surgery was needed.
Due to the fact that revision arthroplasty is often associated with limited function after infection of total knee joint, retention of the implant has to be considered a therapeutic alternative in early infection.
Pain – visual analogue scale (VAS) (0 = no pain, 10 = worst pain ever). Overall function – patients’ perception – VAS (0 = no function, 100 = full function). Objective: Strength – grip and pinch – measured objectively as a percentage of the uninjured side. Range of Motion – Flexion, extension, pronation and supination – measured objectively as percentages of the uninjured side.
For the purpose of this analysis, the fractures were divided into intra- and extra-articular fracture patterns based on the initial pre-operative X-rays.
Subjectively 75% of patients had an excellent result with a pain VAS score of 0–1/10 (mean 0.9 for extra-articular and 1.2 for intra-articular) and an overall function VAS score of 9–10/10 (mean 92% for extra-articular and 86% for intra-articular).
Objective outcome measures were also very good. The results for the extra-articular group showed a mean grip strength of 85%, a mean pinch grip of 91%, a mean flexion of 82%, a mean extension of 88%, a mean pronation of 98% and a mean supination of 98%. The results for intra-articular fractures showed a mean grip strength of 80%, a mean pinch grip of 88%, a mean flexion of 78%, a mean extension of 83%, a mean pronation of 94% and a mean supination of 93%.
This study confirmed excellent functional results comparable with other methods of fixation for extra-articular fractures, but it also showed good results with the more complex intra-articular fractures.
The aim of this study was to find out whether distal radius fractures treated by K wire fixation loose reduction after wire removal and analyze the variables may influence this. Patients who underwent K wire fixation for unstable fractures of distal radius over a period of 3 years were included in this retrospective study. Fractures were classified according to AO classification. Radiographs taken just prior to removal of K wires and radiographs taken at least 1 month after wire removal were analyzed to study three radiological parameters; Palmar or dorsal tilt, radial inclination and ulnar variance. Loss of these angles was analyzed statistically against variables like age, sex, AO classification, type of K wires used, delay in fixation and duration of fixation. 59 fractures were analyzed with mean age of 56 years and male to female ratio of 1:2. Average loss of radial tilt was 2.6 deg, loss of palmar tilt was 2.6 deg and loss of ulnar variance was 1.3 mm. We found that distal radius fractures treated by percutaneous K wire fixation, do not suffer significant loss of reduction of fracture position after removal of wires. This remains true regardless of age, sex, fracture type according to AO type, type of wires used, delay in fixation or duration of wire fixation.
1) A quantification of the fixation spot : If the spot is two times more important on the injuried wrist (than controlateral side) the fracture is sure. 2) If you combine plain Xrays of the the wrist with scintigraphy the fracture is automatically located. This previous report pointed that repeat set of scaphoid views, dynamic and static, Ct scan, proved unsuitable for screening occult fractures of the wrist.
Wrist malalignment, in cases of malunited fractures of the distal radius, is not always a consequence of adaptation of the wrist to new conditions, but an expression of non-diagnosed ligamentous injuries. The aim of our study is to examine if the wrist malalignment is correctable with radius osteotomy.
Twenty nine patients (17 female, 12 male) of mean age 51 years, with symptomatic malunited fracture of the distal radius with dorsal angulation, of duration 3 months -47 years, were examined. Twenty seven patients underwent corrective radius osteotomy (open dorsally in 26 cases and closed palmarly in 1 case). Fixation material (plate and screws) was placed on the dorsal side in 23 cases and on the volar side in 4 cases. In all patients measurements on the lateral X-ray view, concerning the reversal of the normal palmar tilt of the radius, the radiolunate and lunocapitate angles, were performed before and after surgery. Based on those measurements patients were divided in two groups:
a) In group A (23 patients) the malalignment concerned the midcarpal joint, and b) In group B (6 patients) the malalignment concerned the radiocarpal joint.
The radiographic element of evaluation was the radiolunate angle. Radiolunate angle greater than 25° indicated malalignment at the radiocarpal level while radiolunate angle less than 25° indicated malalignment at the mid-carpal level. In 5 patients post-operative measurements were not performed because in addition to the radial osteotomy they were subjected to operative correction of wrist malalignment.
Results estimated immediately postoperative and at the final follow-up, 6 months later. In patients with midcarpal malalignment, correction was possible, under the condition of a sufficient radius osteotomy and a non fixed midcarpal deformity. In patients with radiocarpal malalignment the deformity persisted despite the correction of the radial osteotomy.
We conclude that correction of wrist malalignment is not always achieved with corrective osteotomy of the radius and that preoperative radiological control may be indicative of the possibility of correcting the deformity.
Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork.
Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0–5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54–8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1–16.1mm).
Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0–3.9mm), with a mean lunate ratio of 1.13 (0.61–2.74). These measurements correlated well with measurements of dorsal tilt and displacement.
Distal biceps tendon ruptures are uncommon with a reported incidence of 1.24 per 100,000 per year.
They typically occur in males in the fourth decade.
Operative treatment has been shown to improve functional outcomes in the treatment of distal biceps tendon ruptures. A variety of surgical techniques have been described, usually using the dual incision Boyd-Anderson approach.
We report a series of 10 patients with 10 tendon ruptures treated using a single incision volar approach and using the Arthrex Biotenodesis screw to reattach the tendon to the radial tuberosity.
This method has been previously described in only one case report.
All ten patients underwent clinical assessment using the Mayo Elbow Performance Score (MEPS) and functional assessment using the DASH scoring system. The power was assessed isokinetically using the Nottingham Myometer.
Based on the MEPS and DASH grading system all patients achieved a good or excellent result.
In our experience reattachment of the distal biceps tendon using a single incision approach and Arthrex Biotenodesis screw is a new technique which gives a good functional outcome.
Biomechanical testing was performed with a Zwig tensinometer using a one neuton preload and a distraction rate of 20mm/min. Bulking was measured with a digital micrometer and each repair group was tested for mean load to repair failure and mean load to 2mm gap formation. In each case the mechanism of failure was recorded.
The Synthes scaphoid screw is a cannulated headed screw, which provides superior compression compared with some other devices used to internally fix scaphoid non-unions.
The purpose of this study is to examine the efficacy of internal fixation using Kirschner wires, applied open or closed, treating metacarpal and phalangeal fractures.
The wires were removed after 4 weeks and patients underwent physiotherapy for 2 to 4 weeks. The follow-up period was 3 – 15 mos (average 12 mos) and total range of movement and function of the injured hand was evaluated.
One case of infection, complicating a metacarpal fracture and well responding to antibiotic treatment, was recorded. Three further infections resulted after neglected intraarticular fractures, all of which underwent arthrodesis. No rotational deformities were observed. There was no mechanical failure of the fixation in any case.
The aim of this study was to assess the outcome of a pre-contoured anatomic plate in the treatment of midshaft clavicle fractures.
We treated thirty patients consecutively for middle third clavicle fractures between March 2001 to March 2006. Surgery was performed for acute fractures, non-unions and malunions by a senior surgeon.
Fifteen patients were treated by open reduction and internal fixation with a precontoured small fragment clavicle plate (mean age of thirty-eight years).
Our control group consisted of a consecutive series of fifteen patients treated by internal fixation with conventional plates (mean age of forty-one years). Ten patients had fixation of their clavicles with a reconstruction plate whilst five patients had fixation with a dynamic compression plate (DCP).
Outcomes assessed for both groups were; complications, need for removal of plate, post-operative outcome, and time to union.
All patients were followed up for an average of eighteen months (range eight to thirty months). In the pre-contoured plate group none required removal of hardware. Five patients had complications. Three of these patients complained of numbness around the caudal aspect of the wound which subsequently resolved within six to eight weeks of the operation. The remaining two patients suffered from adhesive capsulitis postoperatively. Their symptoms resolved completely after four months. All patients regained full range of motion. All patients went on to clinical and radiological union with average time to union being 4.7 months (range three to ten months).
In the conventional plate group, nine patients required removal of their plate. Average time to removal of plate from index operation was 7.7 months (range four to thirteen months). Of the nine plate removals there were two plate breakages, five removals for local soft tissue irritation and two persistent painful non-unions. Three patients required subsequent re-plating for non-unions. All fractures united in this group with mean time to union of 5.4 months (range 2 to 14 months).
A pre-contoured clavicle plate provides rigid fixation without compromising plate stiffness and fatigue strength. We have successfully treated patients with acute fractures, nonunions and malunions of midshaft clavicle fractures, where there was gross distortion of normal anatomy. None of our patients required the removal of their plates (minimum follow-up of 8 months). We have also found these plates to be a valuable anatomical template when reconstructing a malunion, nonunion or highly comminuted fracture.
In conclusion, this is the first reported series demonstrating the use of anatomical pre-contoured plates for clavicle fractures. They can reduce time spent on intra-operative contouring, are low-profile and thus far, plate removal has not been necessary.
The standard of treatment for most fractures of distal radius remains closed reduction and immobilization. It is essential to discern which fracture patterns are more susceptible to failure so that surgical intervention can be considered when an acceptable reduction cannot be achieved or has a risk of secondary displacement. A correlation between the severity of the primary displacement, carpal malalignment & an expectant loss of reduction over a given time period when treating distal radius fractures with cast immobilization is reported. Recently, studies have attempted to classify carpal malalignments associated with displaced distal radial fractures based on Effective radio-lunate flexion (ERLF) into: midcarpal with ERLF < 25 and radio-carpal malalignment with ERLF > 25.
The aim of this study was to assess the frequency of carpal instability as a concomitant lesion to fractures of the distal radius, delineate further various factors including associated carpal malalignment based on ERLF that are predictive of instability based on a timeline of early (I week) and late failure (six weeks). Radiographic alignment parameters were compared using paired t-tests and then also analysed in a multiple logistic regression analysis. There was a significant improvement in all the parameters measured (p< 0.01) with mean correction falling within acceptable limits. Early failure group: Regression analysis showed high correlation between the severity of axial shortening before reduction and at six weeks. Age, gender, presence of dorsal comminution and ulnar styloid fracture, initial dorsal angulation and flattening of radial angle were unreliable in predicting early failure at one week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) at one week when analysed independently or in combination(p< 0.01). In the late failure group:Radial shortening, dorsal tilt, presence of dorsal comminution & ERLF > 25 to be significant predictors of adverse radiological outcome. Age, Gender, flattening of radial angle, ulnar styloid fracture, for secondary displacement when analyzed independently or in combination were not found to be significant predictors of failure at 6-week. The incidence of failure was significantly correlated to radiocarpal malalignment pattern in post reduction radiographs (ERLF> 25) and at 6weeks when analysed independently or in combination.(p< 0.01) Our study reaffirms the need to attention to initial fracture characteristics and highlights the importance of radiocarpal instability pattern on post reduction radiographs as a predictor of late instability & anticipate the radiological outcome. This would allow the surgeon to inform the patient of chance of success with closed treatment and alternative treatment options.
The aim of this study was to determine the torsional and 4-point bending properties of a midshaft humeral osteotomy reconstructed with either an intramedullary nail or locking plate.
A transverse midshaft osteotomy was created and a spacer ensured a constant 3-mm gap between the bone ends. Reconstruction was performed with either
Trigen humeral nail (Smith &
Nephew, TN) – 10 specimens Humeral locking plate (Synthes, PA) – 9 specimens
Non-destructive 4-point bending was repeated, and then each humerus was embedded in a low-melting point alloy proximally and distally for torsional testing. Torque was applied at 5 deg/min until failure. Maximum torque, maximum angle and stiffness were calculated.
All data were analysed with SPSS for Windows (SPSS Inc., Il) using ANOVA.
4-point bending: the bones reconstructed with the intramedullary nail were ~50% as stiff as the intact state in both planes. There was no statistically significant difference in stiffness between the intact bones and those reconstructed with the locking plate.
Torsional testing: the locking plate specimens were 3 times as stiff as the intramedullary nail specimens (P< 0.05) and failed at twice the torque (P< 0.05).
Elbow: excellent 69(92%) vs./52(74.3%), good 6(8%) vs./16(22.8%), poor 0 vs./2(2.9%). Complications noted were iatrogenic nerve palsy 1(1.3%) vs./12(17%), delayed union 5(7%) vs./2(3%), non union 1(1.3%) vs./5(7%), infection 0 vs./1(1.4%), fixation failure 1(1.3%) vs./5(7%) and reosteosynthesis 1(1.3%) vs./1(1.4%), shoulder impingement 8(11%) vs./2(3%).
Early percutaneous pin fixation after closed reduction is the treatment of choice for displaced distal humerus fractures.
Our purpose was to study the outcome of closed reduction and external fixation more than 1 week after injury.
We have achieved a retrospective study in 37 cases of complex radial heads fractures (By Morrey classification). We used the Judet bipolar prosthesis (1996) because it has an integrated articulation that allows an arc of motion of 35°. We revised clinical indication and surgical technique. We analyse clinical and radiographics findings with Bro-berg-Morrey scoring system (1986) for clinical outcome and radiographic Morrey evaluation (1981).
We made a clinical and radiographic control at 1, 3, 6 and every 12 months. We used the Broberg and Morrey scale to value the clinical results; and the radiographic value scale of the same author.
The diagnosis distribution was the following:
16 luxation fracture (Masson type-IV fracture) Monteggia variety posttraumatic stiffness after primary treatment Hotchkiss “terrible triad” associated MCL tears
The clinical results were:
Excellent 21, 6% (8 cases) Good 56, 7% (22 cases) Fair 13, 5% (5 cases) Bad 8% (3 cases)
In summary the floating head prostheses is a useful option in Masson III fracture associated with elbow dislocation with or without associated destabilizing fractures but is not free of complications.
The purpose of this study was to evaluate the long-term results of isolated closed Mason type-II and III fractures treated by internal fixation or by radial head resection.
The patients were submitted to clinical and radiographic evaluation. The subjective outcome was assessed with the DASH questionnaire (Disabilities of Arm-Shoulder-Hand); elbow pain on loading and at rest (VAS scale); and tenderness, loss of strength, and range of motion of the affected elbow. The uninjured arm served as the control. Flexion and extension of the elbow and the wrist, pronation and supination of the forearm, and the angle of the extended/flexed elbow were measured with a goniometer. Grip strength of the hand was evaluated with the Jamar vigorimeter. The radiographic evaluation included antero-posterior and lateral projections of the elbow and antero-posterior of the wrist.
In group 1, the definate average DASH value was 21.26, much higher than the value of 2.81 found in group 2. The VAS average value was also superior in the group 1 (3.87) compared with group 2 (1.2).
We also evaluated, in direct manner, the instability of the injured elbow using the valgus-stress test, which revealed a slight instability (48%) and a moderate instability (35%) of group 1. No instability however was found in group 2.
With regard to radiographic analysis, radiographic signs of arthrosis were present in 90% of patients who had undergone capitellectomy, and in 16% of those who had undergone osteosynthesis.