Receive monthly Table of Contents alerts from Orthopaedic Proceedings
Comprehensive article alerts can be set up and managed through your account settings
View my account settingsThe surgical treatment of a secondary gonarthrosis caused by haemophilic arthropathy needs high quality in soft tissue balancing and accurate alignment in total knee arthroplasty (TKA), which are essential for good long-term results. Due to the early-onset severe arthropathy, haemophiliacs undergo prosthetic surgery at a younger age than general population; therefore to ensure a longer duration of implantation is a major objective to be reached in this setting. As several prospective randomised studies could show, Computer navigation in prosthetic surgery improve precision concerning geometry of axes, resection planes and implant alignment, by the determination of joint centres (actual axis), amount of bone resection, size of prostheses and check of ligament balance. At our department, since January 2006, we implanted four TKA in four patients (age range 45–52 years) affected by severe Haemophilia B; the same surgeon used a single system (Orthopilot system) in all cases.
The quality of implantation was studied on postoperative standardized long leg coronal and lateral x-rays. Our results showed that CAS had greater consistency and accuracy in implant placement. Complications influencing the clinical outcome did not occur. In our experience, drawbacks of the navigation systems are the additional costs and the additional operation time between 15 and 25 min. However, one of the most important advantages of using of this technique in patient affected by coagulation disease, according to the international literature, is the reduction of blood loss after operation. A long-term follow-up of these and of larger samples of patients is needed for testing cost/risk-benefit ratio of Orthopilot in prosthetic surgery of haemophiliacs. Therefore navigated total knee arthroplasty in haemophilic arthropathy is not yet a standard procedure, but this technique could become an important surgical choice in management of severe secondary osteoarthritis in the future.
The aim of this study was to identify what aspects of implant alignment and rotation affect functional outcome after total knee arthroplasty (TKA). 159 TKAs were performed at the Royal Perth Hospital between May 2003 and July 2004. All patients underwent an objective and independent clinical and radiological assessment before and after surgery. A CT scan was performed at six months. The alignment parameters that were measured included: sagital femoral, coronal femoral, rotational femoral, sagital tibial, coronal tibial and femoro-tibial mismatch. The cumulative error score, which represents the sum of the individual errors, was calculated. Functional outcome was measured using the Knee Society Score (KSS).
Good coronal femoral alignment was associated with better function at 1 year (p=0.013). Trends were identified for better function with good sagital and rotational femoral alignment and good sagital and coronal tibial alignment. Patients with a low cumulative error score had a better functional outcome (p=0.015). These patients rehabilitated more quickly and their length of stay in hospital was 2 days shorter.
Vertebral compression fractures can affect both sexes and constitute a major health care problem, due to negative impact on the patient’s function, quality of life and the costs to the health care system. Patients can be treated conservatively or by conventional fluoroscopic assisted vertebroplasty – injection of polymethylmethacrylate PMMA into the fractured vertebral body. Conventional vertebroplasty imposes technical challenges with possible complications including cement extravasations, nerve root compression, the possibility of breaching the walls of the pedicle by the osteoplasty needle and prolonged fluoroscopic radiation exposure of the surgeon and the medical team at large.
We present here a comparative study of 20 cases of thoraco-lumbar vertebral compression fracture, treated with robotic assisted vertebroplasty (research group) versus 30 cases of fractures treated by conventional fluoroscopic vertebroplasty (compared group). All patients were diagnosed as suffering from acute vertebral compression fractures (up to 3 weeks from the traumatic event) and were scored 7 and above in the VAS. The mean overall operation time of the fluoroscopic assisted vertebroplasty was 35 minutes compared to a mean operation time of 45 minutes at the robotic assisted vertebroplasty. There was a significant difference in the fluoroscopic time and subsequent exposure time to radiation between the groups: in the research group we used only an average of 3 seconds of fluoroscopic exposure (an average of 5 fluoroscopic images) compared to an average of 7 seconds of exposure (an average of 12 fluoroscopic images). No difference was found between the groups in regard with overall admission time or with the time between the operation and physiotherapy.
Accuracy of implantation is an accepted prognostic factor for the long term survival of total knee replacement (TKR). The use of navigation demonstrated a significant higher accuracy of implant orientation in comparison to conventional methods. However, these systems are often thought to be technically demanding, to increase operating time and to involve a long learning curve. We performed a prospective, multicenter study to compare the accuracy of implantation of a TKR measured on post-operative X-rays in experienced and less experienced centers.
All centers used the same navigation system (Ortho-Pilot ®, Asculap, Tuttlingen, FRG): 4 had already a significant experience with it (group A – 182 cases), 9 centers were considered as beginners with less than 10 cases performed prior to the study (group B – 221 cases). Accuracy of implantation was measured on post-operative antero-posterior and lateral long leg X-rays with five items: mechanical femoro-tibial angle, coronal orientation of the femoral component, sagittal orientation of the femoral component, coronal orientation of the tibial component, sagittal orientation of the tibial component.
When the measured angle was in the expected range, one point was given. The accuracy note was defined as the sum of all points given for each patient, with a maximum of 5 points (all items fulfilled) and a minimum of 0 point (no item fulfilled). The mean accuracy note was compared in the two groups by a Student t-test at a 0.05 level of significance. Power of the study was 0.80.
There were no significant differences in pre-operative parameters between the two groups, except for the clinical KSS. The mean operative time was significantly longer in group B than in group A (110 minutes vs 90 minutes, p=0.01). However this difference occurred mainly during the first twenty cases in the beginner centres where we observed a clear tendency to achieve the same operative time as the experienced centres at the end of the study. The mean accuracy note was 4.3 ± 0.8 (range, 1 to 5) in the control group and 4.3 ± 0.9 (range, 1 to 5) in the study group (p > 0.05). The power of the study to detect a 0.25 point difference in the post-operative accuracy note was retrospectively calculated to be 0.80. There were no significant differences between the two groups for all individual radiographic items.
This study is, to our knowledge, the first one which investigates the learning curve of navigated TKR The used navigation system allowed a very accurate implantation of a TKR in both experienced and less experienced centers. There was no detectable learning curve with respect to accuracy of TKR implantation, clinical outcome and complication rate. The duration of the learning curve when considering the operating time was 30 cases.
Sixteen observers measured eight anatomic parameters on digitalised images of six acute distal radial fractures using the Patient Archiving Communication System (PACS) software and repeated the measurements two weeks later. Inter and intra observer variability for each parameter was calculated using intraclass correlation coefficients (ICC) and tolerance limits (TL). Highest inter-observer agreement was demonstrated in dorsal tilt (ICC 0.858; TL ± 14.2°) with poor agreement on the size of the gap and step. When compared with the results of a similar study published 10 years ago looking at observer variability in x-ray measurement of healed distal radial fractures, the reliability of computerized measurements is not significantly different to those achieved by manual techniques (dorsal tilt inter-observer TL on PACS ± 16° compared with TL ± 15° using ruler and protractor). These results suggest the current guidelines in the literature for acceptable radiological reduction limits based on < 10° change in palmar tilt, < 2mm radial shortening, < 5° change in radial angle and < 1–2mm articular step for acute distal radius fractures cannot be reliably measured
Unicompartmental knee replacement (UKR) is accepted as a valuable treatment for isolated medial knee osteoarthritis. Minimal invasive implantation might be associated with an earlier hospital discharge and a faster rehabilitation. However these techniques might decrease the accuracy of implantation, and it seems logical to combine minimal invasive techniques with navigation systems to address this issue.
The authors are using a non image based navigation system (ORTHOPILOT ™, AESCULAP, FRG) on a routine basis for UKR. We prospectively studied 60 patients who underwent navigated minimally invasive UKR for primary medial osteoarthritis at our hospital between October 2005 and October 2006. We established a navigated control group of 60 patients who underwent conventional implantation of a UKA at our hospital between April 2004 and September 2005. There were 42 male and 78 female patients with a mean age of 65 years (range, 44–87 years). There were no differences in all preoperative parameters between the two groups.
The accuracy of implant positioning was determined using predischarge standard anteroposterior and lateral radiographs. The following angles were measured: femorotibial angle, coronal and sagittal orientation of the femoral component, coronal and sagittal orientation of the tibial component. When the measured angle was in the expected range, one point was given. The accuracy was defined as the sum of the points given for each angle, with a maximum of five points (all items fulfilled) and a minimum of 0 point (no item fulfilled). Our primary criterion was the radiographic accuracy index on the postoperative radiograph evaluation. All other items were studied as secondary criteria.
The mean accuracy index was similar in the two groups: 4.1 ± 0.8 in the study group and 4.2 ± 1.2 in the control group. 36 patients (60%) in the control group and 37 patients (62%) in the study group had the maximum accuracy index of five points. All measured angles were similar in the two groups. There were no differences between the percentages of patients in the two groups achieving the desired implant positions. Mean operating time was similar in the two groups. There were no intraoperative complications in either group. The groups had similar major postoperative complication rates during hospital stay (3% for both).
The used navigation system is based on an anatomic and kinematic analysis of the knee joint during the implantation. The modification of the existing software for minimal invasive approach has been successful. It enhances the quality of implantation of the prosthetic components and avoids the inconvenient of a smaller incision with potential less optimal visualization of the intra-articular reference points. However, all centers observed a significant learning curve of the procedure, with a significant additional operative time during the first implantations. The postoperative rehabilitation was actually easier and faster, despite the additional percutaneous fixation of the navigation device. This system has the potential to allow the combination of the high accuracy of a navigation system and the low invasiveness of a small skin incision and joint opening.
Authors have been using kinematic computer navigation for a total knee replacement surgery since 2003. A contribution and advantage of computer navigation is well recognized. Exact guidance of both tibial and femoral osteotomy along with precise soft tissue balance respecting individual anatomic constitution is achieved by exact collection and computer evaluation of data by a use of special sensors and probes. Use of kinematic navigation in experienced hands minimizes deviation from physiological mechanical Mikulicz axis. This is considered the most important step to achieve a good long term outcome after total knee arthroplasty.
We have been recently using Brain Lab kinematic navigation system in both primary and revision knee arthroplasties. 200 primary and 20 revision knee arthroplasties are included in the retrospective 3 year follow up study. A navigated revision surgery is recently performed only in cases where the axial deformity does not exceed 10 degrees and where no significant bone loss is presented (bone defects less that ½ cm). Standard cemented components are used in both primary and revision cases. A primary navigated knee arthroplasty had no exclusion criteria in the above study.
No need for conversion to a revision knee system using stem and wedges was noticed in the above series. Following the above inclusion criteria standard cemented implants were used only. We conclude that the use of navigation in cases of relatively uncomplicated knee revision arthroplasty guaranties good mid term outcome, good soft tissue balance, saves money on expensive knee revision systems and guaranties an alternative of second stage revision surgery with a use of extensive revision systems. Standard implant selection does not apply for those with deep bone defects and axial deformation higher than 10 degrees.
Revision TKR is a challenging procedure, especially because most of the standard bony and ligamentous landmarks are lost due to the primary implantation. However, as for primary TKR, restoration of the joint line, adequate limb axis correction and ligamentous stability are considered critical for the short- and long-term outcome of revision TKR. There is no available data about the range of tolerable leg alignment after revision TKR. However, it is logical to assume that the same range than after primary TKR might be accepted, that is ± 3° off the neutral alignment. One might also assume that the conventional instruments, which rely on visual or anatomical alignments or intra- or extramedullary rods, are associated with significant higher variation of the leg axis correction.
We used an image-free system (ORTHOPILOT TM, AESCULAP, FRG) for routine implantation of primary TKA. The standard software was used for revision TKA. Registration of anatomic and kinematic data was performed with the index implant left in place. The components were then removed. New bone cuts as necessary were performed under the control of the navigation system. The size of the implants and their thickness was chosen after simulation of the residual laxities, and ligament balance was adapted to the simulation results. The system did not allow navigation for centromedullary stem extension and any bone filling which may have been required. This technique was used for 54 patients. The accuracy of implantation was assessed by measuring the limb alignment and orientation of the implants on the post-operative radiographs.
Limb alignment was restored in 88%. The coronal orientation of the femoral component was acceptable in 92% of the cases. The coronal orientation of the tibial component was acceptable in 89% of the cases. The sagittal orientation of the tibial component was acceptable in 87% of the cases. Overall, 78% of the implants were oriented satisfactorily for the five criteria.
The navigation system enables reaching the implantation objectives for implant position and ligament balance in the large majority of cases, with a rate similar to that obtained for primary TKA. The navigation system is a useful aid for these often difficult operations, where the visual information is often misleading. The navigation system used enables facilitated revision TKA.
Anterior cruciate ligament (ACL) reconstruction allows overall good results, but there is still a significant rate of failure. It is well accepted that the main reason for ACL reconstruction failure is a misplacement of tibial or femoral tunnels. Conventional techniques rely mainly on surgical skill for intra-operative tunnel placement. It has been demonstrated that, even by experienced surgeons, there was a significant variation in the accuracy of tunnel placement with conventional techniques. Navigation systems might enhance the accuracy of ACL replacement.
10 cadaver knees with intact soft-tissue and without any intra-articular abnormalities were studied. We used a non image based navigation system (OrthoPilot ®, Aesculap, Tuttlingen, FRG). Localizers were fixed on bicortical screws on the distal femur and on the proximal tibia. Both kinematic and anatomic registration of the knee joint were performed by moving the knee joint in flexion-extension and palpating relevant intra- and extra-articular landmarks with a navigated stylus. The most anterior, posterior, medial and lateral point of both tibial and femoral attachment of the ACL were marked with metallic pins. The navigated stylus was positioned on these points, and the system recorded its position in comparison to the bone contours. Subsequently, we performed conventional plain AP and lateral X-rays and a CT-scan, and measured the position of the pins in comparison to the bone contours. Finally, all measurements were made again with a caliper after disarticulating the knee joint. We calculated the center of the footprint as the mid-point between the four pins of both tibial and femoral attachment for each measurement technique. All measurements were expressed as percentages of the bone size to compensate for the different sizes.
There were no significant difference in the paired measurements of the location of the ACL footprints on both femur and tibia between anatomic, radiographic, CT-scan and navigated measurements. There was a significant correlation between the paired measurements of the location of the ACL footprints on both femur and tibia with either measurement techniques.
Anatomic measurement is the gold standard experimental technique for the positioning of the ACL foot-print, and CT-scan measurement is currently the gold standard technique in clinical situation. According to this reference, the position of ACL attachments on the tibia and on the femur can be accurately defined by the navigation system. Intra-operative measurement of the location of the bone tunnels during ACL replacement with this navigation system should be accurate as well.
The use of two-dimensional plain X-rays for preoperative planning in total hip arthroplasty is unreliable. For example, in the presence of rotational hip contracture the lateral femoral off set can be significantly under-estimated. Pre-operative planning is of particular importance when using uncemented prostheses. The aim of this study was to determine the precision of a novel 3D CT-based preoperative planning methodology with the use of a cementless modular-neck femoral stem.
Pre-operative computerised 3D planning was performed using HIP-PLAN® software for 223 patients undergoing THA with a cement-less cup and cement-less modular-neck stem. Components were chosen that best restored leg length and lateral off set. Postoperative anatomy was assessed by CT-scan and compared to the pre-operative plan.
The implanted component was the same as the planned one in 86% of cases for the cup and 94% for the stem. There was no significant difference between the mean planned femoral anteversion (26.1° +/− 11.8) and the mean postoperative anteversion (26.9° +/− 14.1) (p=0.18), with good correlation between the two (coefficient 0.8). There was poor correlation, however, between the planned values and the actual post-operative values of acetabular cup anteversion (coefficient 0.17). The rotational centre of the hip was restored with a precision of 0.73mm +/3.5 horizontally and 1.2mm +/− 2 laterally. Limb length was restored with a precision of 0.3mm +/− 3.3 and femoral off set with a precision of 0.8mm +/− 3.1. There was no significant alteration in femoral off set (0.07mm, p=0.4) which was restored in 98% of cases. Almost all of the operative difficulties encountered were predicted pre-operatively.
The precision of the three-dimensional pre-operative planning methodology investigated in this study is higher than that reported in the literature using two-dimensional X-ray templating. Cup navigation may be a useful adjunct to increase the accuracy of cup positioning.
Computer navigation systems enable precise measurement and intra- operative knee range of movement analysis. We present a series of five knees that demonstrated unusual kinematics.
Five of 80 computer navigated knee replacements that were part of a prospective randomised trial were found to have unusual joint lines. Range of motion assessment was performed with computer assisted navigation after exposure and registration of bony landmarks and before bony resection was commenced. This revealed valgus alignment in extension that drifted into varus with knee flexion. We referred to these unusual patterns as ‘oblique joint lines’.
The data from the navigation log files of these five knees was analysed in detail. Average age of patients in this series was 68years and all were female. The average pre- operative angle between femoral axis and distal femoral articular surface was 101 degrees. All five knees had a tibial varus with average angle between the tibial axis and articular surface being 85 degrees. In two knees, more bone was resected from the medial posterior femoral condyle using 4 degrees external rotation. These two knees showed improved kinematics and horizontal joint line post- operatively.
Computer assisted navigation provides a precise understanding of the pre- operative knee kinematics. Bony cuts can be tailored to suit the pre- operative deformity. Increased external rotation of the femur with adequate medial soft tissue release is an alternate approach for difficult knees with ‘oblique joint lines’.
The ligament balancing technique involves precise measurement and equalisation of flexion and extension gaps. A force tension distractor that has separate arms for the medial and lateral joint compartments was used. We describe our experience of 40 total knee replacements (TKR) using this technique.
We undertook a prospective randomised trial using computer assisted navigation in TKRs applying two different soft tissue balancing techniques. The aim was to see how balancing techniques help us achieve a rectangular flexion extension gap. The 40 TKR that underwent the ligament balancing procedure were part of this trial. The distractor used was derived from the Freeman-Swanson knee instrumentation which measures the gap and tension in the medial and lateral compartments. The options to make the gap rectangular were: 1. adjustment of femoral cut by change in external rotation (for the flexion gap); 2. soft- tissue release or 3. a combination of both. Using computer assisted navigation it was possible to perform real time motion analysis during surgery.
We found that three degrees of external rotation for the femoral component was adhered to in only 16 out of 40 knees. The remaining 60% had external rotation of femoral component varying between two and eight degrees. No maltracking of the patella resulted in any of the TKR with increased rotation of the femoral component. The axis of movement was plotted on a graph at the end of the surgery by passive extension to flexion to which the operating surgeon was blinded.
Varying external rotation of femoral component might be an option in balancing difficult knees. Computer navigation enables precise tailoring of bony resection to suit different deformities.
The use of hard-on-hard hip prostheses has highlighted specific problems like the “stripe-wear” and the squeaking. Many authors have related these phenomena to a micro-separation between the cup and the head. The goal of the study was to model the hip kinematics under micro-separation regime in order to develop a computational simulator for total hip prosthesis including a joint laxity, and to use it to perform a sound analysis.
A three-dimensional model of the Leeds II hip simulator was developed on ADAMS® software. A spring was used to introduce a controlled micro-separation (less than 500 microns) during the swing phase of the walking cycle. The increase of the load during the stance phase induced a relocation of the head in the cup. Values of the medial-lateral separation predicted from the model were compared to experimental data measured using a LVDT of less than 5 microns precision. Theoretical wear path predicted from the model was compared to the literature data. The frequencies of the vibratory phenomena were determined, using the Fourier transformation.
There was an excellent correlation between the theoretical prediction and the experimental measurement of the medial-lateral separation during the walking cycle (0.92). Edge-loading contact occurred during 57% of the cycle according to the model and 47% according to the experimental data. Velocity and acceleration were increased during the relocation phase in a chaotic manner, leading to vibration. The contact force according to the model had also a chaotic variation during the micro-separation phase, suggesting a chattering movement. Fourier transformation showed many frequencies in the audible area.
A three-dimensional computational model of the kinematics of the hip after total replacement was developed and validated with an excellent precision under micro separation. It highlighted possible explanations for the squeaking that may occur during either relocation phase or edge loading.
There is a significant variation in registering anterior pelvic plane (APP) among experienced navigated hip surgeons reflecting negatively on the accuracy of determining the inclination and anteversion angles. Registering the APP in a lateral decubitus position is more challenging in obese patients as palpation of pubic tubercle or anterior superior iliac spines (ASIS) is inconsistent. We propose an alternative and easier novel method in which palpation of the posts (pegs) that stabilizes the pelvis will accurately determine the APP plane. The computer data obtained from peg’s palpation was compared to data obtained from post-operative CT scan of the pelvis in determining acetabular and cup version and inclination angles.
The APP was defined and registered in 40 navigated total hip arthroplasty (THA) patients using our novel method. The patient is securely stabilized in a lateral decubitus position as routine with multiple pegs. One peg is positioned against both ASIS with 2 EKG pads placed on the pegs (each represent an ASIS). The other peg supports the pubic symphysis with one EKG pad representing the pubic tubercle. All efforts are made to make sure that the distance between the EKG nipples and the corresponding ASIS or pubic tubercle is equal before scrubbing and draping of the hip. Registration is achieved afterwards, by touching the nipples of the EKG pads placed on the pegs through the drape while the patient is secured in lateral decubitus position. This way sterility is uncompromised. To test the validity of our method of identifying the APP plane, a post-operative CT scan measurements of cup inclination and version angles were independently observed and the data were compared to our navigation registration method using t-student test analysis.(p=0.05 is significant)
The mean CT-scan cup version was 19.4(S.D. ±6.3), and the mean of APP navigated cup version was 14.2(S. D.±3.1). There was no statistical significant difference (p=0.045). Similarly, there was no significant difference between mean CT scan cup inclination angle of 42.3(S. D.±3.7) and the mean navigated cup inclination of 40.9(S.D.± 4.6), (p= 0.69). Therefore, we conclude that the APP plane can be registered reliably and accurately by simply touching the EKG pads on the pegs and through the drapes. Not to mention, both the cup version and inclination angles were within safety zone of Lewinick.
It seems that the accuracy of measuring the inclination angle through our method, although not significant, is better than the accuracy of measuring the cup version. This emphasizes the point that identifying the pubic tubercle is difficult whichever method of registration is used. However, inaccessibility of ASIS or pubic tubercle during manual APP registration leads to great cup orientation inaccuracies. The readily palpable EKG nipples on the pegs, irrespective of patient’s weight or the thickness of surgical draping, makes this novel technique a reliable and an easier alternative registration method than the manual palpation of APP in navigated THA.
The purpose of mini-invasive hip arthroplasty is least damage to skin and muscles. Unlike Roettinger modification to Watson-Jones, our approach requires no special table or instruments. Besides, direction of skin incision is perpendicular to interval between glutei and tensor muscles, thus called a Crisscross Approach. Potentially, a cross shape exposure allows a larger view and therefore a lesser damage to skin and muscles during retraction. Skin incision, being in line with the femur (almost parallel), allows expansion of incision proximally and distally. No tendon or muscles are severed achieving a true inter-muscular minimally invasive approach.
After working with 3 cadavers to perfect the technique and with investigation and research board (IRB) approved consent, 40 prospective patients underwent mini-invasive crisscross technique from December 06–June 07 with 6 months follow up. A standard non-cemented hip was implanted. Previously disrupted hip muscles patients were excluded. Patients were positioned in a lateral decubitus with pelvis secured and flexed 20°–30°. Incision started 2 inches inferior and posterior to ipsilateral anterior superior iliac spine (ASIS) extending distally for 3 inches or more for obese or muscular patients. Acetabulum is exposed using curved Hohmann retractors one above and one below femoral neck after excising most of the anterior capsule with releasing the superior and inferior capsule. The femoral neck is osteotomised as routine extracting the femoral head. Then the same curved retractors are placed behind anterior and posterior rim of acetabulum with an optional third curved retractor may be placed at the inferior rim. The acetabulum is reamed with the usual straight reamers and the cup is then implanted as routine. Angled reamers are not necessary as our skin incision is in line with the reamer direction. Femoral neck exposure starts with the surgeon positioned anterior to pelvis. Paralysis of the muscles is confirmed with anesthesiologist and table is tilted 20°–30° posteriorly. Hip is then extended 20°–30°, externally rotated to 80°–90° and adducted with a retractor underneath femoral neck. Another curved retractor is placed gently on greater trochanter to protect glutei. Leg is allowed to drop in a bag. Canal finder and use of box osteotome is helpful to avoid breaching the femoral cortex or varus positioning of the stem. Broaching or reaming and final implant insertion is done as routine. Hip reduction is achieved as routine by reversing the table tilt and bringing the leg forward with traction and internal rotation.
36 out of 38 eligible patients were sent home after their rehab goals were met in 4 therapy sessions (2–3days). Full weight bearing was allowed in 4 weeks. One stem was undersized, two were in slight varus, and total blood loss was less than 5 gm/dl of Haemoglobin at post op day three. No dislocation or complications related to exposure. No neurovascular injury and no re-operation. Surgery time averaged 20 minutes longer mainly at femoral exposure. As experience is gained the time is lessened. Post-operative intravenous morphine pump administration was stopped in 24 hours in 82% of patients after surgery instead of the 48 hour routine.
Crisscross approach differs by transecting no tendon or muscles, requiring no special table or instruments with incision that gives more exposure, allows expansion and reduces skin damage resulting in true non-invasive approach. Exposure of the femur was difficult in the first few cases. Tilting the operating table posteriorly, releasing superior and inferior capsule as has been recommended by previous authors helped femoral exposure. Recovery from surgery in terms of rehab sessions and postoperative pain control were improved compared to our previous standard of care. Long term follow up is under current research investigation.
Most common complication of non-navigated classic total knee arthroplasty (TKA) relates to patella. Not resurfacing the patella makes exposure more difficult in a mini-approach which may add to its potential complications. Effect of navigated mini sub-vastus TKA on native patella is clinically and radiologically studied, observing also, whether severity of deformity or obesity adds to patellae complications in such approach.
92 of 100 subjects were eligible. Peri-operative radiological and navigation data with follow up visits to 24 months provided alignment, patella tilting or displacement data. Clinical outcome gauged by “KSS” documented pain from patella movements, or pain generated from stair climbing, or rising from a chair. Patella is considered subluxated if it displaced ≥ 5mm. No exclusion by obesity or severity of deformity. Results were evaluated with descriptive statistics.
Of the 92 patients, 3 had patella pain (3%). 72% had < 5° of patella tilting (of which 3 had patella pain) while 28% had a 5°–17° tilting. As for patellae displacement, 12% displaced laterally (≤3 mm) but with no pain. None had patellar displacement ≥ 4mm (which we define as subluxation), and none had a dislocation. Pre-operative knee deformity ranged from 19° varus to 13° of valgus. 70% of subjects had pre-operative varus/valgus deformity of < 10°. The other 30% had deformity of ≥ 10°. Post-operative mean mechanical axis alignment was 0° (± 1°) with a mean range of motion of −3.8° to 133.6°. No vascular injuries, skin necrosis, deep infection, or fractures.
The BMI ranged from 25–46 Kg/m2. 16% had a BMI ≥ 40 with no patellar pain, tilting or displacement.
Incidence of native patella pain in a navigated mini sub-vastus TKA was low irrespective to body mass or pre-operative deformity. Perhaps navigation helped align the components ideally and thus reducing the complication rate of a mini-approach. However, 28% of native patella tilted > 5° but unlike tilting of a resurfaced patella, it did not correlate with patella pain. In this study, whether non-resurfacing caused the 3% of patella pain is undetermined. Nevertheless, the pain level was not severe to make the patients seek a revision of the patella. Finally, as we compare with other studies, we cannot conclude that mini sub-vastus approach is superior; however its low patella complication rate is comparable if not superior to classic approach.
Femoral component malrotation is a major cause of patello-femoral complications in total knee arthroplasty. In addition, it can affect varus/valgus stability during flexion which can lead to increased tibiofemoral wear.
Debate exists on where exactly to rotate the femoral component. The three principal methods utilise different anatomical landmarks: the posterior condylar axis, the transepicondylar axis and the antero-posterior axis (Whiteside’s line).
A prospective randomised controlled trial was undertaken. Sixty consecutive patients undergoing total knee arthroplasty by a single surgeon (LML) at the Royal Perth Hospital were randomised into 3 groups based on the intra-operative method for measuring femoral rotation using the PFC sigma prosthesis (Depuy) with computer navigation (Depuy/Brainlab). All patients received the usual post-operative treatment, rehabilitation and JRAC (Joint Replacement Assessment Clinic) follow up. All underwent a CT scan according to the Perth CT protocol designed specifically to accurately measure component alignment and rotation.
No significant difference in femoral rotation was found between the three groups using a one-way analysis of variance (p=0.67). However, Whiteside’s line had a significantly greater variability than the posterior condylar or transepicondylar axis using the F Test for variances (p=0.02, p=0.03). In conclusion, whilst there was no significant difference in femoral rotation, Whiteside’s line did show greater variability (−6° to 3°), and therefore we recommend the use of either the transepicondylar or posterior condylar axis in Total Knee Replacement.
The necessity of soft tissue release to achieve a stable, balanced knee in previous publications has a high rate and a wide range of 50–100% of total knee arthroplasties (TKA). This reflects disagreement regarding the determinants for soft tissue release which is partly due to lack of standardized quantitative measures. Recent advances in navigation may standardize and replace conventional methods regarding soft tissue balancing. We propose two navigation predictors that quantitatively determine the least amount of collateral ligament release necessary to achieve a stable neutral knee, thus reducing the frequency of release.
100 patients underwent navigated TKA. Data of 93 were eligible. Preoperative deformity ranged 18°varus −13° valgus. Ratio of Varus/Valgus= 66/27. Ages were 46–85 yrs. Mean BMI= 36Kg/m2
First navigation predictor determines collateral release when varus/valgus deformity is uncorrectable by stress deflection test before tibia resection. Second predictor determines release when delta mediolateral gap > 4mm before femoral resection using a Tensioner with two independent pads.
10 out of 93 cases (10.75 %), required collateral ligament release to achieve a postoperative mechanical axis of 0° (SE±0.11) with a mean mediolateral deflection in extension of 1.43°, and a mean range of motion of −3° to 127° of flexion. First predictor has 98% accuracy. Second predictor has 96% accuracy but their combination had 100% accuracy with no false negative predictions.
Balanced neutral TKA is achieved by soft tissue release, bone resection or as in this study, by adjusted navigated femoral resection (through rotation, size and level of resection) which balanced knees that otherwise should have soft tissue release. Navigation predictors are reliably accurate to quantitatively determine the necessity of soft tissue release to achieve a neutral stable knee with a significantly lower release rate in comparison to non navigated TKA series rate of 50–100%. (p< 0.001) (95% confidence interval).
Studies suggest that specialty hospitals and high surgical volume decrease adverse outcomes related to hip arthroplasty. Little is known, however, concerning the influence of imageless computer navigation systems on a surgeon’s experience and subsequent placement of implants in the setting of hip resurfacing arthroplasty.
A retrospective review of 71 consecutive hip resurfacing arthroplasties placed with computer assisted navigation during 2006 and 2007 was performed. Forty-seven operative days encompassing the surgeon’s entire experience with hip resurfacing were analysed. Within this single surgeon series, operative time, intraoperative cup inclination and femoral stem/shaft angles, as well as postoperative cup inclination and femoral stem/shaft angles were measured and compared over three discreet, sequential operative time intervals.
Intraoperative cup inclination angles were comparable to postoperative radiographic values as there was no significant difference (p=.059). Computer assisted navigation produced consistent values despite different levels of surgeon experience in the setting of intraoperative cup inclination (42.8°, 43.5°, and 40.1°) and postoperative cup (46.1°, 43.9°, and 42.9°) and femoral stem (147.9°, 146.5°, and 144.0°) radiographic alignment. A statistically significant difference existed between intraoperative femoral stem/shaft angles compared to postoperative radiographs measurements (p< .001), however, all means maintained a valgus orientation compared to the native neck angle. There was a correlation between evolving surgeon experience and intraoperative stem placement (143.5°, 142.1°, and 138.0°, respectively) despite the mean values remaining well clustered (p< .001). Operative times significantly decreased (p< .001) with surgeon experience, showing the largest decrease after the 1st sequence interval (109.6, 97.8, and 94.8 min, respectively). No femoral notching (0/71) occurred throughout the series.
Computer assisted navigation provides a dependable method of accurate hip resurfacing arthroplasty component positioning as measured by cup inclination, in addition to a reliable technique for valgus stem placement and avoidance of notching. Furthermore, computer navigation allows for consistency and offers a protective effect on component alignment independent of surgeon procedural experience.
The navigation system recently introduced in an ACL reconstruction is reported that it would be helpful for determining the accurate tunnel position and better clinical results in. It also provides intra-operative information such as knee kinematics and anteroposterior translation and internal-external rotation of the tibia during the reconstruction. Our hypothesis was that a double bundle reconstruction would provide better anteroposterior and rotational stabilities than a single bundle reconstruction.
The aim of this study was to assess the changes of anteroposterior and rotational stabilities using a navigation system achieved by double bundle reconstruction (20 knees) and compare them with those by single bundle reconstruction (20 knees).
After registering the reference points, anteroposterior ad rotational stability test with 30° knee flexion using a navigation system was carried out and measured before and after reconstruction on both groups.
The anteroposterior stability showed significant improvement from 17.5 mm before the reconstruction to 5.1 mm after the reconstruction in the double bundle group and from 16.6 mm to 6.1 mm in the single bundle group, showing a significant inter-group differences (p< .05). The mean rotation stability of the double bundle group showed more significant improvement after reconstruction than those of the single bundle group (9.8° in single and 6.1° in double bundle group, p< .05).
The double bundle ACL reconstruction tends to be more stable in rotational stability than the single bundle reconstruction, but not so much in anteroposterior stability. Clinically the double bundle ACL reconstruction may provide better rotational stability reducing residual pivot shift phenomenon after reconstruction.
The aim of our study was to compare the precision and effectiveness of a CT-free computer navigation system against conventional technique (using a standard mechanical jig) in a cohort of unselected consecutive series of hip resurfacings.
One hundred and thirty nine consecutive Durom hip resurfacing procedures (51 navigated and 88 non-navigated) performed in 125 patients were analysed. All the procedures were done through a posterior approach by two surgeons and the study cohort include the hip resurfacings done during the transition phase of the surgeons’ adoption of navigation.
There were no significant differences in the gender, age, height, weight, BMI, native neck-shaft angles, component sizes and blood loss between the two groups. There was a significant difference in the operative time between the two groups (111 minutes for the navigated group versus 105 minutes for the non-navigated group; p=0.048). There were 4 cases of notching in the non-navigated group and none in the navigated group. There were no other intra-operative technical problems in either of the groups nor were there any femoral neck fractures.
No significant difference was found between the mean post-operative stem-shaft angles (138.5° for the navigated group versus 139.0° for the non navigated group, p=0.740). However there was a significant difference in the difference between the planned stem-shaft angle versus the post-operative stem-shaft angle (0.4° for the navigated group versus 2.1° for the non-navigated group; p=0.005). There was significantly more scatter in the difference between the post-operative stem-shaft angle and the planned stem-shaft angle in the non-navigated group (standard deviation = 3.6°) when compared with the navigated group (standard deviation = 0.9°; Levene’s test for equality of variances = p≤0.01). No case in the navigated group showed a post-operative stem-shaft angle of more than 5° deviation from the planned neck-shaft angle when compared to 33 cases (38%) in the non-navigated group (p≤0.001). While only 4 cases (8%) in the navigated group had a postoperative stem-shaft angle deviating more than 3° from the planned stem-shaft angle, this occurred in 50 cases (57%) in the non-navigated group (p≤0.001).
Hip resurfacing is a technically demanding procedure with a steep learning curve. Varus placement of the femoral component and notching have been recognised as important factors associated with early failures following hip resurfacing. While conventional instruments allowed reasonable alignment of the femoral component, our study has shown that use of computer navigation allows more accurate placement of the femoral component even when the surgeons had a significant experience with conventional technique.
Scarf osteotomy is widely used as a surgical treatment for hallux valgus. It is a versatile osteotomy, allowing shortening, depression or medial displacement of the capital fragment but it remains uncertain how stresses within the bone subsequently vary. The aim of this study was to design a computerised model to explore the effect on bone stress of changing the position of bony cuts for a scarf osteotomy.
A computerised image was constructed using finite element analysis. This utilises a mathematical technique to form element equations which represent the effect of applied force to the object appropriate to each finite element. Maximum bone stresses were then measured using different osteotomy variables. The osteotomy variables studied were the length of the longditudinal cut, apex of the distal cut to articular cartilage, resection level of the longditudinal cut and combinations of these variables. A saw bone model was used to test the findings of the study.
The results of this study show that lowering the longditudinal resection level and shortening via the distal cut beyond 6 mm will decrease bone stress. Additionally, raising the longditudinal resection level and shortening via the proximal cut caused an increase in bone stress. A saw bone model confirmed the findings of the study.
In conclusion, our experience is that finite element analysis is a very useful model in studying the bony stresses for a scarf osteotomy and assists in optimising the direction and angle of bony cuts used.
Correct alignment of the leg and positioning of the implant has shown to be an important factor in the successful long term outcome of total knee arthroplasty and navigation systems enable an accuracy of corrections and alignment within intervals of 1 mm or 1 degree. This study is to test if there is any discrepancy in accuracy which was sometimes observed in clinical trials between Orthopilot (Aesculap, Tuttlingen, German) and AxiEM (Medtronic Navigation, CoalCreek, Colo., USA).
A synthetic bone model (Sawbones, Pacific Laboratories, Vashon, Washington) including pelvis and leg with mobile joint made up of titanium which does not affect the electromagnetic field was constructed. Mechanical axis was checked by ORTHODOC system (Integrated Surgical System, CA, USA) that is a preplanning system for ROBODOC (ISS, CA, USA) assisted total knee arthroplasty (TKA) and total hip arthroplasty (THA). The CT images were scanned with 1.25 mm or less slice interval. The CT images were converted to 3-dimensional (3D) volume-rendered model in ORTHODOC. Two orthopaedic surgeons measured it ten times independently.
For the measurement of mechanical axis using navigation, 4 orthopaedic surgeons (two experts having more than 100 navigation experiences and two residents) registered anatomical landmarks and kinematic center of bone model ten times using Orthopilot as well as AxiEM. After that, one surgeon intentionally registered the wrong anatomical landmarks (10 mm medial and lateral to the center of distal femur, proximal tibial and ankle, and both malleoli) in both navigation system and observed the change of mechanical axis.
True mechanical axis was varus 1.25° using Orthodoc, Orthopilot displayed varus 1.10±0.64° and AxiEM did varus 1.78±0.79°. The difference of mechanical axis between two navigations was not observed (P=0.12) and there were no intra and inter-observer variation in statistical analysis (Correlation=0.934, P=0.00). In the case of erroneous identification of the anatomical landmarks, Orthipilot showed much less variation compared to AxiEM. AxiEM altered the mechanical axis more in palpating center of the distal femur and ankle center and Orthopilot did in palpating the center of ankle.
Both navigation systems provide high accuracy and reproducibility of mechanical axis of lower limb in experimental condition. But both were affected by the wrong identification of the anatomical landmarks. AxiEM had more variations. So surgeon should pay attention to register the precise anatomical landmarks.
Unexpected findings were sometimes observed such as hyper extension, oversize of femoral component, or anterior notching of anterior femoral cortex in total knee arthroplasty (TKA) using computer system. We conducted this study to evaluate these findings by a virtual simulation using ORTHODOC and then confirmed them on real patients with TKA.
Virtual simulations of distal femoral cut in 50 patients using ORTHODOC system were made by way of being perpendicular to mechanical axis (CAOS way) and to intramedullary guide (manual way) in the same knee and measured the difference of sagittal cutting planes. We compared the maximum AP dimensions of femoral condyle parallel to distal cut plane. We also compared sagittal alignment and size of the femoral component in 30 bilateral TKAs, one side using ROBODOC (CAOS way) and the other side using IM guide (manual way).
On virtual simulation, distal femoral cut was more extended (3.1±1.6°) in CAOS than in manual way and anteroposterior size of the femoral condyle in CAOS way was also larger than in manual way (p=0.001). Radiographic sagittal alignment of femoral component performed using CAOS way was slightly more extended than those using manual way, showing a significant difference (p=0.024). The larger femoral components were required in six patients on CAOS and in two patients on manual way, whereas twenty-two patients showed same size on both side.
CAOS can provide more accurate sagittal cut perpendicular to mechanical axis than manual system, which may lead to slightly extended position or larger femoral component.
In total knee arthroplasty, navigation systems that help achieve accurate alignment of the lower limbs have been applied widely, and these techniques are currently being used in minimally invasive unicondylar knee arthroplasty (MIS UKA) with good alignment results. To the best of our knowledge, there are no studies showing whether or not MIS UKA using a navigation system has a significant influence on the clinical results. This prospective study investigated the hypothesis that minimally invasive uni-compartmental knee arthroplasty using navigation system (NA-MIS UKA) will produce better short-term clinical results than MIS UKA without navigation system.
After a minimum two-year follow-up, the short-term functional results included the ranges of motion, Hospital for Special Surgery (HSS) scores, and WOMAC scores and the alignment accuracy of the components of 31 NA-MIS UKAs (NA-MIS group) compared with those of 33 MIS UKAs without a navigation system (MIS group). The surgery time was also recorded and compared.
The HSS and WOMAC scores showed significant improvement at the final follow-up in both groups, showing no significant inter-group difference (p=0.071, p=0.096, respectively). The ranges of motion also showed significant improvements in both groups, but there was no significant difference between two groups (p=.687). However, the surgery time was longer in MIS group than in NA-MIS group. NA-MIS UKA produces significant improvement in the desired mechanical axis with prosthetic alignment outliers compared with that without the navigation system.
However, at the final follow-up, there were no significant differences in any of the functional parameters between the two groups.
This prospective study was undertaken to compare the clinical and radiological results achieved using navigation assisted minimally invasive (NA-MIS) and conventional (CON) techniques in bilateral total knee arthroplasty (TKA).
Forty-two bilateral patients with a minimum 2-year follow-up who were available for study after NA-MIS TKA were included in this study. Clinical evaluations (ROM, HSS and WOMAC scores) were performed at 3 and 6 months and at 1 & 2 year postoperatively. Patient subjective preferences and radiological accuracies were compared at 1 year postoperatively.
Preoperative HSS scores were 68.5 in the NA-MIS group and 66.5 in the CON group, and these scores improved to 93.6 and 92.5 at 1 year postoperatively, respectively. Knees had a higher average HSS score in NA-MIS group than in the CON group till six months, but not after nine months postoperatively. In terms of WOMAC scores, pain scores in the NA-MIS group were better up to nine months postoperatively, but not at one & 2 year postoperatively, and total WOMAC scores were better up to six months, but not after nine months postoperatively. ROM was comparable in both groups at all times. However, more patients preferred NA-MIS sides than CON sides. Radiological results demonstrated no difference between the mean values of the two groups, although the NA-MIS group contained fewer outliers than the CON group.
NA-MIS TKA results in better functional scores than CON-TKA over the first or nine months postoperatively. However, no differences in any functional parameters were evident at one & two year postoperatively.
The aim of study was to provide normal value of anteroposterior and rotational stability of knee joints using navigation system.
From March 2007 to November 2007, 35 patients (23 men, 12 women) with a mean age of 36.1(16–57) years, who were treated with arthroscopy, without ligament injury of knee were included in our study. We measured amount of anteroposterior displacement and rotation of the knee in 0, 30, 60 and 90 degrees of flexion position using Orthopilot navigation system. All tests were performed by same single surgeon under manual maximal force.
The mean anterior displacement was 3.7±2.0, 6.6±2.2, 5.8±2.0 and 4.7±1.8 mm in 0, 30, 60 and 90 degrees of flexion respectively. The amount of anterior displacement at 30 degree of flexion was significantly larger than those of other degrees. The mean posterior displacement was 2.0±0.5, 2.2±0.4, 2.1±0.4 and 2.0±0.6 at each degree. There was no statistical difference in posterior displacement. The mean internal rotation was 10.3±2.7, 14.6±3.3, 16.2±2.9 and 15.0±4.3 degree at each degree. The amount of internal rotation at 0 degree of flexion was significantly smaller than those of other degrees. The mean external rotation was 8.4±3.4, 16.5±3.3, 13.3±3.8 and 15.0±4.3 degree at each degree. The amount of external rotation at 0 degree of flexion was significantly smallest and that of 30 degree was largest.
In the measurement of laxity using navigation, we could acquire previously mentioned results. The measurement of stability of knee will be useful in diagnosing ligament injury and evaluating degree of postoperative symptomatic improvement.
Bilateral sequential total knee replacement with a Zimmer NexGen prosthesis (Zimmer, Warsaw, Indiana) was carried out in 30 patients. One knee was replaced using a robotic-assisted implantation (ROBOT side) and the other conventionally manual implantation (CON side). There were 30 women with a mean age of 67.8 years (50 to 80).
Pre-operative and post-operative scores were obtained for all patients using the Knee Society (KSS) and The Hospital for Special Surgery (HSS) systems. Full-length standing anteroposterior radiographs, including the femoral head and ankle, and lateral and skyline patellar views were taken pre- and post-operatively and were assessed for the mechanical axis and the position of the components. The mean follow-up was 2.3 years (2 to 3).
The operating and tourniquet times were longer in the ROBOT side (p < 0.001). There were no significant pre- or post-operative differences between the knee scores of the two groups (p = 0.288 and p = 0.429, respectively). Mean mechanical axes were not significantly different in the two groups (p = 0.815). However, there were more outliers in the CON side (8) than in the ROBOT side (1) (p = 0.013). In the coronal alignment of the femoral component, the CON side (8) had more outliers than the ROBOT side (1) (p = 0.013) and the CON side (3) also had more outliers than the ROBOT side (0) in the sagittal alignment of the femoral component (p = 0.043). In terms of outliers for coronal and sagittal tibial alignment, the CON side (1 and 4) had more outliers than the ROBOT side (0 and 2).
In this series robotic-assisted total knee replacement resulted in more accurate orientation and alignment of the components than that achieved by conventional total knee replacement.
Navigation was used to achieve a balanced flexion-extension gap for total knee arthroplasty and it’s 3 years clinical results were reported.
From 112 osteoarthritic knees with varus deformity the flexion and extension gap were measured with distraction of 50 lb/inch using special torque wrench following completion of controlled medial release with guidance of navigation system & tibial bone cut. Distal & AP femoral bony cut were finished according to the data of measurement of flexion-extension gap. After confirmation of the balanced flexion-extension gap by navigation total knee arthroplasty was completed.
The differences between flexion and extension gap varied from case to case, and could be classified into 3 kinds; balanced, tight flexion gap and tight extension gap.
HSS score was 96.7, ROM was 128.5 degree. 39 patients (35%) can have comfortable kneeling 75 patients(67%) can sit with cross leg. Gap technique with navigation could provide excellent clinical results of total knee arthroplasty and 3 classifications of flexion and extension gap should be taken into considerations for balanced total knee arthroplasty
Computer based navigation system improved the accuracy of limb and component alignment and decreased the incidence of outliers. The majority of previous studies were based on the infrared navigation system. We evaluate the availability and accuracy of the electromagnectic(EM) navigation system in total knee arthroplasty
From July 2006 to January 2007, 40 patients (50 TKAs) with osteoarthritis were participated in this study. AxiEM(Medtronics) was used and Nexgen CR(26 cases), and Nexgen CR flex(24 cases) were used. We analyzed the failure mode of navigation (7 cases), operation time and radiologic results (limb and component alignment)
Total registration time was 4 minutes 45 seconds in average (Range : 3 minutes 45 seconds ~ 6 minutes 55 seconds). Failures in clinical applications resulted from non-recognition of EM tracker or paddle by metallic interference in 4 cases and from informational changes during surgery by fixation loss or loosening of the tracker in 3 cases. Radiologically, the mechanical axis changed from −11.2±7.21 (Range : −25.8~3.1) to 1.0±1.25(Range : −2.1~4.0) and 1 case of outlier occurred (valgus 4°). Component alignment is measured as followed: 89.3±1.6° of Theta angle, 89.9±1.5° of Beta angle, 1.8±2.5° of Gamma angle, 86.1±2.9 of Delta angle°. There were no complications related to the EM navigation.
The EM navigation system helped to achieve accurate alignment of component and lower leg axis without any complications. It had several advantages such as relatively less invasiveness in fitting small instruments, not disturbing operation field, no interrupted line of sight, portable use, and applicability to any implant. However, metallic interference may be still problematic.
The EM navigation had advantages; less invasiveness, no disturbing operation field, no interrupted line of sight, portable use and applicability to any implants. But metallic interference may be still problematic.
Computer assisted total knee arthroplasty (TKA) is still a relatively novel technique. Surgeons wishing to adopt any new practice undergo a learning curve. The learning curve experienced with navigated TKA, its duration and cost in terms of complications, has not been well defined in the literature. Therefore we set out to analyse the learning curve of a newly appointed consultant with no previous experience of navigated TKA by using a surgeon who has completed over 1000 TKAs in over 10 years of experience with this technique as a baseline.
The study used the inexperienced surgeon’s first ever fifty navigated TKAs and the experienced surgeon’s most recent fifty TKAs over the same period in the same theatre using the same CT free navigation system (Orthopilot®) and prosthesis. Operative time, bone cuts and limb alignment before and after prosthesis implantation were recorded, along with the navigation specific difficulties and complications encountered by the inexperienced surgeon.
There was no statistical difference in the accuracy of postoperative limb alignment in either the coronal (p = 0.33) or sagital (p = 0.35) planes between the novice and experienced surgeon. There was also no difference in the executed bone cut angles (tibial p = 0.79, femoral p = 0.92). The operating time showed a difference between the two surgeons with the novice having a median of 80 mins (inter-quartile range of 20 mins) and the experienced surgeon had a median of 70 mins (inter-quartile range of 20 mins), p = 0.001. However there was a statistically significant reduction in operating time between the inexperienced surgeon’s first twenty and last twenty TKAs (p = 0.001). Comparison of the last 20 TKAs for each surgeon showed no difference in the operative time (medians of 70 mins and 75 mins respectively, p = 0.945). The navigation specific difficulties and complications recorded for the novice navigator were all related to the trackers: one loosening, one tibial tracker placed too proximally, one superficial infection in a tibial tracker wound and one incompletely engaged pin-tracker coupling which brought about the only conversion to manual TKA in this series.
We conclude that in terms of execution and outcome, a beginner using computer assisted TKA can match the results of an experienced navigator from the outset. The only parameter assessed that underwent a clear learning curve was the operative time, which took approximately 20 procedures to approach the same as the experienced surgeon.
Only limited data exists concerning outcomes after total knee arthroplasty (TKA) using a surgical robot. We conducted this study to evaluate the clinical and radiographical results in robotic-assisted implantation of TKAs with a minimum follow-up of two years.
A total of 50 primary TKAs using ROBODOC were included in this study. The mean duration of follow-up was 28.3 months. The radiographic measurement with regard to the change of mechanical axis, and the inclination of the femoral and tibial components were assessed. The value within ± 3° of optimum was classified to be “acceptable”, and the value exceeding more than ± 3° to be “outlier” results. Also we evaluated clinical results with the range of motion (ROM), Hospital for Special Surgery (HSS) scores, and Western Ontario and McMaster University (WOMAC) scores.
The mechanical axis was changed from 6.57 varus to 0.81 valgus. Mean coronal inclination of the femoral and tibial component were 88.61 and 89.76 at the last follow up. Also, mean sagittal inclination of the femoral and tibial component were 0.82 and 85.49. On the other hand, all prostheses had no radiolucent lines. On the clinical assessment, the range of motion improved from 124.9 to 128.4, and the improvement of HSS score and Womac score were 70.06 to 95.72 and 65.64 to 28.92 in each. No major adverse events related to the use of the robotic system have been observed. However, one case of the formation of seroma around the pin track and two cases of the partial abrasion of patellar tendon occurred in relation to procedures.
A surgical robot system in TKAs provides good clinical and radiographical results at least 2 years follow-up, however further study for the long term follow-up may be needed. A clear advantage of robot-assisted TKA seems to be ability to execute a highly precise preoperative planning and intraoperaive procedures. But current disadvantages such as increased operating times and inability of adjusting the preoperative planning during the procedure have to be resolved in the future.
Short leg radiographs remain the standard radiographs available in many UK hospitals. The aim of this study was to see if these radiographs are reliable when assessing the post-operative alignment of total knee arthroplasty in comparison to a Hip-Knee-Ankle (long leg) radiograph.
Twenty consecutive 6 week post-operative long leg radiographs, taken with a standardised protocol, and a short leg radiograph derived from the same digital image were each examined on two separate occasions by two observers. On the long leg radiograph the anatomical and mechanical axis were calculated and on the short leg radiograph the anatomical and surrogate mechanical axis were calculated. These data were used to investigate intra- and inter-observer error. A single observer also collected the same measurements on an additional 30 radiographs (total of 50) to further investigate any patterns of error.
On long leg radiographs, intra-observer agreement was good for both anatomical and mechanical axis for both observers (Intraclass Correlation Coefficients [ICC] of 0.95 to 0.98). The anatomical axis on short leg radiographs was also good (ICC = 0.92 and 0.76). Intra-observer agreement for the short leg radiograph derived mechanical axis was not as consistent (ICC = 0.73 and 0.56). Inter-observer variability was good for long leg radiographs for both anatomical (ICC = 0.89) and mechanical (ICC = 0.95) axis. On short leg radiographs, however, agreement was not as good, in particular for the mechanical axis (ICC = 0.51), but also the anatomical (ICC = 0.73). Taking the long leg radiograph values as the “gold standard” there was a difference in the magnitude of errors seen on short leg radiographs dependant on the knee alignment. Varus aligned knees (n=24) had an average error of 1.2° (0° to 3°) for the anatomical axis and 1.6° (0° to 4°) for the mechanical axis. Perfectly aligned knees (n=8) had an average error of 3.0° (1° to 6°) for the anatomical axis and 2.9° (1° to 5°) for the mechanical axis. Valgus aligned knees (n=18) had an average error of 3.4° (0° to 8°) for the anatomical axis and 5.8° (2° to11°) for the mechanical axis. Using a Mann-Whitney test the magnitude of error was greater for valgus knees for both anatomical (p< 0.0001) and mechanical (p< 0.00001) axes when compare to varus knees. Interestingly all except one knee measured on the long leg radiograph as valgus aligned appeared to be in varus on the short leg radiograph.
In conclusion, short leg radiographs are inadequate to make any comment on leg alignment in total knee arthroplasty. This is most pronounced in a valgus aligned knee.
Long term successful results of high tibial osteotomy (HTO) strongly depend on the degree of correction, and inadequate intraoperative measurements of the leg axis can lead to under or over correction, and surgeons have to solve these problems based on personal experience.
This study was undertaken to investigate and compare the clinical and radiological results of navigation assisted open wedge high tibial osteotomy (HTO) versus conventional HTO at 12 months after surgery, for unicompartmental gonarthrosis.
Forty navigated open HTOs with an anterior opening gap of approximately 70% of the posterior gap were included and compared with forty open HTOs performed using the conventional cable technique in terms of intraoperative leg axis assess.
Navigated HTOs corrected mechanical axes to 2.9° valgus (range 0.5–6.2) with few outliers (12.5%), and maintained posterior slopes (7.9±2.3° preoperatively and 8.3±2.8° postoperatively) (P> 0.05). However, in the conventional group, only 63% of cases were within the satisfactory range (valgus 2–5°), and tendencies toward undercorrection and an increase in posterior slope were observed. Clinically both groups showed satisfactory results.
Navigated HTO significantly improved the accuracy of postoperative mechanical axis and decreased correction variabilities with fewer outliers.
Total knee arthroplasty (TKA) is actually a satisfactory technique to reduce pain and enhance mobility in osteoartritic pathologies (OA) of the knee. However, life of the implant is strictly dependent on restoration of correct knee kinematics, as alteration of motion pattern could led to abnormal wear in prosthetic components and also damage soft tissues. The aim of our study was to evaluate new kinematic tests to be performed during surgery in order to improve the standard intra-operative evaluation of the outcome on the individual case. We used Kin-Nav navigation system to acquire anatomic and kinematic data, which were analysed by a dedicated elaboration software developed at our laboratory. Ten patients undergoing rotating platform cruciate substituting TKA were considered for this study. Immediately before the implant and immediately after component positioning, the surgeon performed 3 complete knee flexion imposing internal tibial rotation (IPROM) and 3 complete knee flexion imposing external tibial rotation (EPROM). Tibial rotation during IPROM and EPROM tests was plotted in function of flexion (in the range 10°–110°). Repeatability of IPROM and EPROM was tested by calculating ICC (Intra-class Correlation Coefficient) between 3 repeated curves. Distance between IPROM curve and EPROM curve was computed at various degree of flexion. Maximum distance obtained during all range of flexion before and after the implant were compared by Student’s t-test (significant level p=0.05).
ICC for repeated motions were 0.99 for IPROM and 0.98 for EPROM. Maximum distance between tibial rotation in IPROM and EPROM was 27.82±6.98 before implant and significantly increased (p=0.001) to 40.09±6.92 after TKA. In one case we observed that the value remained similar before and after implant (from 33.11 to 33.98) while in one case we observed very large increase of rotation (from 30.56 to 50.01).
The proposed kinematic tests were able to quantify the increase of tibial rotation after TKA implant. Future development of the study are encouraging and will include a larger sample and reflections on individual findings.
In orthopaedic trauma surgery, X-ray fluoroscopy is frequently employed to monitor fracture reduction and to guide surgical procedures where implants are inserted to fix the fractures. Fluoro-navigation is the application of real-time navigation on intraoperatively acquired fluoroscopic images to achieve the same goals. The theoretical advantages of fluoro-navigation are:
Minimising exposure to X-ray on surgeons, operating room personells and patients, Accurate positioning of implants, Expanding the application of minimally invasive surgery, Shortening the operation time
Fluoro-navigation is particular indicated in orthopaedic trauma as the fracture fragments are mobile and the orientations are not fixed before surgery. At this time, many procedures that require intraoperative fluoroscopic control can now be done with fluoro-navigation. These procedures include:
Fixation of femoral neck fractures with percutaneous cannulated screws, Intramedullary locked nails for long bone fractures, Intramedullary fixation of trochanteric fractures Percutaneous fixation of sacro-iliac fractures dislocations Percutaneous fixation of iliac wing fractures Percutaneous fixation of acetabulum fractures Insertion of Ilizarov tension wires for complex articular fractures Many percutaneous fixation procedures that need fluoroscopic controls
Since 2001, we have been using fluoro-navigation orthopaedic trauma surgery. 535 different procedures of operative treatment of fractures were carried out. These operative procedures included. Operation, amount, success rate:
Femoral neck fractures, 65, 100%, Gamma nailing, 172, 100%, Femoral locked nails, 77, 98.5%, Tibial locked nails, 53, 100%, Sacro-iliac screws, 45, 95.1%, Pelvic acetabular fractures, 29, 96.1%, Ilizarov tension wires, 13, 100%, Percutaneous screws, 18, 100%, Distal locking without X-ray, 15, 100%, 3-D Navigation, 48 92.7%.
Our clinical experience has confirmed the advantages and the extended applications of this technique benefited many of our patients by enhancing minimally invasive technique in orthopaedic trauma surgery, better implant position and significantly decreasing the radiation of the fluoroscopy (p< 0.05). We have modified the operative procedures in order to adapt better with the fluoro-navigation procedures. We also worked with the industrial partners to design specific instruments as well as modified the existing surgical instruments to facilitate the fluoro-navigation procedures. Most of the failure were due to poor quality fluoro-images, unstable operating system and poorly adapted surgical instruments in the early phase of the applications.
Further improvement is expected in the system on the hardware and software for quicker image acquisition with improved quality, accurate and precise registration, increase interactivities and adaptation of surgical instruments as well as implants. There is a great need for the development of dedicated surgical instruments for orthopaedic trauma sugary in line with the further improvement of the navigation system. With the establishment of image libraries for implants and skeleton, further minimising the need for standard fluoroscopy will be possible. The combination of 3-D fluoroscopy and the navigation will improve percutaneous fixation of articular fractures. At the time, it is only possible to navigate the images obtained during the operation after fracture reduction or manipulation is completed. The possibility to navigate on each individual fracture fragment will extend the technique even more to real-time fracture reduction.
The fluoro-navigation system will also play an important role in surgical training as well as assessment in the virtual surgical environment. We also developed specific training models for fluoro-navigation for preoperative training and practice of standard procedures. This will help to promote further application of fluoro-navigation in orthopaedic trauma.
The recognition of its clinical significance will help to stimulate more research and thus encourages industries to devote more resources in the development of fluoro-navigation for orthopaedic trauma.
Flexion contracture is a common deformity encountered in patients requiring total knee arthroplasty (TKA). Both the soft tissue envelope and articular bones are involved in the knee extension lag. A few studies in the past have assessed the relationship between bone cuts and extension deficit by using goniometers and rulers. Using navigation for TKA enables the accurate measurement of knee flexion contracture and bone cuts. The aim of this study was to try to establish a relationship between extension lag correction and the size of bone cuts made.
One hundred and four continuous TKA were completed by a single consultant using the OrthoPilot® (BBraun, Aesculap) navigation system and Columbus implants. Seventy-four knees had preoperative flexion contracture (including neutral knees) while 30 were in hyperextension. Data was recorded prospectively using the navigation system. These included preoperative flexion and extension angles, actual bone cuts of tibia and femur (both medial and lateral), postoperative correction of flexion and extension angle, size of the prosthesis with thickness of polyethylene and soft tissue release. Of the 74 knees with fixed flexion, 57 had no release and 13 had a posterior release (four had an intermediate release and were excluded from the study).
For knees with fixed flexion (n = 70) there was a significant statistical difference between the pre and post implant extension angle (p < < 0.0001). There was no correlation between the thickness of bone cuts and postoperative extension lag either for the group with no release (p = 0.495) or posterior release (p = 0.516). There was also no correlation between bone cuts and preoperative angles for either type of release (p = 0.348 and p = 0.262). There was a significant difference between the preoperative extension deformity for the two soft tissue releases performed (p = 0.00019), the mean fixed flexion angles being −4.4° and −10.4° for no release and posterior release respectively.
Flexion contracture deformity in TKA can theoretically be solved in two ways: either by extensively releasing the soft tissue or by increasing the extension gap by cutting more bone (logically the distal femur). Appropriate soft tissue management and release in TKA is crucial in balancing the prosthesis in the coronal as well as the lateral plane. This study seems to confirm the supremacy of soft tissue management and release over bone cut resection. Cutting more or less bone could in fact lead to a poorer outcome as this will change the joint line level without having any additional beneficial effect in correcting the flexion contracture. Conversely adequate soft tissue release has corrected the flexion contracture when needed. In conclusion, there was no correlation between bone cut resection and extension lag correction and with large extension deficits, a posterior soft tissue release and osteophytes resection was more important than bone cuts.
Information on knee kinematics during surgery is currently lacking. The aim of this study is to describe intra-operative kinematics evaluations during uni-compartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) by mean of a navigation system. Anatomical and kinematic data were acquired by Kin-Nav navigation system and analysed by a dedicated elaboration software developed at our laboratory. The study was conducted on 20 patients: 10 patients undergoing mini-invasive UKA and 10 patients undergoing posterior-substituting-rotating-platform TKA. In both group of patients the surgeon performed passive knee flexion immediately before and immediately after the prosthetic implant. Pattern and amount of internal/external tibial rotation in function of flexion were computed and significant changes between before and after implant were evaluated adopting Student’s t-test (significant level p=0.05).
UKA implant did not significantly change the pattern of internal/external tibial rotation, nor the total magnitude of tibial rotation (15.75°±7.27°) during range of flexion (10°–110°), compared to pre-operative values (17.87°±7.34°, p=0.25). Magnitude of tibial rotation in TKA group before surgery (8.00°±3.67°) was significantly less compared to UKA patients and did not changed significantly after implant (5.96°±4.88°, p=0.09). Pattern of rotation before and after TKA implant were different between each other and between pattern in UKA patients both before and after implant.
Intra-operative evaluations on tibial rotation during knee flexion confirmed some assumptions on knee implants from post-operative methods and suggest a more extensive use of surgical navigation systems for kinematic studies.
Flexion contracture in total knee arthroplasty (TKA) remains a challenge. Soft tissue management and additional bone resection are traditional options for flexion contracture correction. Our hypothesis was that the post implant computer aided measurements would not be significantly different to the extension angles measured at six weeks post-operatively in the follow-up clinic.
One hundred continuous TKA were performed by a single consultant using the OrthoPilot® (BBraun, Aesculap) navigation system and Columbus implants. Of the group, 45 were male and 55 were female. Average age was 68 (range 49–87), mean BMI was 32.86 (22.26–51.86) and mean Oxford score preoperatively was 42 (range 21–56) and post-operatively 28 (range15–50). Data recorded at the preoperative assessment clinic included clinical flexion contracture and Oxford scores. Intra-operatively data were recorded using the navigation system. These included pre-operative flexion and extension angles, actual bone cuts of tibia and femur (both medial and lateral), postoperative correction of flexion and extension angles and soft tissue releases. At six weeks post operation, patients were seen in the follow clinic and clinical flexion contracture and Oxford score reassessed by the Arthroplasty outcome service.
Measurements were grouped and comparisons were made using a Pearson Chi-square test. There was no relationship between post-implant extension angle measurements (by computer) and extension angles at six weeks (by goniometer) (p=0.682). Also, there was no relationship between pre-operative measurement angles collected at the pre-assessment (by goniometer) and the pre-implant angles measured on the table (by computer) (p=0.682). We found that BMI (up to 35) and postoperative Oxford scores were significantly related to the extension levels with values of (p=0.008) and (p=0.027) respectively. Pre-operative Oxford scores, pre-operative extension, amount of bony resection and soft-tissue releases did not show any significant relationship with the post-operative extension obtained at six weeks.
The conclusions that we draw from this study are that there might be other factors that are likely to influence extension lag between the operation and the follow-up at six weeks. One of the factors that we could identify was the BMI. Attention to extensor lag is important because it leads to a poorer knee function, as indicated by the Oxford scores. Despite most of the post-implant measurement angles showing no extensor lag, about 20% of our patients still had more than five degrees flexion contracture at six weeks.
Computer assisted total knee arthroplasty (TKA) enables the measurement of the dynamics of the knee both before and after the implant of the prosthesis. Much time has been spent looking at the outcomes of navigated TKA however less time has been invested on understanding how the data collected pre-operatively can inform the surgeon and help the surgical decision making process. The aim of this work was to use navigation as a tool to quantify and classify preoperatively valgus knees.
Between August 2006 and September 2007 a group of 51 patients who demonstrated intra-operative initial neutral or valgus aligned knees underwent navigated TKA using the Columbus knee prosthesis and the Orthopilot® navigation system (BBraun, Tuttlingen, Germany). Demographic data were recorded, along with the preoperative radiograph appearance and clinical assessment of alignment. During the surgery the approach used and the knee mechanical femorotibial (MFT) angle though the range of flexion were recorded. The knees were then categorised as either “True” valgus or “False” valgus based on whether the MFT angle at 30°, 60° and 90° flexion was still valgus (True) or had gone into varus (False).
Five patients were excluded from the study group as they had incomplete data in knee flexion. Of the remaining 46 patients, 28 were True valgus and 18 were False valgus. For the two groups demographic data were compared. Male to female ratio was 9:19 for the True valgus and 4:14 for the False valgus. The mean age of the True group was 70 years (range 52–85 years) and the False was 69 years (range 53–84 years). For BMI the True group had mean of 31 (range 20–40) and False of 33 (range 26–42). Twenty-five of the 28 True valgus knees showed preoperative evidence of clinical genu valgum deformity and radiologic evidence of predominantly lateral compartment osteoarthritis. Five patients had ipsilateral hip replacements in the past and five had rheumatoid arthritis. Seventeen were operated by lateral parapatellar approach. Eighteen required ilio-tibial band release with additional lateral collateral ligament release in five knees. Six true valgus knees did not require any soft tissue release. Five patients required lateral retinacular release to achieve thumb free patellar tracking. The median operating time for the True valgus group was 80 mins. Ten of the 18 false valgus knees showed evidence of clinical varus deformity and radiological evidence of predominantly medial compartment osteoarthritis. Only one patient had an ipsilateral hip replacement in the past and one had rheumatoid arthritis. All 18 knees underwent TKA by medial parapatellar approach, requiring no additional soft tissue release in 17 knees and a moderate release in one knee. The median operating time for the False valgus group was 60 mins.
True valgus knees had more significant deformities clinically and radiologically, longer surgical time and more incidence of soft tissue release when compared to the False valgus knees. False valgus knees behaved like varus knees clinically, radiologically and intra-operatively and should therefore be treated as such when making surgical choices.
Although acetabular centre positioning has a profound effect on hip joint function, there are very few studies describing accurate methods of defining the acetabular centre position in 3D space. Clinical and plain radiographic methods are inaccurate and unreliable. We hypothesize that a 3D CT-based system would provide a gender-specific scaled frame of reference defining the hip centre coordinates in relation to easily identifiable pelvic anatomic landmarks.
CT scans of thirty-seven normal hips (19 female and 18 male) were analysed. The ratios of the hip centre coordinates to their corresponding pelvic dimensions represented its horizontal (x), vertical (y), and posterior (z) scaled offsets (HSO, VSO, and PSO).
The mean HSO for females was 0.08 ± 0.018, mean VSO was 0.35 ± 0.018, and mean PSO was 0.36 ± 0.017. For males HSO averaged 0.10 ± 0.014, VSO was 0.32 ± 0.015, and PSO was 0.38 ± 0.013. There was a statistically significant gender difference in all three scaled offsets (p=0.04, 0.002, and 0.03 for HSO, VSO, and PSO respectively). Inter-observer agreement tests showed a mean intra-class correlation coefficient of 0.95.
We conclude that this frame of reference is gender-specific giving a unique scale to the patient and allowing reliable derivation of the position of the hip centre from the pelvic dimensions alone. The gender differences should be borne in mind when positioning the centre of a reconstructed hip joint. Using this method, malpositioning, particularly in the antero-posterior (or z) axis, can be identified and addressed in a malfunctioning hip replacement. Pathological states, such as dysplasia and protrusio, can also be accurately described and surgery addressing them can be precisely planned.
The role of CAOS systems is now well established in several areas of orthopaedic surgery. The increasing use of these systems, particularly in knee arthroplasty, has been supported by clinical trials that demonstrate a more accurate final position of implanted devices compared with conventional instrumentation. CAOS technology is constantly evolving along with its expanding list of potential indications. This requires the adaptation of both software and hardware components. It is therefore essential that potential users have confidence in the accuracy of these systems. The aim of this project was to design and manufacture a standardised measurement object (phantom) to independently evaluate CAOS system performance.
The American Society for Testing and Materials (ASTM) International along with CAOS International recently drafted a standard for measuring technical accuracy of navigation systems. This proposed standard was obtained and its recommendations used to design a phantom model. This consisted of a 150×150×20mm base plate and two additional levels including a single 30° slope. This created a 3D surface on which points could be placed. Co-ordinates for 21 points were given to establish the x, y and z axes of a Cartesian system and then to have points at a variety of known locations in this 3D space. The final model was machined from a billet of marine grade aluminium alloy 6082-T6 (chosen for its dimensional stability) using a vertical computer numerical controlled (CNC) milling machine with the co-ordinate points drilled with a Ø0.8mm 60° BSO centre drill to a depth of 1.2mm. The drill holes, with chamfers of Ø1.0mm, were designed to accommodate a ball-nosed pointer tip of a known diameter. A Perspex base unit with three different sites of rigid tracker attachment was made to hold the phantom and provide its reference frame. This avoided the need to directly modify the phantom itself.
The final design has been used to measure the positional accuracy of a novel portable navigation system and demonstrate that it is not yet suitable for clinical evaluation due to errors of 1 – 6 mm in point location. It has also allowed independent technical validation of current pre-existing navigation systems.
Background: Leg length equality and femoral offset restoration are important parameters related to success of total hip arthroplasty (THA). However, it is not uncommon for errors to occur during surgery which can lead to less optimal functional result and potential source for litigation. Several techniques that are commonly used to assess leg length and femoral offset during THA include pre-operative templating, intra-operative measurements with a ruler using bony landmarks, assessing soft tissue tension and using measurement device with a reference pin in the iliac crest. We have previously reported on our precision to reconstruct the diseased hip with THA done without navigation. Post-operative radiographic analysis demonstrated that leg length was restored to within +/− 4mm of the contralateral side in only 60% of the patients with 4 patients needing a shoe lift. With regards to femoral offset reconstruction, it was increased by a mean of 5.1 mm and restored to within +/− 4mm of the normal contralateral side in only 25% of patients.
Computer navigation has proven to be a more precise tool to achieve optimal positioning of THA implants and precise biomechanical reconstruction of the hip joint. However, performing complete THA using navigation is complex including the requirement to change the position of the patient during registration. A recent stand-alone CT-free hip navigation software from Orthosoft Inc allows navigation to be used for limb length and offset measurements during THA. We report our results from a preliminary study using this technique in 14 hips undergoing THA.
In this technique, a tracker is placed over the iliac crest. There is no need to fix a tracker on the femur. Registration of the following are done: greater trochanter (using a screw), patella (using an ECG lead) and the plane of the operating table (using three points on the surface of the operating table in a triangular configuration). The centre of rotation of the hip is determined by either mapping the acetabulum or by using the appropriate sized calibrated reamer. With the definitive acetabular component in place, the new center of rotation is registered and the hip is reduced with trial femoral component. Re-registration of the new position of the greater trochanter and patella allows the computer to calculate the relative change in the limb length and offset compared to the pre-operative status. The differences in the pre-operative and post-operative limb length and offset were calculated using Imagika software and compared with the navigated values recorded by the computer.
The mean absolute error for the relative change in the limb length as measured by the computer when compared to the radiographic measurement was 1.25 mm with a standard deviation of 1.77 mm. The mean absolute error for the relative change in the offset as measured by the computer when compared with the radiographic measurement was 2.96 mm with a standard deviation of 2.56 mm. The process of navigation was quick and on average adds 10 minutes to the operative time.
Our preliminary study shows that the accuracy of the navigation software is very good in estimating the change in the limb length intra-operatively with a maximum error of 3 mm. The accuracy was also good in estimating the offset (3 mm or less except in one case where the error was 5 mm and this may be due to technical error in registration). This compares favorably with our own data on THA done without navigation. This easy to use navigation technique has the potential to decrease the magnitude of error in restoration of limb length and offset during THA.
We thank Francois Paradois and Michael Lanigan from Orthosoft Inc. for their technical advice.
The rotational alignment of the tibia is an as yet unresolved issue for arthroplasty surgeons. Functional variation may be due to minor malrotation of the tibial component. The aim was to find a reliable method for positioning the tibial component in arthroplasty.
CT scans of 21 knees were reconstructed in three dimensions and oriented vertically. A plane was taken 20 mm below the tibial spines. The centre of each tibial condyle was calculated from points taken round that condylar cortex. A tibial tubercle centre was also generated as the centre of the circle that best fit points on the surface of the tubercle in the plane of its most prominent point.
The derived points were identified by three observers with errors of 0.6 – 1mm. The medial and lateral tibial centres were constant features (radius 24mm ± 3mm, and 22mm ± 3mm respectively). An ‘anatomic’ axis was created perpendicular to a line joining these two points. The tubercle centre was found 20mm ± 7mm lateral to the medial tibial centre. Compared to this axis, an axis perpendicular to the posterior condylar axis was internally rotated by 6° ± 3°. An axis based on the tibial tubercle and the tibial spines was also internally rotated by 6° ± 10°.
We conclude that alignment of the knee when based on this ‘anatomic’ axis is more reliable than either of the posterior surfaces. It is also more reliable than any axis involving the tubercle, which is the least reliable feature in the region. The ‘anatomic’ axis can be used in navigated knee arthroplasty for referencing the rotational alignment of the tibial component.
Radiological measurements are an essential component of the assessment of outcome following knee arthroplasty. However, plain radiographic techniques can be associated with significant projectional errors because they are a two-dimensional (2D) representation of a three-dimensional (3D) structure. Angles that are considered within the target zone on one film may be outside that zone on other films. Moreover, these parameters can be subject to significant inter-observer differences when measured. The aim of our study therefore was to quantify the variability between observers evaluating plain radiographs following Unicompartmental knee arthroplasty.
Twenty-three observers, made up of Orthopaedic Consultants and trainees, were asked to measure the coronal and sagittal alignment of the tibial and femoral components from the post-operative long-leg plain radiograph of a Unicompartmental knee arthroplasty. A post-operative CT scan using the low dose Imperial knee protocol was obtained as well and analysed with 3D reconstruction software to measure the true values of these parameters. The accuracy and spread of the pain radiographic measurements were then compared with the values obtained on the CT.
On the femoral side, the mean angle in coronal alignment was 1.5° varus (Range 3.8, SD 1, min 0.1, max 3.9), whereas the mean angle in sagittal alignment was 8.6° of flexion (Range 7.5, SD 1.5, Min 3.7, Max 11.2). The true values measured with CT were 2.4° and 11.0° respectively. As for the tibial component, the mean coronal alignment angle was 89.7° (Range 11.6, SD 3.3, Min 83.8, Max 95.4), and the mean posterior slope was 2.4° (Range 8.7, SD 1.6, Min -2, Max 6.7). The CT values for these were 87.6° and 2.7° respectively.
We conclude that the plain radiographic measurements had a large scatter evidenced by the wide ranges in the values obtained by the different observers. If only the means are compared, the plain radiographic values were comparable with the true values obtained with CT (that is; accuracy was good) with differences ranging from 0.3° to 2.4°. The lack of precision can be avoided with the use of CT, particularly with the advent of low-dose scanning protocols.
To evaluate short term results of 126 computer assisted unicompartmental knee arthroplasty (UKA) with ligament balancing.
Between September 2003 and November 2007 we performed 126 computer asssited surgery UKA Preservation. We using kinematic navigation Ci system. This is cemented system with mobile or fixed bearing. Our groups included 72 women and 54 men. Average age at surgery was 71,2 years. The indication for UKA include primary or postraumatic osteoarthritis limited to one compartment, a functional anterior cruciate ligament, no inflamatory disease. In all cases was only medial femorotibial osteoarthritis. Arthroscopic partial medial menisectomy was performed in 25 cases. Approach: medial parapatellar arthrotomy. Clinical evaluation was performed by Hospital for Special Surgery knee scoring system (HSS). Imaging: AP,lateral and stress X-rays.
The average HSS score was 57 point (range, 40–79 points) preoperatively and 94 points (range 62–100 points) postoperatively. 90% patients were classified as excellent or good using the HSS. The average range of motion before surgery: S 0-0-120 gr., 6 days after surgery S 0-0-110 gr. and 3 months after surgery S 0-0-125 gr.
No significant difference in maximum flexion was seen between the preoperative and postoperative values. There were no infection, fracture of tibia plateau, poor pain, or sign of patellar impingement.
UKA together with modern design, reproductible instrumentation and kinematic navigation can eliminate the previous cause of early failures, contralateral tibiofemorial degeneration and tibial loosening. The patient’s selection must be strict regarding (the ideal patient more than sixty years old, low Body Mass Index, low demand of physical activity). Kinematic navigation reduces the possibility of surgeon’s mistake, alignement of the femoral and tibial component, resection level, soft tissue balancing. It increases the accuracy of the comoponent position, especially in the side of the tibia. A continued long term follow-up is necessary to evaluate polyethylene wear after 10 years.
To evaluate first short term results of the 82 Articular Surface Replacements (ASR) of the hip joint with kinematic navigation.
Between March 2006 and March 2007 we performed 82 resurfacings of the hip. In all cases we used Articular Surface Replacement of the Hip joint (ASR-DePuy) with kinematic navigation (Ci system). Our group included 47 women and 35 men. Patients’ mean age at surgery was 68.2 years. The indication for resurfacing was just primary osteoarthritis. Clinical evaluations were conducted using the Harris Hip Scoring system. Imaging studies: AP, axial X-rays.
Patients were followed for an average 12 months postoperative (7–20 months). The average postoperative Harris Hip Total Score was 97%, and 98% of the patients were in the good to excellent range of 80–100 points. No patients were lost to follow-up. We noted a greater range of movement, faster postoperative rehabilitation and shorter time of hospitalization compared with traditional total hip arthroplasty. There were no cases of neurological complication, deep infection, wound dehiscence or dislocation. All X-rays refer correct position of femoral component in both projections. Our experiences with Articular Surface Replacement of the Hip Joint (ASR-DePuy) powered by Ci navigation system are good, but long term followup will be continued.
Articular Surface Replacement of the Hip Joint with modern design, reproductible instrumentation and kinematic navigation can eliminate the previous cause of early resurface failures and loosening. The patient selection must be strict regarding. The kinematic navigation define precise position of the components of ASR. A continued long term follow-up is necessary after minimum 10 years.
There are many reports in the literature about the benefits of computer-aided surgery with regards to improved limb alignment, reduced blood loss and embolic events but surgeons remain sceptical about its routine use because of availability, cost and time implications. To maximise these benefits and overcome the distractions, a modified navigation technique has been developed after evaluation of the standard measurements.
The true varus/valgus angle of the distal femoral cut achieved with navigation is unknown but represents presumed accurate alignment with regards to the mechanical axis through the femoral head. With placement of the femoral tracker in the medial supracondylar region clear of the intramedullary canal, the navigated cut was correlated with the cut placement determined with the standard intramedullary jig in 10 patients undergoing knee replacement. In addition, jigged femoral rotation was checked with the tracker placement. Tibial slope, varus/valgus angle and rotation were determined using surgeon placement of an external alignment jig and confirmed with tracker placement.
The navigated distal femoral cut ranged from +3 degrees to −2 degrees when measured against the distal cutting block stabilised over an intramedullary rod. The femoral rotation was within 1 degree of the trans-epicondylar line as outlined by navigation when a 3 degree externally rotated jig was used. All of the tibial measurements were within 0.5 degrees of the navigated planned positions.
The femoral cuts are presumed to be accurately determined with navigation as judged from long-leg alignment x-rays but this study highlights the potential error if a fixed valgus cut angle with alignment jigs is used. Tibial preparation, however, was accurately predicted by the surgeon using a traditional external alignment jig. Bone preparation time was reduced to 4 minutes (modified technique) compared to 12 minutes (full navigation, p< 0.05).
With this information, computer-aided navigation is now routinely used to determine the distal femoral cut only and an external alignment jig is used for tibial preparation without navigation. The reduction in blood loss and embolic events and improved limb alignment is now achieved with a reduction in preparation time over full navigated techniques. Use of the pinless surface mounted femoral jig alone highlights these advantages further.
One of the most important factors on which Total Knee Replacements results depend is accuracy of restoration of normal mechanical axis. It is believed that computer navigated TKR give better implants position therefore should improve long term results. We decided to check if computer navigation actually improves restoration of mechanical axis and implants placement in a single surgeon, single implant type series. We prospectively assessed 58 patients (60 knees). Each group (navigated versus non navigated) consisted of 30 knees. Patients were assessed clinically and radiographically using weight bearing full-length AP and short lateral films (PACS and IMPAX software). Clinical Results at 2 years were comparable in both groups (89% vs. 88% good or excellent result). Radiological results proved to be better in navigated knees regarding mechanical axis. There were no statistically important differences in other radiological parameters.
This prospective study is designed to assess intra-operative trauma to soft tissue envelope around the knee joint especially quadriceps due to rigid body fixation on the femur and its influence on rehabilitation outcome obtained using a kinematic navigation system for TKR. We also evaluated the impact of the extra time needed to adopt this system on immediate post-operative rehabilitation.
One hundred and sixteen operations were performed with the aid of the kinematic navigation system. Results, including operation time, radiographic alignment of the prosthesis and complications, were compared with non-navigated group. Outcome measures included preoperative knee function, intra-operative factors, blood loss and postoperative rehabilitation.
The operation time (from skin to skin) in the navigation group was average 32 minutes longer compared historical controls. No major complications such as delayed wound healing, infection or pulmonary embolism occurred during this study. Mean blood loss in both the group showed no difference
A higher incidence and duration of early postoperative quadriceps dysfunction was not associated with computer-assisted TKA through the lateral Para patellar approach. No patient who received surgery had a lag of more than 20 degrees, at 48 hours postoperatively, regardless of the duration of intra-operative time used.
Although the total surgical time was longer, it does not translated into increased postoperative morbidity. Use of a kinematic navigation system has a short learning curve, and requires an additional operation time of less than 32 minutes. We found no impact of patients’ perioperative times on short-term outcomes obtained during our learning curve and next two years. The mechanical axis of the leg was within 3 degrees of neutral alignment along with accurate component alignment. The Computer-assisted TKA through a lateral parapatellar approach was not associated with delayed recovery of the patients during early postoperative rehabilitation.
The Authors performed a matched paired study between 2 groups UKR or CA-TKR implanted with a mini-incision (MICA group) in the treatment of isolated medial compartment knee arthritis. The Authors hypothesized that UKR offers a real less invasive surgery with lower economical costs despite a worse limb/implant alignment. Furthermore at a minimum 40 months follow-up they hypothesized that this small implant guarantees still both better clinical score and patient satisfaction than in the MICA group.
Thirty two patients with isolated medial compartment knee arthritis who underwent to a medial UKR from February 2001 to September 2002 were included in the study (UKR group). In all 32 knees the arthritic change was graded according to the classification of Älback 1. Arthritic change did not exceed grade IV in the medial compartment and grade II in the patello-femoral compartment. All patients had an asymptomatic patello-femoral joint. All patients had a varus deformity lower than 8° and a body mass index lower than 30. No patient had any clinical evidence of ACL laxity or flexion deformity and all had a preoperative range of motion of a least 110°. At a minimum follow-up of 48 months, every single patients in group A was matched with a patient who had undergone a computer assisted TKR performed with a less invasive approach (shorter than 12 cm) for an isolated medial compartment knee arthritis between August 1999 and September 2002 (MICA group) in our hospital. At latest follow-up the clinical outcome was evaluated using both the Knee Society Score and a dedicated UKR score developed by the Italian Orthopaedic UKR Users Group (GIUM). The HKA angle and the Frontal Tibial Component angle (FTC) were measured at latest follow up on long leg standing anterior-posterior radiographs and the mean values between the 2 surgeons assessments were used as final values. Furthermore during the hospital staying we registered in both the groups when each patient was standing comfortably in full weight-bearing according to a self- answered questionnaire and the data were compared. Statistical analysis of the results was performed using parametric test (Student’s t-test). A statistical comparison of the percentage of results for the GIUM score was performed using the Chi-square test. A statistically significant result was given a p≤ 0.05.
Both hospital stay and operative time were statistically longer obviously in MICA group. In the UKR group the mean surgical time was 51.5 minutes (range: 36–75) (p< 0.001) while in the MICA group was 108.8 minutes (range: 80–132) (p< 0.001). In the UKR group the patients remained in the hospital for a mean of 5.1 days (range: 3–7) and in the MICA group 8.2 days (range: 4–16). At the latest follow-up the mean Knee Society Score was 80.5 (range: 70–100) and 78.4 (range: 70–87) for group A and B respectively. No statistically significant difference was seen for the Knee Society score between the 2 groups (p=0.08). The mean Functional score was 83.5 (range: 73–100) for group A and 78.8 (range: 59–90) for group B. A statistically significant difference was seen for the Functional score with superior results for group A (p=0.02). A statistically significant difference was seen for the GIUM score with better results for group A (p=0.01). The mean GIUM score was 76 (range: 67–90) and 73.02 (mean: 65–85) for group A and B respectively. At latest follow up the mean HKA angle was 176.8° for group A (range: 174°–182°) and 179.3° for group B (range 177–182) (p< 0.001). The mean FTC angle was 86.9° (range: 84°–90°) and 89.4° (range: 87°–92°) for group A and B respectively (p< 0.001). All TKR implants were positioned within 4 degrees of a HKA angle of 180° and FTC angle of 90°.
At the latest follow-up (minimum 48 months) no statistically significant difference was seen in the postoperative Knee Society score for either group. However, significant differences were seen between the 2 groups in the functional results and in the GIUM score with better results in the UKR group. All the patients achieved a range of motion greater than 120° and could walk for longer distances. During the hospital staying in this group the patients reported a statistically significant earlier full weight-bearing. This was despite a significant less accurate limb alignment. In addition to inferior results for the computer assisted mini-invasive TKR group the costs of the procedure were obviously greater because of the expensive implants and technology along with statistically significant longer surgical times and hospital stay
The aim of this work was to compare the oxygen saturations in patients in the early period following total knee joint replacement surgery performed using either computer navigation or conventional intramedullary mechanical jigs.
Between August and November 2007 twelve consecutive patients who had computer navigated total knee joint replacements were prospectively reviewed. A comparison group from the same period was made of twenty patients who had knee replacements performed with conventional jigs in this same period. Non-invasive oxygen saturations were measured and recorded as a percentage. Preoperative oxygen saturations measured at the assessment clinic were used a baseline. For the duration of the patients postoperative hospital stay oxygen saturations were measured five times a day as well as their oxygen requirements.
We found that the patients in the computer navigation group on average reached oxygen saturation levels on air equal to those measured in the assessment earlier than the intramedullary jig group (2.2 days versus 2.8 days). There was also a lower need for oxygen and shorter length of stay in the computer navigated group during this early post operative period (4.6 versus 6.0 days).
Previous studies using transcranial Doppler and transoesophageal echocardiograms have shown a reduction of systemic emboli with computer navigated total knee joint replacements. Using oxygen saturation monitoring we have shown there may be a considerable clinical advantage using computer navigated surgery over conventional intramedullary jigs in knee replacement surgery.
Navigated Total Knee Arthroplasty (TKA) is a new technique in our hospital. Any new procedure can be associated with both technical difficulties and difficulties due to patient and theatre staff expectations. The aim of this study was to demonstrate our learning curve and assess patient and staff acceptance. We highlight common technical problems unique to navigation and offer our solutions.
A prospective study of 231 consecutive Emotion TKA were implanted over a 30 month period with Orthopilot version 4.2 Navigation system using soft tissue management (BBraun Aesculap, Tutlingen). They were done by a single knee surgeon previously experienced only in non-navigated TKA. Patient height and weight were measured preoperatively and the BMI calculated. Tourniquet times were recorded digitally with fixed timing criteria. Informed consent was obtained.
Our results showed a significant decrease of tourniquet time with experience (p=< 0.0001) with other possible factors being preoperative deformity and BMI. There was full patient acceptance with the exception of the first patient. The surgical team had to modify patient positioning on the operating table, setup of the theatre and navigation equipment, placement of the scrub staff and delegation of tasks.
Navigated Emotion TKA with Orthopilot software provided a comfortable learning curve. It was readily acceptable to patients and staff and has been adopted as our standard practice. The discussion of problems and the introduction of solutions had a positive effect on building our team. Further investigation is needed to elucidate other variables that affect the tourniquet time.
To study intra- and inter-observer variability with the use of the ultra-sound transducer and percutaneous digitiser point probes
To assess the learning curve with the use of the ultrasound transducer probe
As part of a larger cadaver study evaluating navigated total hip replacement via the posterior approach, we assessed data relating to acquisition of bony landmarks of the Anterior Pelvic Plane (APP) by four surgeons with an ultrasound transducer and a percutaneous point probe. The surgeons had differing levels of experience with hip surgery in general, and also with surgical navigation per se, but none of them had previously used the ultrasound probe for the specific purpose of landmark acquisition.
Without fixing an absolute positional value for any of the bony landmarks, the points registered for individual landmarks by each surgeon were then studied, looking at the three-dimensional spread of these points relative to each other about the mean value. The data from all four surgeons were analysed, looking at the global dispersion of points acquired by the ultrasound and percutaneous point digitiser probes.
Our results show that with the exception of a few isolated outliers, the ultrasound probe generated values fell within a +/− 10 mm range. For all four surgeons, the global spread of ultrasound-registered points was noted to be less than that acquired by percutaneous point probe acquisition. Of interest was the finding that points registered by individual surgeons using the ultrasound probe tended to be grouped distinctly together but spatially separate from those of the other surgeons; it would appear that each operator was “homing” in on what he perceived to be the bony landmark in question on the projected ultrasound image.
With the percutaneous pointer probe, and with the anterior superior iliac spines as the target, there was closer grouping of points around the mean positional value for the two surgeons who were experienced with its use. However, at the symphysis pubis, the spread of points for these surgeons were not much different from the other two less experienced one, with these points showing a global spread as great as 25 mm.
Regardless of the experience of the surgeon, the use of the ultrasound transducer probe appears to be more accurate than percutaneous pointer probe for acquisition of the bony landmarks that constitute the anterior pelvic plane. The learning curve associated with its use is seemingly short and steep. Its accuracy is limited by the fact that the identification of the bony land marks on the on-screen display is open to interpretation by the individual. Methods to standardise the identification of these landmarks on ultrasound images may help improve its accuracy in the future.
Valgus knees present a surgically demanding challenge. Dissimilar bone and soft-tissue deformities compared to varus knees complicate restoration of proper alignment, positioning of components, and attainment of joint stability. Our study examined the relationship between tourniquet time and valgus deformity.
A prospective study of all valgus knees were implanted over a 30 month period with Emotion Ortho-pilot version 4.2 Navigation system (BBraun Aesculap, Tutlingen). They were done by a single knee surgeon. Tourniquet times (TT) were recorded digitally with fixed timing criteria. The software recorded all pre- and post-operative deformities. We performed the lateral parapatella approach for all valgus knees. No patella resurfacing was done but all tibiae were cemented.
There were a total of 56 valgus knees (1° to 22°, Mean 5.9°, SD 4.9). The TT varied from 42 min to 121 min (mean 72 min, SD 17.4). There was a statistically significant relationship between TT and Valgus deformity. Tourniquet Time = 59.6 + 2.1 * Pre-operative Valgus (p= < 0.0001, R2 = 36.4%)
Thirty six percent of the observations were explained by this analysis. Other factors will need to be considered in future studies. This equation can be used as a guide in the allocation of theatre time. It applies to a specific surgical team and we would expect different teams to have different coefficients. This may be useful in comparisons of different teams.
To describe our experience with computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy. It may provide long-term symptom relief and improved function in patients with medial knee arthrosis and ACL-deficiency, while delaying or possibly eliminating the need for further surgical intervention such as arthroplasty.
Two patients who had medial unicompartmental arthrosis and chronic ACL-deficient knees underwent ACL reconstruction along with femoral osteotomy in one case and upper tibial osteotomy in the other. We used Orthopilot software to perform computer assisted combined anterior cruciate ligament (ACL) reconstruction and osteotomy.
Subjective evaluation at postoperatively indicated significant improvement compared to preoperative evaluation and better scores for patients who obtained normal knee range of motion. Objective evaluation by International Knee Documentation Committee showed improved score postoperatively. Both had minor complications occurred in the immediate postoperative period. The average correction angle of the osteotomy was 7 degrees (7–10).
Computer assisted ACL reconstruction and osteotomy may provide long-term symptomatic pain relief, increased activity and improved function. Only Anterior cruciate ligament reconstruction may not effectively provide pain relief to the ACL-deficient knee with degenerative medial arthrosis. The results of this study suggest that combined high tibial or femoral osteotomy and ACL reconstructions are effective in the surgical treatment of varus, ACL-deficient knees with symptomatic medial compartment arthritis. Computer aided surgery allows precise correction of the axial deformity and tunnel orientation intraoperatively.
Primitive stem cells from bone marrow become osteocytes in the presence of hydroxyapatite ceramic (HAC). Consequently there is osseointegration of an HAC surface in bleeding cancellous bone/marrow.
However, damaged bone in the revision situation does not provide the necessary stem cells for osseointegration. Revision surgery using standard length (150mm) HA coated stems is not always satisfactory.
Using a 200 mm stem will extend the operating field into fresh, undamaged cancellous bone and marrow.
The system works with improved HHS. Defects from debris disease fill in and stems are seen to bond to the host bone particularly at the tip. There have been no prosthetic fractures.
Only one case has needed re-revision when a stem remained un-bonded in the presence of a transverse femoral fracture. Two other stems are probably not bonded. This represents 4% failure.
From a consecutive series of 114 patients who had undergone a two-stage exchange without prolonged antibiotic therapy we report the outcome of those patients who continued to have persistent infection.
Seven patients elected not to undergo a further two-stage revision. Five patients have retained their arthroplasty with lifelong suppressive antibiotic therapy. One has a pseudarthrosis and one disarticulation has taken place for inadequate tissue cover.
Hip arthroscopic debridement of FAI lesions offers similar results to open procedures allowing for full inspection of the joint and the treatment of any chondral lesion but with a quicker recovery time. It nonetheless has a very long learning curve and even in the most experienced hands the treatment of impingement lesions is complicated and technically challenging.
The purpose of this cadaveric study was to assess the degree of exposure obtained using two different limited anterior approaches to the hip which would allow effective surgical treatment of cam and pincer FAI.
In summary cam and pincer impingement of the hip can be treated by either the direct anterior or Heuter approach. The choice of approach would be dictated after careful consideration as to which portion of the anterior acetabular rim required surgery, with more lateral acetabular lesions being favoured by the Heuter approach and more medial impingement sites by the anterior approach we have described.
The SAP searches for infection only using three ICD-10 codes. Six ICD-10 codes had been used to classify these 12 patients.
The Exeter Universal Stem has limited published data with greater than 10 year results, this is from specialist orthopaedic centres using predominantly posterior approach. Our aim was to establish whether the published results could be reproduced in a District General Hospital (DGH) using a Hardinge approach.
We reviewed 131 consecutive primary THRs implanted into 127 patients between 1995 and 1997 (minimum10 year follow up). Surgery was performed through a Hardinge approach using the Exeter universal stem with the Ogee Elite acetabular component.
Outcome was assessed by patient review, completing an Oxford Hip Score (OHS) and reviewing the hospital records. Deceased patients’ hospital records were reviewed and their GP questioned.
5 of 131 hips required revision: 3 for infection at 4–7 years following implantation and 2 for aseptic loosening (one acetabulum only, one both components). There have been no cases of dislocation or sciatic nerve palsy. Kaplan-Meir survival analysis demonstrates ten year survival as follows: 95.3% survival with revision for any cause as the end point; 98.9% with revision for aseptic loosening of the stem as the endpoint, 98.1% with revision for aseptic loosening of the acetabular component as the endpoint, 97.2% with revision for infection as the endpoint.
The mean OHS was 22.7 (median =20, interquartile range 15–26).
This is the first series to report on the 10 year results with the Exeter Universal stem used exclusively in conjunction with the Ogee Elite acetabular component. It is also the first series to report the 10 year results using only the Hardinge approach. Our findings are the first to show that the Exeter universal stem in combination with the Ogee Elite acetabular component can be inserted through a Hardinge approach in a DGH setting with results comparable to surgery performed in a specialist unit and through a posterior approach.
We set out to examine the survivorship after primary Charnley low-frictional torque arthroplasty (LFA) with revision as the end point, but documenting all the operative findings.
Survivorship with revision as the end point was: infection 95%, dislocation 98%, fractured stem 88.6%, loose stem 72.5%, loose cup 53,7%.
Infection and dislocation are early problems. With improved cementing techniques stem loosening does not become a problem until 11 years after the primary. Loosening and wear of the ultra high molecular weight polyethylene cup is a significant long-term problem.
Our conclusion is that regular follow-up after hip replacement is essential. The frequency, judged from the revision patterns, would suggest that every two years would not be unreasonable. Recording of all operative findings at revision is essential.
Methods: 76 patients (79 hips) had died, and 121 patients were alive and well enough to attend for radiographic analysis at a minimum of 10 years. One patient was lost to follow up.
We present the results of 148 hips at a mean follow-up of 20 months (range 4 – 55).
141 patients, 148 hips. Average age 35, range 10–65 years Ratio Male to Female 73:75 All patients underwent femoral osteochondroplasty. 60% of cases had the labrum detached, acetabular rim recession and labral repair with bone anchors. 3 patients had the labrum reconstructed with the ligamentum teres autograft. We have had 9 failures (6%) as defined by revision to arthroplasty. 2 hips underwent successful revision open surgery for inadequately treated posterior impingement. 3 patients required arthroscopy after open surgery (2 of whom are now pain free). 7 further patients have persistent groin pain but not required further intervention.
We have had the following complications: 4 trochanteric non unions requiring revision fixation, 2 deep vein thrombosis, 2 haematomas, 1 superficial infection, no deep Infections.
Life table survival curve with revision to arthroplasty defined as failure.
None of the 4558 stems have been revised for aseptic loosening or fracture.
The patient’s mean age at surgery was 48 years (range 15–76), and 171 hips with a mean follow-up of 11 years (range 10–13.7) have now passed 10 years. There were 97 females and 64 males in this group with 10 patients having bilateral C-stems. The main underlying pathologies were Primary Osteoarthritis 30%, Developmental Dysplasia of the hip 27% and Avascular Necrosis of the hip 19%.
Clinical outcome graded according to d’aubigne and postel for pain, function and movement has improved from 3.1, 3.1 and 2.9 to 5.9, 5.7 and 5.6 respectively.
A good quality proximal femur had been maintained in 47.1% and improved in a further 29.9%.
Both groups had statistically improved post-operative hip scores, however, at the 1 year follow-up the MIS group were significantly better in terms of WOMAC, Harris Hip, Merle d’Aubigne and SF-12 scores when compared with a standard posterior approach.
Despite initial enthusiasm for minimally invasive total hip replacements (THR), there has been a marked paucity of level 1 evidence studies assessing it.
100 patients fulfilling the inclusion criteria were randomised in theatre to a standard posterior or muscle-sparing short incision (MIS) approach. A hybrid hip replacement was used routinely. Post-operative management was the same. Follow-up occurred at 2, 6 and 12 weeks. Patients, as well as functional and radiographic assessors were blinded.
50 patients were recruited to each group. There was no difference in demographics Mean incision length was 12.8cm and 19.1cm respectively. There was no statistically significant difference in operation time, post-op functional recovery (ILOA score) or length of stay. Pain (VAS) was similar post-operatively, and at 6 and 12 weeks. There was no significant difference in 10 metre walking speed or 6 minute walking distance at 2, 6 or 12 weeks; nor was there a difference in Oxford hip score, patient satisfaction with surgery (VAS), or SF-12 score at 6 or 12 weeks. Blood loss, fall in haematocrit, transfusion rate and CRP rise were similar. There was no significant difference in cementation of the stem (Barrack) or cup position (Dorr). There was one death from PE in the MIS group and one deep infection in the standard group. There was one dislocation in the standard group. The only statistical difference between the groups was less dependence on walking aids at 2 and 6 weeks in the MIS group; there was no difference at 12 weeks.
MIS surgery is safe, and may allow earlier independent mobility after THR. However, the claims of significantly reduced pain, less morbidity, better function and improved patient satisfaction appear to be unfounded.
At the end of the follow up period, 11 of the 70 acetabular components (polyethylene liner or the acetabular shell) had been revised. The cumulative survival was 94.0% (95% confidence interval 88.4–99.7) with revision of the metal shell as the end point, and 84.0% (95% confidence interval 74.5–93.5) with revision surgery of the acetabular shell or liner due to any reason as an end point. Radiologically, 4 patients require acetabular revision and 22 patients had femoral osteolysis in gruen zone 7, indicative of polyethylene failure. This gave a combined revision, impending revision and zone 7 osteolysis cumulative survival of 55.3% (95% confidence interval 40.6–70.0).
linear wear rate (depth of the femoral head and acetabular socket wear patch/time from operation); the diagnosis and severity of ALVAL from histological sections of periprosthetic tissue (Wilhert grading system); pre-revision whole blood cobalt, and chromium levels using Inductively Coupled Plasma Mass Spectrometry.
All implants and tissue samples were analysed against control samples from patients undergoing revision of MOM hips for fractured femoral neck or impingement.
Thinning of the femoral neck occurs in 77% of patients undergoing hybrid Birmingham hip resurfacing using a posterior approach (Shimmin 2007). Villar recently reported lower neck thinning rates in uncemented Cormet resurfacings (11.7%) compared with hybrid Birmingham resurfacing (13.4%), both via a posterior approach.
We have evaluated implant position and femoral neck thinning in a cohort of 273 uncemented HA coated Cormet 2000 hip resurfacings using ‘B’-series (Titanium/HA coated) cups in 269 patients (mean age 54 years, 39% female) with a mean follow-up of 3 years (range 1–4 years).
Mean cup inclination was 45° (30°–63°), mean SSA 138° (120°–178°). No lucent or sclerotic zones have been identified around the stem of the component. Only one femoral neck fracture has occurred (incidence 0.36%)
We have identified only one case of femoral neck thinning in our series (0.36%).
Whilst Villar has demonstrated a slight reduction in neck thinning rates using the same implants compared to a hybrid fixation Birmingham resurfacing, his neck thinning rates are almost 40 times higher than in our series. Shimmins ‘severe neck thinning (> 10%) rates (27%) are approximately 120 times higher than our series. In addition, we have been unable to confirm the relationship between implant position and neck thinning described by Shimmin in our series using the combined Ganz/uncemented resurfacings compared with Birmingham resurfacings.
Implant design and surgical approach have an impact on ‘neck thinning after resurfacing; we should be wary of treating all resurfacing implants and techniques as a uniform cohort.
Radiographic analysis was undertaken using Harris’, Hodgkinson’s and Amstutz’s criteria, evaluation of component position, neck narrowing and migration using diagnostic PACS workstations with standardised scaled images.
Component position was satisfactory in 93% of cases. Radiographic analysis showed no cups, or stems were definitely loose. Radiolucent lines were present in 8/100 acetabular and 3/100 femoral components, osteolytic lesions were seen in three acetabular components. Mean neck narrowing was 9mm. No patients show any radiographic evidence of avascular necrosis.
Conclusion This independent series shows the results of the Birmingham hip resurfacing are reproducible and comparable to those reported in the originating centre. The Birmingham hip resurfacing gives excellent clinical results, and there is no early evidence of radiographic failure. The high rate of neck narrowing gives us cause for concern and we would recommend regular radiographic follow up.
The mean Harris hip score at follow up was 96.4. The mean Oxford Hip Score fell from 41.6 preoperatively (Range 16–57) to 15.3 postoperatively (Range 12–49) p< 0.0001. The UCLA Activity Scale rose from 3.93 preoperatively (Range 1–10) to 7.54 postoperatively (Range 4–10) p< 0.001.
Radiographic analysis revealed an average stem shaft angle of 130.6 degrees (Range 112–148) with average cup alignment of 36 degrees (Range 22–47). Neck thinning was present in 16 hips (14%) and we define a technique for measuring thinning.
There have been 3 revisions for cup loosening (0.29%) and 3 for pain (0.29%). 5 patients have died (0.51%). There was one revision for infection and one for impingement.
Average Harris Hip Score rose from 57.0 to 97.1, and 60% of patients scored 100.
UCLA activity score was 6 or over in 91%, and the median score was 7.5.
All failures were evident by 12 months
The Cumulative Survival Rate at 3 years was 97.4%,, 99.5% for 55 years and under, 98.3% for under 65 years, and 94.2 % 65 years and over.
Discussion: Pre-operative measurements of height, weight, haemoglobin and packed cell volume, together with factors including sex & type of surgery can identify those patients who are at greater risk of post-operative transfusion allowing selective transfusion prevention strategies.
The gold standard for the CTR is 2:1 or less. Procedures with ratios greater than 3:1 should substitute for a ‘group and save’. The TI establishes the likelihood of blood being transfused for a certain procedure, i.e., the number of units transfused divided by the number of patients having the procedure. If the TI is less than 0.5, then cross-matching blood is considered unnecessary.
In revisions of non-infected TKR (n=95), the CTR=4.33 and TI=0.48. In infected cases (n=54) the CTR=2.16 and TI=1.35.
There was considerable change in the practice of ordering cross-matched blood following the introduction of intraoperative cell-salvage devices (Revision THR: CTR=1.93, TI=0.84; Revision TKR: CTR=1.20, TI=0.16)
The introduction of this MSBOS in conjunction with intraoperative cell-salvage, could promote blood conservation and financial savings.
Since 2003 we have adopted an aggressive approach to the management of the SUFE deformity, an important cause of anterior femoro-acetabular impingement, associated with the development of early adult hip arthritis.
16 patients aged 16.7 years (range 11–20, 3 female, 13 male, 8 right, 8 left hips) underwent surgery to manage their SUFE deformity.
7 patients had secondary correction of deformity after previous in-situ pinning and 9 underwent primary surgical management using a Ganz approach (7) or primary in-situ pinning with femoral neck resection via a Smith-Peterson approach (2).
Of the 7 patients who had primary in-situ pinning 26 months (range 4–44 months) earlier, 2 had acetabular chondral flap tears with eburnated bone and 6 had significant labral degenerative changes associated with calcification or tears.
Only one of the nine patients who underwent primary aggressive management of their SUFE, had a labral tear.
4 patients underwent mobilisation of the femoral head on its vascular pedicle followed by anatomical realignment.
At an average follow-up of 22.3 months (range 1–41 months) 15 remained well with excellent function. Leg lengths remained equal in 12, with an average shortening of 2cm in the remaining 4 patients.
Segmental AVN occurred in the first patient after damage to the vascular pedicle during drilling of the neck; the technique has been modified to prevent further occurrences.
Removal of the trochanteric osteotomy screws has been performed in 4 cases.
Despite having performed over 400 surgical hip dislocation, the authors continue to find the management of this condition challenging; nevertheless, having seen the direct consequences of femoro-acetabular impingement at an early stage in these young patients, we believe that aggressive management to correct anatomical alignment is essential for the future well being of the hip.
We present the results of prospective evaluation of digital compared to plain radiographic pre-operative templating for primary total knee replacement. All consecutive patients undergoing primary knee replacement under the senior author (AS) were eligible. Patients with previous knee replacement or without calibrated digital or plain radiographs were excluded. Plain radiographs were templated against acetate templates supplied by the manufacturer. Digital images were templated with the help of commercial software TraumaCad. A 25mm spherical metal ball placed nearest to the affected knee joint acted as calibration object. AS performed all the templating. The ICC value for intra-rater reliability was 0.846 for tibial templating and 0.840 for femoral templating. PFC sigma cruciate substituting components were implanted in all patients. 28 consecutive patients between April 2006 and June 2007 were included. Accurate digital templating score was 80% for tibial implant and 40% for femur. Accuracy of analog templating was 55% for tibial implant and 50% for femur. There was no mismatch of over one size. The differences between templated and implanted sizes were plotted against their mean in Bland-Altman plot. The 95% confidence interval of the differences between digital and actual sizes were: 0.78 to − 0.75 sizes for tibial implant and 1.15 to −0.93 sizes for femoral implant. The 95% confidence interval of the differences between plain and actual sizes were: 0.38 to −0.99 size for tibial implant and 0.93 to −1.32 size for femoral implant. The two tailed P value for difference between digital and analog templating from a Wilcoxon matched pair signed rank test was 0.021 for tibia and 0.006 for femur. We found preoperative templating by the operating surgeon reliable and accurate but digital templating did not offer any additional advantage.
We aimed to determine the reliability, accuracy and consequently the clinical role of digital templating in the pre-operative work up for total knee arthroplasty patients.
With the increasing use of digital radiology images, analogue templating may soon be defunct. Digital templating is a more recent development and its role is yet to be determined.
Ten pre-operative digital radiographs were templated by four independent observers. Inter-observer and intra-observer reliability was assessed using the kappa measure of concordance. Subsequently, 40 consecutive total knee arthroplasty patients underwent pre-operative digital templating. This was a blinded process by a consultant surgeon not involved with the operation. Each patient underwent TKR using the PFC Sigma System sized intra-operatively, without the operating surgeon having knowledge of the pre-operative templating result. Comparison was made between the pre-operative digital templates and the blinded intra-operative sizing.
For both the femoral and tibial templating there was good to very good inter- and intra-observer agreement. For the femoral component the templating was correct in 47.5% (± 1 size difference 97.5%). The tibial templating was correct in 55% (± 1 size difference 100%).
The inter- and intra-observer reliability of digital templating process has been shown to be acceptable but the correlation between digital templating and the actual size implanted is poor. Our series shows a similar accuracy to the published data on analogue templating for the same implant. Like analogue templating, its clinical role remains uncertain and its poor correlation to the actual implant sizes limits its usefulness.
There is little good evidence about the relative merits of different knee replacement designs as no adequately powered randomised controlled trials have been undertaken. To address this, a pragmatic multi-centre randomised trial involving 116 surgeons in 34 UK centres was begun in 1999. Within a partial factorial design 1715 patients were randomly allocated to patella resurfacing or not, 539 to mobile bearing or not and 409 to metal backing of the tibial component or not. Primary outcome measures are the Oxford Knee Score (OKS), SF-12, EQ-5D and need for further surgery.
At two years there was no evidence of differences in complications, clinical outcome, functional status or quality of life measures between randomised groups.
95% of the patient are now 5 year post-operation and have been sent questionnaires. 93% of these have been returned. By January 2008, all will be past 5 years and will have been sent questionnaires. When the complete 5 year data set is available it will be analysed. The 5 year data relating to the randomised groups will be presented.
38 patients (41 knees) who received a primary SMILES knee prosthesis by one of the senior authors between 1990 and 2006 were retrospectively studied. Knee function was assessed pre and post-operatively using the Oxford knee score (0–48 scoring system) and the Knee Society Score. Patients receiving surgery for tumours were excluded. The main indications for primary SMILES were bone loss and ligamentous laxity.
2 patients died and 5 were lost to follow-up. 2 patients required revision surgery (one for infection and one for re-bushing). Post-operative complications included peroneal nerve palsy (1) and DVT (1). The mean Oxford knee score improved from 9 pre-op to 44 post-op, and the mean knee society score improved from 24 pre-op to 71 post-op. The average range of motion was 57 degrees pre-op and 88 degrees post-op.
revision surgery and poor functional outcome as the end-points.
A total of 299 knees in 209 patients were included in the final analysis. The mean age was 69.6 years. Majority of the prostheses were cemented (95%) and had patellar resurfacing (89.6%). The mean post-operative period was 5.1 years.
17 knees (5.7%) underwent revision surgery. 6 knees (2%) were revised for infection at mean 17.3 months & 11 (3.7%) for aseptic loosening or instability at mean 4.9 years. 7 left knees (lead knee) of 11 right-handed golfers required revision for aseptic loosening.
The main problems experienced after playing 18 holes were knee stiffness (47%) & swelling (18%).
To establish the efficacy of a new arthroscopic technique, for the treatment of stiffness after TKR.
The aim of this work was to compare the oxygen saturations in patients in the early period following total knee joint replacement surgery performed using either computer navigation or conventional intramedullary mechanical jigs.
Between August and November 2007 twelve consecutive patients who had computer navigated total knee joint replacements were prospectively reviewed. A comparison group from the same period was made of twenty patients who had knee replacements performed using conventional jigs. Non-invasive oxygen saturations were measured and recorded as a percentage. Preoperative oxygen saturations measured at the assessment clinic were used a baseline. For the duration of the patients postoperative hospital stay oxygen saturations were measured five times a day as well as their oxygen requirements.
We found that the patients in the computer navigation group on average reached oxygen saturation levels on air equal to those measured in the assessment earlier than the intramedullary jig group. There was also a lower need for oxygen in the computer navigated group during this early post operative period.
Previous studies using transcranial Doppler and transoesophageal echocardiograms have shown a reduction of systemic emboli with computer navigated total knee joint replacements. Using oxygen saturation monitoring we have shown there may be a considerable clinical advantage using computer navigated surgery over conventional intra-medullary rod jigs in knee replacement surgery.
Twenty one procedures were performed on 18 patients with a mean follow up of 18.8 months (3–57.9). There were 14 primary total knee replacements and 7 revision procedures. The mean age at the time of surgery was 90 years and 10 months (89 years 1 month to 94 years 4 months). The majority of patients were female (15). All patients were ASA grade 2 or 3. The average orthopaedic inpatient stay was 17 days. Thirty percent of patients required a period of further inpatient rehabilitation or convalescence after discharge from our institution. Nine patients experienced a post-operative complication. Mortality at 30 days was 0%, at 1 year 6% (1/16), and is currently 17% (3/18).
The purpose of this study was to determine if a single physiotherapy intervention would enable patients to kneel following Unicompartmental knee arthroplasty (UKA).
Kneeling is an important functional activity that is frequently not performed after knee arthroplasty, thus affecting a patient’s ability to carry out basic tasks of everyday life. There is however no clinical reason why patients should not kneel and many with proposed knee surgery ask about the possibility of kneeling after their operation.
Sixty adults participated in a prospective randomised controlled trial with blinded assessments. At 6 weeks post-operatively UKA patients were randomised to either the Routine care group where no advice on kneeling was given or to the Kneeling intervention group where participants were taught and given advice on how to kneel and were encouraged to do so. They were re-assessed at 1 year. The primary outcome measure was Question 7 of the Oxford Knee Score which asks the question “Could you kneel down and get up again afterwards?”
Pre-operatively there was no difference in the kneeling ability of the two groups. At 1 year the difference in kneeling ability between the two groups was highly significant (p< 0.05). Spearman’s correlation coefficient showed no significant association between a change in score of Question 7 at 1 year and the following factors; scar position, numbness, range of flexion, arthritic involvement of other joints and pain. Linear regression analysis also confirmed that these factors were not successful in predicting a change in kneeling ability.
This study showed that the single factor predictive of kneeling ability was the physiotherapy intervention provided at 6 weeks post-operatively and it is suggested that kneeling should be incorporated into patient’s post-operative rehabilitation programmes.
This study demonstrates that medial overhang of less than three millimetres for the tibial component is acceptable in the Oxford UKA. Excessive overhang equal to this or more results in significantly worse ΔOKS and ΔPS. However, no difference in the five year ΔOKS and ΔPS was demonstrated between underhang and the other two groups in this study.
Following introduction of the second offer scheme in April 2004, Cardiff and Vale NHS Trust sent 227 patients (254 knees) to the independent sector treatment centre in Weston-Super-Mare for total knee arthroplasty. The Kinemax total knee system was used in all cases.
There was a perception that there were a large number of dissatisfied patients, and a previous British Orthopaedic Association report (of a 14 case sample) questioned the quality of the surgery performed.
All of the patients concerned were offered a review in order to assess the outcome. Of the 227 patients (254 knees), 77% have been reviewed (167 patients, 190 knees). 23% (59 patients, 64 Knees) have not been seen. Of these, 30 patients (34 knees) declined review on the basis that they were happy with the result of surgery. 14 Patients (15 knees) were unobtainable by post of by phone. A further 12 patients (12 knees) did not attend appointments. 3 Patients (3 Knees) had died.
The total number of re-operations was 27/254, giving a re-operation rate of 10.6%. There were 21 revisions, 17 for aseptic causes (oversized components, malalignment, aseptic loosening) and 4 for infection. There were 6 secondary patella resurfacings.
A life table survivorship analysis was calculated for the 254 knees. The cumulative survival rate at 3 years was 85.8%. These results are considerably worse than those reported in the current published literature. This has resulted in a significant economic impact on our service.
Removal of solidly fixed implants is a challenge in revision knee arthroplasty. It is fraught with the risk of intraoperative fractures and bone stock vital for the success of subsequent revision surgery. We describe the double extraction technique for extraction of solidly fixed implants. This technique was first tested in laboratory setting and then replicated in the operation theatre with successful results.
In this retrospective study we analysed all our patients in which we used the double extraction technique for the removal of solidly fixed implants. In this procedure, the surgeon and the assistant each place an osteotome on the cement metal interface at symmetric positions, directly opposite each other on the medial and lateral sides. They deliver synchronous blows with a mallet at positions around the interface until the cement fractures. The femoral component can then be easily removed. The technique was tested in a laboratory before it was used clinically. Polyurethane mouldings, representing a suitable substrate for cementing metal components were fixed on to a steel rod of similar weight and length as the lower leg. Stainless steel discs (40mm diameter × 4mm thickness) were cemented on to the polyurethane substrate to form a model of a cemented implant. The discs were instrumented to allow recording of the mechanical processes caused by the double extraction technique and to allow comparison with the single osteotome extraction technique. The methodology successfully demonstrated that the double osteotome technique increases the contact force of the second blow. When the synchronous blows are delivered, less energy is expended in the movement of tibia and more is contributed to the removal of the component.
In this study we looked at a total of 206 patients were the solidly fixed tibial and femoral components were removed using the double extraction technique. There were 86 men and 126 women. The mean age of the patients was 66.8 years (range 37–87 years). Only patients with solidly fixed implants were included in this study. Stability of implants was assessed with preopera-tive radiographs and then confirmed intraoperatively. Patients with loose implants intraoperatively were excluded from this study. We present our results with use of this technique in 206 patients with follow up of 1 to 5 years.
The St Leger total knee replacement is a bicondylar prosthesis developed as an cheaper alternative to other similar implants of its time. Between October 1993 and June 1999, 144 St Leger total knee replacements were implanted in 114 patients.
The aim of this study was to clinically and radiologically assess these patients after a mean follow up of 10.22 years.
Between February and July 2007 ninety-one patients recalled for clinical evaluation (using functional and objective American Knee Society Scores) and radiological assessment (using the American Knee Society Scoring System). 11 patients had died and 12 were lost to follow up or were medically unfit to attend evaluation. Of the ninety-one patients recalled, 18 had had their prostheses revised (19 knees). 63% of prostheses had survived 10 years or more.
Of the patients with St Leger knees in situ (99 knees) the American Knee Scores showed 78% poor, 10% fair, 6% good and 6% excellent results. Radiological assessment identified 12 arthroplasties that had failed (5 femoral components, 5 tibial components and 4 patellae,) 58 that needed close follow up (18 femoral components, 31 tibial components and 38 patellae) and 29 that were well fixed. A best-case Kaplan-Meier cumulative survivorship was 87% at 10 years. (Worst-case was 71% at 10 years)
These 10 year results showed that the St Leger total knee prosthesis did not perform as well as other bicondylar prostheses of the same generation and had a higher revision rate. Despite favourable published mid-term results, the long-term results for the St Leger total knee replacement have shown it to be unreliable and not worth the initial financial saving.
24 ± 5, 22 ± 10, and 22 ± 9 and for Objective-AKSS were 84 ± 12, 82 ± 15 and 91 ± 11 respectively.
The frequency of five year radiolucency for the groups A, B, and C were 42%, 35%, and 45% respectively.
A number of measurements of patella height exist all of which use a position on the tibia as a reference. The Patellotrochlear Index has recently been proposed as a more accurate reflection of the functional height of the patella and described in normal knees.
Statistical analysis revealed good inter-observer reliability for all measurements (0.78 for PTI, 0.78 for IS, 0.73 for BP and 0.77 for CD). Intra-observer reliability was also good (0.80, 0.83, 0.75, 0.78 respectively). When comparing the different measurements for patella alta there was a weak correlation between the PTI and the others. There was a strong correlation between the CD and BP ratios (0.96) and a moderate correlation between IS and CD and IS and BP ratios (0.594 and 0.539 respectively).
It was found that there was more medial-lateral motion (shift) of the patella than proximal-distal (tilt) motion during the gait cycle.
It was noted that the patella shift motion occurred in the swing phase or the early stance phase of the gait cycle of all subjects with the maximum patella shift occurring when the knee was flexed between 30–56 degrees in the majority of subjects.
Similarly the patellar tilt motion occurred in the swing phase or the early stance phase of the gait cycle with the maximum patella tilt occurring between 20–36 degrees of knee flexion in the majority of subjects.
Idiopathic anterior knee pain (AKP) is common in adolescents and young adults. Most believe that the origin of the problem lies in the patello-femoral joint. Hamstring tightness has also been attributed as an important cause.
The aim of our study was to compare biometric parameters in patients with idiopathic AKP and controls. We also wanted to assess whether there was a difference in the relative electromyographic (EMG) onset times of the medial and lateral hamstrings.
We prospectively recruited patients with idiopathic anterior knee pain in the age group 11 to 25. Patients, but not the control population, had AP, lateral and skyline radiographs taken to rule out other pathology.
We had 34 patients (60 knees) with a minimum one year follow up. There was no difference in the symptoms of patients who attended physiotherapy as compared to those who did not. Patients with knee pain had significantly more hip external rotation (63 deg) as compared to the control (47 deg) group (p=0.001). Patients also had significantly more hamstring tightness (p=0.04).
Surface EMG was recorded (17 patients and controls each) from the medial and lateral hamstrings during 3 repetitions of a maximal voluntary isometric contraction exercise with the knee at 45° of flexion. The lateral hamstrings contracted 48.7 m.sec earlier than the medial hamstrings in patients as compared to controls.
AKP is a multifactorial and self-limiting disorder. Earlier contraction of the lateral hamstrings may cause tibial external rotation and contribute to the symptoms. Our data suggests that physiotherapy did not significantly alter the course of the condition. We believe that increased hip external rotation may contribute to the symptoms by increasing medial facet stress.
101 arthroplasties in 91 patients were followed up for average period of 48.8 months (6–96 months). The average age was 57 years with female patients thrice as common as male patients. Concomitant procedures in the form of 23 lateral retinacular release or 6 osteochondral autograft transfer system (OATS) were performed. There were 6 complications with 2 infections and 4 stiff knees. Subsequent procedures included arthroscopic debridement (18), arthroscopic lateral retinacular release (8), tibial tuberosity transfer (3) and manipulation for stiffness (2). A total of 4 arthroplasties underwent revision to TKA, 2 for infection and 2 for progression of tibiofemoral osteoarthritis.
Kinematic data from in-vivo fluoroscopy measurements during a step-up activity was used to determine the relative tibial-femoral position as a function of knee flexion angle for each model. Medial and lateral force distribution was adapted from loads measured in-vivo with an instrumented implant during a step-up activity. The affect that varying the bearing thickness has on the stresses in the bearing was investigated. In addition, varus-valgus mal-alignment was investigated by rotating the femoral component through 10 degrees.
The cartilage within the area of macroscopic damage was divided into equal thirds: T1(most damaged), to T3 (least damaged). The area of macroscopically undamaged cartilage was taken as a 4th sample, N. The specimens were prepared for histological (Safranin-O and H& E staining) and immunohistochemical analysis (Type I and II Collagen, proliferation and apoptosis).
Immunoassays were undertaken for Collagens I and II and GAG content. Real time PCR compared gene expression between areas T and N.
The GAG immunoassay showed decreased levels with increasing severity of cartilage damage (ANOVA P< 0.0001).
There was no significant difference in the Collagen II content or gene expression between areas.
The Collagen I immunohistochemistry showed increased staining within chondrocyte pericellular areas in the undamaged region (N) and immunoassays showed that the Collagen I content of this macroscopically and histologically normal cartilage, was significantly higher than the damaged areas (ANOVA P< 0.0001). Furthermore, real time PCR showed that there was a significant difference in Collagen I expression between the damaged and macroscopically normal areas (p=0.04).
computerized histomorphometry and an overall histology assessment. Clinical outcome was measured using the Knee Injury and Osteoarthritis Outcome Score (KOOS). Safety was recorded throughout the study.
Coagulase negative Staphylococcus was the most commonly grown organism from the tourniquets (96%).
Some tourniquets had growths of important pathogens including MRSA, Pseudomonas and Staphylococcus aureus (these organisms have not been previously cultured from tourniquets). On cleaning five tourniquets with clinell (detergent and disinfectant) wipes, there was a 99.2% reduction in contamination of the tourniquets five minutes after cleaning.
We have found a 99% reduction in contamination of tourniquets by employing disinfectant wipes. This is a simple, cost-effective and quick method to clean tourniquets and we recommend the use of wipes before every case in addition to the manufactures guidelines for general cleaning of tourniquets.
It is established good practice that joint replacements should have regular follow-up and for the past seven years at the North Hampshire Hospital a local joint register has been used for this purpose and we compare this with results of the Swedish and UK national registries.
Since March 1999, all primary and revision knee arthroplasties performed at North Hampshire Hospital, Basingstoke have been prospectively recorded onto a database set up by one of the senior authors (JMB). Data from patients entered in the first six years of the register were analysed. All patients have at least one year clinical and radiological review then a minimum of yearly postal follow-up.
As of 31/12/2006, 2854 knee replacement procedures had been performed under the care of 13 consultants. OA was the most common diagnosis in over 75% of knees. 5.2% of patients had died and 4.6% were lost to follow-up. Our revision burden was 3.5% and we had a revision rate of 1.4% for primary total knee replacements. Audit of data for revisions and patello-femoral replacements has enabled us to change our practices. Mean length of stay was 7.2 days for primary total knee arthroplasty versus 4.0 days for unicompartmental knee arthroplasty and 5.4 days for patellofemoral replacement and mean flexion at discharge was 88.4, 93.7 and 88.7 degrees respectively. WOMAC and Oxford scores at 2 years had improved from a mean of 52 and 21 pre-operatively to 74 and 39 respectively for primary total knee arthroplasty. Our costs are estimated at approximately £35 per patient for their lifetime on the register.
Compared to other registries:
Our dataset is more complete and comprehensive Our costs are less All patients have a unique identifier (at least 19% of UKNJR data is anonymous) Our audit loops have been closed
The purpose of this study was to investigate the safety and outcome of bilateral simultaneous ACL reconstruction. In patients presenting with an ACL-deficient knee, 2 – 4% have bilateral ACL deficiency. A staged or simultaneous approach can be adopted when the patient requires reconstructive surgery for both knees. We report a case series of 8 patients (6 male, 2 female, average age 30.4 years) who underwent bilateral simultaneous ACL reconstruction.
Simultaneous or bilateral ACL reconstruction using ipsilateral patella tendon graft has been reported as a safe procedure with outcome and complication rate no different to unilateral procedures. Considerable cost savings of simultaneous over staged procedures have also been described. There are no case series in the published literature that describe the use of hamstring tendon autograft for bilateral simultaneous ACL reconstruction.
We used two camera stack systems and instrument sets to allow for simultaneous bilateral surgery by two surgical teams. Quadrupled hamstring tendon graft was used in 4 patients although in one patient patella tendon graft was used on the second side due to poor quality of hamstring tendons. Patella tendon graft was also used in a further 4 patients. At two weeks all patients were able to discard crutches and were independent in mobility. There was no difference in outcome at one year between those patients undergoing bilateral simultaneous ACL reconstruction in comparison to the outcomes of unilateral ACL reconstruction with respect to Lysholm, Tegner and IKDC scores. The mean follow up period was 2.3 years.
Our results demonstrate that bilateral simultaneous ACL reconstruction is safe and cost effective. A simultaneous approach also has the benefit of reducing the overall period of rehabilitation required by the patient. We report good short-term functional outcome but no long-term data is yet available.
This study evaluated the long term outcome of isolated posterior cruciate ligament (PCL) reconstruction. Thirty patients underwent surgery with hamstring tendon autograft after failing conservative management. At 10 years after surgery patients were assessed with radiographs, full IKDC examination and KT1000 instrumented testing. The mean IKDC subjective knee score was 87 out of a possible 100. Regular participation in moderate to strenuous activities improved from 26% preoperatively to 88% of patients. At 10 years endoscopic reconstruction of the PCL with hamstring tendon autograft is effective in reducing knee symptoms. Patients can expect to continue participating in moderate to strenuous activties over the long term. Osteoarthritis is observed in some patients with 18% showing some loss of joint space which compares favorably with non-operatively managed PCL injuries. This is a successful procedure for symptomatic patients with PCL laxity who have failed conservative management.
Since 1994, the proportion of women seen with ACL injury doubled from 12% to 25% The proportion of skiing related injuries trebled from 9% to 28% The average age at presentation rose by 6.5 years from 26.5 to 33 The average age of the skiers is 41 and 90% of them are female
14 subjects were recruited at routine follow up, and assessed by interview, clinical examination and plain digital raiodgraphs.
All radiographs were taken under clinical supervision, with a scale reference, hence allowing digital rescaling.
Examination of the radiographs demonstrated only a 1.1mm (+/− 0.9mm) mean femoral tunnel widening, which represents a 12% increase in diameter (21% increase in area), and compares very favourably to the observed tunnel widening in high suspensory techniques, as cited in the literature.
Systems of low suspension benefit from the advantage of not relying on interference fit which risks posterior cortical ‘Blow Out’. A shorter graft working length within the tunnel lessens graft micro-movement, making early low biological fixation within the femoral tunnel more likely, and reduces the amount of tunnel widening. These micro-movement have been described as the ‘Windscreen Wiper’ and ‘Bungee Cord’ effects, and are well documented in traditional high suspensory fixation.
A recurrence of objectively measured knee laxity after anterior cruciate ligament (ACL) reconstruction has previously been reported in various papers; the purpose of this study was to accurately measure in vivo knee laxity after both bone-tendon-bone (BTB) and hamstring reconstruction using radiostereometric analysis (RSA), and to differentiate between graft fixation slippage and graft stretching and their relative contributions to any increase in laxity.
Twenty patients were studied prospectively after ACL reconstruction. Ten had been operated on using BTB grafts, and ten using hamstring (four-stranded semitendinosus/gracilis) grafts. Tantalum markers were inserted in the distal femur, proximal tibia and into the graft itself. (RSA) was used to measure sagittal laxity, graft stretching and fixation slippage early post-operatively, and then at intervals up to 1 year.
A steady increase in total anteroposterior laxity was found in both groups over the year. For the BTB group, total mean slippage of the bone plugs increased to 1.28 mm at 1 year. For the hamstring group, the tunnel attachments had slipped by a total of 6.82 mm. More stretching was found for the hamstrings grafts than for the BTB grafts and the amount of stretching increased significantly with time post-surgery. The hamstring grafts stretched by a mean of 4.18%, the BTB grafts by 1.18%.
This is believed to be the most detailed application of RSA in analysing the performance of the two commonly used grafts in ACL reconstruction. Details such as graft stretching and fixation slippage have not been available previously; the data obtained in this study may have implications for clinical practice.
Of the 25 Gracilis tendons, the most common number of accessory bands was 2, varying from 0 to 3. The average distance of the proximal most band was 5.14cm. The most common number of accessory bands for the Semitendinosus tendon was 3, varying from 1 to 4. The average distance of the proximal most band was 8.14cm. Five of the Semitendinosus and none of the Gracilis tendons had a proximal band located > 10cm. Average length and diameter of the four strand graft was 7.7cm and 13.2cm.
On the tibia, the centre of the AM attachment was located 18 mm anterior to the Retro-eminence ridge (RER). The centre of the PL bundle lay 8.4 mm posterior to the centre of the AM bundle. These positions were at 35% and 52% along Amis and Jacob’s line
Patient’s charts and radiology findings were reviewed with special attention to operative notes and preoperative knee MR imaging. Patients with knee symptoms prior to presenting injury were excluded.
The mechanism of injury, the time elapsed from the original injury to anterior cruciate ligament reconstruction, associated meniscal injury, and quality of cartilage in the knee- at the time of MR imaging and ACL reconstruction were noted. Degenerative cartilage changes were graded upon reconstruction using the Outerbridge classification.
The average time from Injury to MR imaging and MR to ACL reconstruction was 4.85 and 12.65 months respectively.
We found a direct relationship between the time elapsed after the ACL injury and the severity of the chondral lesion (p< 0.05). Furthermore, a significant worsening in chondral degeneration of the involved knee was seen when the MR imaging and ACL reconstruction were more than 12 months apart (p< 0.01).
Early reconstruction may protect the knee from chondral wear and subsequent degenerative arthritis.
25 (41.67%) patients presented with complications (synovitis in 10 patients, prominent tibial swelling in 21 patients and both in 7 patients). In comparison, no complications were noted in 60 other age and sex matched patients in whom PLLA (Bio RCI; Smith & Nephew) screws were used by the same surgeon.
The symptoms in the PLC screw group often settled conservatively and did not affect knee stability. 6 patients underwent exploration of the tibial tunnel site. A sterile white cheesy substance was noted which was removed, leaving an empty tibial tunnel. The ACL graft was found to be well attached to tibial tunnel in all cases. The PLC screw size did not have any correlation to the occurrence of complications. 2 patients required multiple washouts, one of whom developed a deep infection.
The study aims to determine the effects of obesity on the patients’ symptoms and their knee function before knee arthroplasty, as well as their states of anxiety and depression.
Ethical approval was obtained before the start of the study. Weights and heights of all patients were measured and BMI calculated on admission. Anxiety and depression states were recorded using the Hospital Anxiety and Depression Scale (HADS). The severity of pain and loss of function of the knees undergoing arthroplasty was measured using the Oxford Knee Score and the American Knee Society Score. All scores were measured per-op and again at 6 weeks post-op.
To date, 28 patients were included. The mean body mass index was 28.9. Only six patients had a BMI of < 25. Patients with normal BMI (< 25) had mean anxiety and depression scores of 6.8 and 5.67 respectively. Overweight patients (BMI > 25) had scores of 5.59 and 4.9 respectively. Patients with BMI > 30 had scores of 6.71 (p= 0.22) and 7.0 (p= 0.04) respectively.
Patients with BMI > 30 had an improvement in anxiety scores of 1.33 points compared with 0.55 for patients with BMI < 30 (p= 0.3). Depression scores improved by 4 points in the BMI > 30 group compared with 0.67 in the BMI < 30 group (p= 0.03).
Improvements in the knee scores were comparable in both groups.
Obese patients with BMI of > 30 have higher rates of anxiety and depression pre-operatively. At 6 weeks follow up, there is an improvement in both measures of psychological distress but this is more pronounced for depressive symptoms.
Nerve blocks are a common form of peri-operative analgesia that is administered for patients undergoing joint Replacement surgeries. The long term sequel following these peripheral nerve blocks used in total knee replacement not reported in the literature. Nerve blocks given under the guidance of nerve stimulators are in practice in most of the hospitals and are considered safe.
We report a series of two cases with residual neurological deficit following these peripheral nerve blocks in total knee replacements. In both these cases the femoral, sciatic, obturator and lateral cutaneous nerve of thigh were blocked with 0.25% of Bupivacaine with the help of a nerve stimulator.
First patient post operatively had residual numbness in the right lower leg after 4 weeks of surgery. Nerve conduction studies confirmed absent response in right Saphenous and superficial peroneal nerves. Patient has no improvement in her neurological deficit even after 16 months post operatively. Further to this she developed complex regional pain syndrome on the affected side.
Second patient post operatively developed knee extensor weakness of grade II/V and loss of sensation in femoral nerve distribution. Nerve conduction studies confirmed severe femoral nerve damage around groin. She went through a turbulent phase, knee stiffness range of movements 0–20 degrees requiring Manipulation Under Anaesthesia, later Exploration and Release of adhesions which improved her range of movements to 0–95 degrees. At 12 months post operative the neurological status improved to grade 3/5 in knee extensors.
26 knees had normal tibial rotation pattern with the tibia rotating internally during knee flexion (mean rotation: 15.5°). In 22 knees (40%) the tibia was rotating internally and then externally as the flexion was progressing (mean rotation: 6.7°). In 7 joints (13%) a reverse tibial rotation was recorded, the tibia was rotating externally in all flexion increments (mean rotation: 2.2°).
We also recorded that most of the tibial rotation occurs in the first 0–30° of flexion (70%) p< 0.001.
The medial collateral (MCL) length at full extension ranged from −9mm to 11mm and post-operatively was reduced to −16mm and 8mm, (p=0.042). At 90o flexion the length ranged from −3mm to 9mm and postoperatively was reduced to −8mm and 10mm (p=0.025).
The lateral collateral (LCL) length at full extension changed from −10mm to 9mm pre-operatively to −13mm and 6mm post-operatively (p=0.011). At 90o flexion the range from −8mm and 9mm pre-operatively changed to − 5mm and 11mm post-operatively (p=0.005).
All the above changes correspond to improvement in the post-operative axial alignment.
To share our results following Medial Patellofemoral ligament (MPFL) reconstruction for patellar instability problems using ipsilateral semitendinosus graft anchored to the patella and the medial femoral condyle using biotenodesis screws.
Study design and methods: 35 patients were assessed with a mean follow up of 18 months. All patients had preoperative true lateral knee x-ray, MRI or CT scan to look at trochlear dysplasia and the sulcus tuberosity distance. They all under went MPFL reconstruction using ipsilateral semitendinosus tendon. Two patients had sulcus tuberosity distance greater than 20 mm and they under went a tibial tubercle transfer in addition. Two patients had trochlear dysplasia and hence a trochlearplasty was also done. In skeletally mature patients the hamstrings tendon were anchored to the medial side of the patella in a 5×15mm blind tunnel using biotenodesis screw. This significantly reduces the risk of having patella fracture. All patients were treated by the same surgeon and assessments were performed by a different surgeon based on kujala scores and tegner scores.
We included 50 sets of radiographs from 48 patients (17 men and 31 women). The prostheses used were PFC (40) and Scorpio (10) and six of them were navigated and 44 were standard TKR.
We compared the difference between the angle of the tibial component with the mechanical axis of the tibia in the long leg image and the angle of the prosthesis with the midline of the visualised tibia in a standard antero-posterior knee view. Statistical analysis was carried out using the student t-test.
Methods & Results: The study was a prospective trial. The criterion for recruitment was knee pain indicative of arthritis that required arthroscopic assessment with a view to possible surgical management. Joint space narrowing (JSN) was assessed in the affected knee, in both the standing full extension and Schuss views. Joint arthroscopy was performed and each compartment area of the knee was calibrated and graded corresponding to the arthritic changes identified. In the 60 patients recruited, 61.7% were found to have grade 4 arthritic changes on knee arthroscopy. JSN in those with associated grade 4 changes on arthroscopy on either full extension or Schuss views was 75.7% and 78.4% respectively. However in 24.3% of those with grade 4 changes on arthroscopy no JSN was demonstrated on either full extension or Schuss views. Arthroscopic assessment of severe arthritic changes of the knee was significantly superior compared to the radiographic method (p< 0.05).
We found that both the Schatzker and AO/OTA classifications have a high intra-observer (kappa=0.57 and 0.53 respectively), and inter-observer (kappa=0.41 and 0.43 respectively) variation. Classification of tibial plateau fractures into unicondylar vs. bicondylar and pure splits vs. articular depression +/− split conferred improved inter and intra-observer variation.
patients’ pre-operative demographics for age, weight, height, BMI, intra-operative variables such as the operating surgeon (n=2), insert and component sizes, post-operative varus/valgus deformity, and clinical outcome, assessed by the change in Oxford knee (OKS) and Tegner (TS) scores, from before surgery to five-year post-operatively.
We found no significant relationship between physiological RL, pre-operative demographics, intra-operative variables and clinical outcome scores in this study. Tibial RL remains a common finding following the Oxford UKA yet we do not know why it occurs but in the medium term, clinical outcome is not influenced by RL. In particular, it is not a sign of loosening. Physiological RL can therefore be ignored even if associated with adverse symptoms following the Oxford UKA.
Post traumatic myositisossificans is a benign condition of heterotropic ossification of unknown aetiology which typically is related to trauma from a single blow or repeated episodes of microtrauma. We describe an unusual case of myositis ossificans which developed as a complication at the donor site for hamstring autologous graft used in open anterior and posterior cruciate repair and posterolateral corner reconstruction in a 15 year old girl.
13 days later she had an open reconstruction of her anterior and posterior cruciate ligaments with allograft and a repair of popliteus and lateral structures with Larson reinforcement with controlateral hamstring autologous graft.
Eight months following open reconstruction the patient represented to her primary care practitioner with a painful lump in the postero-medial controlateral right thigh. MRI study showed that there was a lobulated hypervascular appearance with a thin enhancing rim of low signal on all sequences indicating calcification. An xray revealed a calcified mass consistent with the diagnosis of myositis ossificans.
The purpose of this study was to assess the accuracy of a modified version of the pivot shift test in detecting ruptures of the anterior cruciate (ACL) ligament.
This study evaluates the relationship between radiographic knee osteoarthritis and the presence of a relevant meniscal tear detected with MRI in symptomatic patients over the age of 60.
Seventy-seven patients over 60 investigated with a knee MRI in a 1 year period were identified. 60 patients had a full set of data available for analysis. The plain radiographs were graded for osteoarthritis using the Kellgren – Lawrence (K-L) scale in a blinded manner. The indication for the MRI was subdivided into: meniscal symptoms, general knee pain and other. These indications were correlated with the K-L grade and result of the MRI.
Overall, 40% of patients with a K-L grade of 0 had a meniscal tear compared to 89% of patients with a K-L score of 3 and 88% with a K-L score of 4. The indication for a MRI was meniscal symptoms in 49, general pain in 6 and other in 5. In the group investigated for meniscal symptoms, the incidence of meniscal tears was 92% and 100% with a K-L grade of 3 and 4 respectively.
In patients with meniscal symptoms and significant radiographic osteoarthritis the outcome of the MRI is so predictable that the scan is unnecessary.
Evidence of fixation failure was established subjectively by clinical examination (Lachman, Anterior Draw, Pivot Shift) and objectively via KT-1000 arthrometer.
Following ethical approval, post-operative CT scans (immediate and 1 year) were performed on our first 10 patients allowing assessment of tunnel dimensions/fill.
A previous study published by Seibold (2007) has shown tunnel widening and communication when suspensory fixation is used in Double Bundle reconstruction. This has the potential risk of leading to fracture between the tunnels.
This has not been seen with the Calaxo screw which may be a result of the biological action of the screw which should ultimately lead to a reduction in these risks.
Tibial lesion: In lateral OA, the midpoint of lesions was 2.0mm (SD:6.5) posterior to the reference line passing through the mid-coronal plane of the resected tibia. This was located significantly more posterior (p=0.038) than midpoint in medial OA, which was 2.2mm (SD:5.7) anterior to the reference line.
Knee Flexion Angle: In lateral OA, the midpoint of lesions was on average at 40° flexion and sites of smaller lesions were very variable. The lesion expanded both anteriorly and posteriorly. In medial OA, smaller femoral lesions occurred in full extension and extended further posteriorly with disease progression.
No significant difference was demonstrated in medial and lateral localisation of the lesions.
We report the experience of a Grade 1 Trauma Centre in treating distal femoral and tibial fractures with the Less Invasive Stabilisation System (LISS). Medium term outcomes are presented with a discussion of clinical indications.
We conducted retrospective study of patients presenting to St James University Hospital with distal femoral and proximal tibial fractures. Case notes were reviewed for demographics, mode and severity of injury, clinical time to union and complications. AO fracture classification and radiological time to union were assessed.
24 patients (10 males, 14 females) underwent LISS fixation. Average age was 69.7 years (range 31–95 years). Mean injury severity score was 14 (Range 9–36). Overall, there were five patients with isolated proximal tibial fractures, seventeen with isolated femoral fractures and two with fractures of both the distal femur and proximal tibia. Two of the distal femoral fractures were open (Gustillo type IIb). According to the AO classification, the distal femoral fractures were sub-divided into 4 Type 33A fractures, 5 Type 33B fractures, 6 Type 33C fractures, 2 Type 32B fractures and 2 Type 32C fractures. The proximal tibial fractures comprised 3 Type 41-A2, 2 Type 41-C1 and 2 Type 41-C2 fractures.
HSS scores for the 24 acute cases were 8 excellent, 8 good, 6 fair and 2 poor results. Average HSS score was 78.8 points. Time to union was determined clinically and radiologically. Bony union was achieved in 23 cases (95.8%). Mean time to radiological union was 3.9 months (range 2–5 months), and clinical union at a mean of 4.46 months (range 3–6 months).
We illustrate that the LISS is a useful technique for treating distal femoral and proximal tibial fractures which are often a complex management problem in the elderly population. With increasing incidence of fragility fractures we suggest that this may be an underused treatment option.
Midvastus vs Medial Parapatellar approach: Quadriceps function in the early post operative period was better preserved in the MV group. Post operative pain, blood loss and the need for LRR tended to be lower in the MV group. There was no difference in ROM, hospital stay, knee scores, complications or radiological alignment. Subvastus vs Medial Parapatellar approach: Quadriceps function was better preserved in the SV group up to 3 months post operatively. ROM was generally greater up to the 4 week time point. Post operative pain and blood loss was lower in the SV group. There was no difference in operative/tourniquet time, hospital stay, rate of LRR, or complications. Modified “Quadriceps sparing” Medial Parapatellar vs Mini-Subvastus (MSV) approach: A tendency for earlier restoration of SLR and better early ROM was noted in the MSV group. Midvastus vs Subvastus approach: The SV group suffered with significantly more pain at six months post operatively.
None of the investigated parameters predicted ROM at six weeks.
A 58 year old man underwent TKR with computer navigation using our standard technique. His post operative course was characterized by thigh swelling and pain. He was discharged on postoperative day 3 with a range of movement of 0–30°.
3 days later he was readmitted with increasing thigh pain and swelling. A quadriceps haematoma was suspected and a computerized tomography scan with intravenous contrast was performed. This showed active bleeding into the femoral canal at the site of the pin tract from a branch of the profunda femoris artery as it entered the linea aspera and a large haematoma within the quadriceps muscle centred over the pin tract anteriorly. There was no extraosseous posterior haematoma.
An 800ml haematoma was drained and two small fragment cortical screws were inserted into the pin tracts. Unicortical screws were used to minimize the risk of causing posterior bleeding.
Arterial injury has not been reported before in this setting. The previously reported complications are: pin breakage, superficial wound infection, interference with line of sight, broken pelvic drill, prolonged operation time and prolonged tourniquet time.
The mean Oxford Knee Society ratings was 52 (range 47–55; SD, 3.18) preoperatively, and 19 (range 14–24; SD, 3.72) at final follow up. The pre op mean range motion was 84.28° (range 45°–120°; SD 21.73). At final follow up the average range of motion was 107.5° (range 95°–120°; SD 8.93). Accord
There were no clinical failures or cases of postoperative instability and no cases of radiographic loosening or wear.
There is an ever-increasing clinical need for the regeneration and replacement of tissue to replace soft tissue lost due to trauma, disease and cosmetic surgery. A potential alternative to the current treatment modalities is the use of tissue engineering applications using mesenchymal stem cells that have been identified in many tissue including the infrapatellar fat pad. In this study, stem cells isolated from the infrapatellar fat pad were characterised to ascertain their origin, and allowed to undergo adipogenic differentiation to confirm multilineage differentiation potential.
The infrapatellar fat pad was obtained from total knee replacement for osteoarthritis. Cells were isolated and expanded in monolayer culture. Cells at passage 2 stained strongly for CD13, CD29, CD44, CD90 and CD105 (mesenchymal stem cell markers). The cells stained poorly for LNGFR and STRO1 (markers for freshly isolated bone marrow derived stem cells), and sparsely for 3G5 (pericyte marker). Staining for CD34 (haematopoetic marker) and CD56 (neural and myogenic lineage marker) was negative.
For adipogenic differentiation, cells were cultured in adipogenic inducing medium consisting of basic medium with 10ug/ml insulin, 1uM dexamthasone, 100uM indomethacin and 500uM 3-isobutyl-1-methyl xanthine. By day 16, many cells had lipid vacuoles occupying most of the cytoplasm. On gene expression analyses, the cells cultured under adipogenic conditions had almost a 1,000 fold increase in expression of peroxisome proliferator-activated receptor gamma-2 (PPAR gamma-2) and 1,000,000 fold increase in expression of lipoprotein lipase (LPL). Oil red O staining confirmed the adipogenic nature of the observed vacuoles and showed failure of staining in control cells.
Our results show that the human infrapatellar fat pad is a viable potential autogeneic source for mesenchymal stem cells capable of adipogenic differentiation as well as previously documented ostegenic and chondrogenic differentiation. This cell source has potential use in tissue engineering applications.
At 6 week review, the patient complained of increasing pain, inability to fully weight bear and a decreased range of movement. 35 fixed flexion deformity, 30 degrees external rotation and 20 degrees of valgus of the leg. Radiographs revealed a transverse supracondylar fracture extending through the level of the pin fixation.
Subsequent surgery involved an osteotomy to correct the deformity and application of a lateral femoral plate After fixation direct inspection of the retained anterior cruciate ligament, revealed and intact graft that functioned through the full range of movement.
At nine months, the patient is fully weight bearing has returned to her pre-injury sporting level and has a range of movement of 0–110 degrees. There was no objective knee instability and the patient is satisfied with the outcome.
Femoral fractures have rarely been reported in the literature following ACL reconstruction and these are usually associated with drilling of an enlarged femoral tunnel. We report a rare case of a transverse supracondylar femoral fracture following ACL reconstruction, with the fracture occurring through the fixation tract not the femoral tunnel.
Conclusion: Patellar reconstruction using non- vascularised bone graft via a medial patellar pouch is a viable alternative surgical option to aid stability in those patients undergoing primary TKR with previous patellectomy.
Patient’s height and size of femoral component used at time of surgery was recorded. The results showed a positive correlation between the patient’s height and a well fitting femoral prosthesis.
We have demonstrated that the height of a patient can be a used to guide and assist in the sizing of the femoral component of the Oxford uni-compartmental knee replacement. This study may also have implications for the sizing of other prostheses currently in use.
There are about 63,000 primary total knee replacements done annually in England and Wales. One of the biggest challenges of modern NHS is to ensure high quality care for the patients. A reduced length of stay in the hospital following primary total knee replacements could be the key factor in significant cost reduction.
The aim of the study was to assess the efficacy of our rapid recovery programme following total knee replacements in terms of reducing length of stay, morbidity, complications, and readmissions rates.
A prospective study of 252 patients who underwent primary total knee replacement for a period of one year between October 2006 to 2007 were included in the programme. There were 123 (49%) males and 129 (51%)females. The average age was 71 (range-53 to 86). The average BMI was 30 (range-22 to 46). The median ASA grade was 2 (range-1 to 4). There were no exclusion criteria. The programme included pre-operative education of patient and relatives, standardised operation protocols, infection control, pain management, continuous motivation by nursing staff and physiotherapists in the ward as well as intensive rehabilitation by a community based physiotherapy team in patient’s own environment. The patients were discharged when they had achieved the ward physiotherapy requirements.
The average length of stay was 5.2 days. The complications encountered during inpatient stay was wound discharge(43), surgical site infection(1), DVT (1), pneumonia(1).12 patients needed post operative blood transfusion. The readmissions rate was 4%. Deep infection was noted in 4 patients, DVT(1), pulmonary embolism(1)and 3 patients had medical complications.
In conclusion the rapid recovery programme following total knee replacement is an efficient method of speeding the recovery and reducing the length of hospital stay after primary knee replacements. It is useful for the modern NHS to achieve a balance between financial savings and a consistent, responsive and high-quality care for patients.
We describe our early experience with this new system, the technique of fixation, short-term clinical results, functional outcome and MRI features of these implants.
Tunnel view of the harness was excellent in 79%. Linvatec Tensioner was used in 60%. Graft was not detached in 20%. The mean follow up period was 7 months (2 –12). At last follow up Lachman and pivot shift were negative in 85% and grade 1 in 15%, The mean postoperative scores were Tegner-7 (5–10), Lysholm-7 (5–10) and IKDC-71 (57–93) respectively.
1 wound problem required washout. The tibial screw twisted off at final turn in 1 patient. The cross pin drill missed the guide in 1 patient.
At 32 weeks MRI scan: the implants were still evident, However apart form 1 patient, there was no surrounding bone reaction and none showed tunnel widening.
Theofilos Karachalios et al. described the new ‘Thessaly test’ and concluded that it could be safely used as a first line screening test for the selection of patients who need arthroscopic meniscal surgery (Ref: J Bone Joint Surg Am. 2005 May; 87(5):955–62). Our objective was to study the role of physical diagnostic tests in screening for meniscal tears and to validate the diagnostic accuracy of the Thessaly test.
McMurray’s test and the Thessaly test were assessed by an independent investigator blinded to any imaging data in all patients. MRI and subsequent arthroscopy results were then collated.
Our study showed a much lower diagnostic accuracy for the Thessaly test (61.25 % for medial meniscus and 80 % for lateral meniscus) It is comparable to McMurray’s test (57.14 % for medial meniscus and 77.38 % for lateral meniscus). The Joint line tenderness test has a far superior diagnostic accuracy (80.95 %for medial meniscus and 90.48 % for lateral meniscus). Combining the joint line tenderness test with McMurrays test or the Thessaly test further increased the diagnostic accuracy. Magnetic resonance imaging (MRI) detected 96% of meniscal tears. Arthroscopy was diagnostic and therapeutic in all cases.
Nine patients required a medial gastrocnemius flap. Three patients received fasciocutaneous flaps (one bipedicle); one patient was managed with a tissue expander pre-operatively; one with a split skin graft, and one patient required perforating skin incisions in order to close the wound. 60% of patients developed local wound complications and 27% required further soft tissue procedures.
The overall limb salvage rate was 73.3% (four patients required an above knee amputation for persistent infection). Five patients had successful re-implantation surgery. Four patients had arthrodesis surgery with successful eradication of infection. Two patients developed chronic infection.
a retrograde distal femoral nail with condylar bolts and multi-planar locking screws, a retrograde nail with two parallel distal screws, and a dynamic condylar screw and plate construct.
The distal femoral geometry was been taken from the BEL repository. The bone was aligned with the mechanical axis and a compressive load of 2000N and separately a torsion load of 10Nm were applied. A fracture was introduced by removing a transverse 15mm slice of material and a saggital slice of 1mm thickness.
The FE model examined whether any of the constructs was markedly stiffer than any other.
This observational study was undertaken to explore the relationship of the foot posture of patients with Medial Compartment Osteoarthritis of the knee (MCOA), patients with hip osteoarthritis (OA) and a healthy control group, using the Foot Posture Index (FPI). Goniometric measurement of talocrural dorsiflexion was also included.
The relationship of foot posture to MCOA and hip osteoarthritis OA has not been explored although in other medical fields, such as neurology and sports medicine, the relationship between foot posture, lower limb pain and function has been acknowledged. In view of the current high incidence of lower limb OA, any investigation of associations that may lead to improved assessment and conservative management is worthy of consideration.
Currently, systematic examination of the foot is not undertaken in routine clinical assessment of patients with lower limb OA and, if this were to be introduced, there would be difficulty in selecting suitable clinical outcome measures. The recent development of the Foot Posture Index (FPI) has addressed the need for a diagnostic clinical tool that measures foot posture in multiple planes and anatomical segments
Sixty participants took part: twenty patients with radiographic and clinical evidence of MCOA grade IV, twenty patients with radiographic and clinical evidence of stage IV OA hip, and twenty age-matched healthy volunteers as a control group.
A one way Analysis of variance (ANOVA) was performed to investigate any differences between the 3 groups for foot posture using FPI scores and talocrural dorsiflexion measurements. This showed that there were significant differences between the groups (p< 0.001). Patients with MCOA had a high positive FPI score (indicating a pronated foot), patients with hip OA had a low negative FPI score (indicating a supinated foot). The healthy controls had a normal score distributed over a wider range than the other two groups. In addition, the results of the Pearsons test indicate that the FPI correlated positively with talocrural dorsiflexion (r = 0.55, p< .001).
Differences in foot characteristics may be influenced by specific treatment modalities such as gait reducation, orthotic provision, specific lower limb strengthening and stretching exercises. Foot assessment might therefore be a useful adjunct to conservative management of both MCOA and hip osteoarthritis.
We report the results of patellofemoral joint replacement done at our institution for predominantly patellofemoral arthritis.
Patellofemoral joint replacement has always been a controversial subject, particularly in elderly patients where a more predictable result can be obtained with TKA. Patellofemoral joint replacement surgery was commenced at our institute in 2002 using the Avon design (Stryker corp, UK,) pioneered at the Avon Orthopaedic centre, Southmead, Bristol, UK. We report retrospective analysis of 43 consecutive Patellofemoral replacements done in 39 patients between 2002 and 2006, with a minimum of 6 months follow-up. 38 patients (5 bilateral) were available for review while 1 patient died 3 years after the operation following unrelated causes. They were all assessed clinically and radiologically on the last follow up. Follow-up ranged from 6 to 56 months, average being 21 months. Females outnumbered males by 3:1. All patients were scored pre and postoperatively using Melbourne Knee scoring system (Bartlett et al) and Knee Functional Score. The average Melbourne Knee score increased from 10 to 25 postoperatively, while the knee functional score increased from 57 to 85. Postoperative flexion ranged from 100–140°, average being 116°. Commonest complication was clicking (17%), half of which resolved by arthroscopic lateral release. 87% patients graded the result as excellent or good, while 2% (1 patient) rated it as poor. 59% patients had radiologically proven early tibiofemoral arthritis preoperatively, out of which progression was noted in 28% at the last follow-up. No complications related to deep infection or loosening were noted, and one knee needed revision on account of progression of lateral compartment arthritis. With revision as the end point, the survivorship was 97.7% at average of 2 years after surgery.
56 patients fulfilled the criteria and 50 patients were included in the study between September 2006 – May 2007. Male/female ratio was 18: 32. Mean age was 66.2 years. Procedure included 33 total knees, 13 bilateral and 4 revision knee replacements.
Prior to our study the expenditure on allogenic blood transfusion was £13,230. The estimated cost of using the re-infusion system was £6230
A saving of £ 7500 was achieved as a result of using the drain in the “at risk” patient.
much better, better, un changed or worse after treatment; was obtained at 3 months.
Patients were also asked the duration of any relief obtained. Statistical methods utilized included the two tailed t-test, the Wilcoxon Rank Sum test, Odds ratio (OR) and the Chi Squared Test.
Pearson’s correlation coefficient between deformity angles obtained by the two methods was highly significant (0.86) with a P value < 0.0001. The measurements from four independent sites were not significantly different.
the regenerative cells are viable following implantation. supplementing adipose cells following injury supports regeneration. morphology was maintained. intervertebral disc height was not lost. MRI signal remained similar to native control. hyaluronic acid was insufficient to prevent disc degeneration or desiccation. lack of intervention resulted in progressive degeneration.
The area of the dural sac and neuroforamina was examined with MRI for the narrowest spinal segment. ODI and VAS were used for clinical assessment.
plain x-ray plain xray and flexion/extension x-rays and plain x-ray and flexion/extension x-rays and CT scan.
These results were correlated with a fusion rate based on the micro CT. The specificity and sensitivity of these radiological measures in diagnosing pseudarthrosis and inter-rater reliability using Fleiss’ Kappa scores for each method were calculated.
classified as WAD I, III or IV lost consciousness as a result of a motor vehicle crash (MVC) previous history of MVC previous non-traumatic neck pain diagnosed with any neurological, metabolic or inflammatory conditions or were pregnant.
The measure was performed for the rectus capitis minor/major, multifidus, semispinalis cervicis/capitis, splenius capitis and upper trapezius. The values for all muscles were plotted for level and side and linear regression analysis was used to determine segmental trends (C3-7). A multi-factorial analysis of variance (MANOVA) was applied to investigate group means of whiplash and controls for fat indices across muscle, side and level. Bonferroni post-hoc comparisons were used to compare group by muscle interactions at each level. Multiple regression analyses were performed to determine if the score on the Neck Disability Index (NDI), age, Body Mass Index (BMI), compensation status and duration influenced fatty infiltrate. Significance was set at p < 0.05. Data presented as mean ± SD.
MANOVA revealed significant main effects for group, muscle, segmental level and side (p < 0.0001), and significant interactions between Group:Muscle, Group:Level, Muscle:Level and Group:side (p < 0.0001). Sides were averaged for each muscle and level for post-hoc analysis.
There was a linear decrease in the fat indices from C3 – C7 for each muscle in both groups. No significant differences in fat indices across muscle, levels and side were noted in controls (p = 0.09). For the WAD subjects, the multifidus muscle had significantly higher fat content at each level compared to the other segmental muscles (p < 0.0001) and was highest at C3 (p < 0.0001).
There were higher fat indices in the whiplash group compared to the controls for the rcpmin and rcpmaj muscles (p < 0.0001).
No relationship was found for fat indices in all WAD muscles and NDI scores (p = 0.81), age (p = 0.14), duration (p = 0.99), compensation (p = 0.37) or BMI (p = 0.74).
the mid-sagittal plane of 10 male and 10 female discs aged 13–79 years; 7 parasagittal slices through a single disc; discs showing various types of tears.
Most chondrocytes were unicellular but bicellular and multicellular chondrons were common in the margins of large tears and the nucleus in degenerate discs. Cellularity was highest in the right posterior quadrant, lowest in the left anterior quadrant, about equal in the left posterior and right anterior quadrants, and substantially higher in the right half of the nucleus. The correlation of increasing age with declining cell density was much stronger for the nucleus than for the annulus. Nucleus cellularity continued to decline throughout life whereas the annulus ceased its decline after the age of 50. Cell density was low in the vicinity of tears but elsewhere the disc was unaffected. Extensive inferior and superior end-plate separations reduced cellularity throughout the disc. Increased thickness of the cartilage end-plate was associated with higher cellularity in the nucleus.
For phase angle (approximate magnitude 5°), no significant overall effects due to degeneration were found across any loading direction (P> 0.2). ANOVA analyses on maximum/minimum principal strains found no significant effect due to disc grade (P> 0.063). However, a small number of significant effects due to disc grade were found at particular strain gauge locations for the isolated disc in flexion, the intact FSU in extension, and the intact FSU/isolated disc in right lateral bending.
The non-significant small phase angles suggest that the disc behaves more like an elastic solid than a poroelastic material, and that dehydration associated with degeneration does not adversely affect damping. Principal strains were not significantly affected by disc degeneration overall, suggesting that the cortical shell adjacent to the disc-endplate boundary maintains a relatively homeostatic condition, with more dramatic architectural changes probably occurring within the trabecular bone. Applications of this research include providing important validation data for analytical/finite element models of the intact FSU and isolated disc segment, and a better understanding of the magnitudes of cortical strains that need to be maintained in order to avoid damaging vertebral bone stress-shielding effects after treatments for disc degeneration.
The aim of this case report was to highlight the development of severe vertebral body osteolysis following posterior lumbar interbody fusion with recombinant human bone morphogenetic protein (rhBMP-2).
punctate deposits in the outer annulus, diffuse deposits in the transitional zone or inner annulus fibrosus with occasional deposits in the nucleus, or large deposits in the transitional zone extending variably into the nucleus.
Their maximal incidence was in the lower lumbar discs (L4/5-L6/7) with no calcification seen in the lumbosacral or lower thoracic discs. All deposits were hydroxyapatite with large crystallite sizes (800–1300 angstrom) compared to cortical bone (300–600 angstrom). No type X-collagen, osteopontin or osteonectin, were detected in calcific deposits although positive staining for bone sialoprotein was evident. Calcified discs had less proteoglycan of smaller hydrodynamic size than non-calcified discs.
CT scans performed at 3 months postoperative in case 1 and 3.5 months postoperatively in case 2 demonstrated osteolysis in the vertebral bodies adjacent to the implant. In both cases however, CT scans performed 12 months post-operatively showed that the osteolytic cysts were beginning to resolve and fusion at the bone-titanium junction may have begun. No other cases of cystic osteolysis were found amongst other anterior cervical cases or 115 posterior lumbar interbody fusion (PLIF) cases similarly followed-up with serial CT scans. The concentration of rhBMP-7 used in a subgroup of 8 corpectomy cases undergoing anterior cervical corporectomy and reconstruction using a titanium rod and buttress implant was at least twice the concentration used in other anterior cervical cases and approximately one quarter to one fifth the concentration used in lumbar interbody PLIF cages.
Osteolysis has been described in association with the use of rhBMP-2. Following these reports, the manufacturers of rhBMP-2 have advised surgeons strongly not to use more than the (recently) recommended dose, despite there being no published evidence that osteolysis is dose-related. Similar recommendations have not been made regarding the use of BMP-7 (OP1).
The concentration of BMP-7 (OP1) which led to osteolysis in these cases was much greater than used elsewhere in the spine, where OP1 (3.5mg) is usually mixed with 10–15 mls of finely-milled autograft. This suggests that the concentration achieved by mixing 3.5 mg of OP1 with 5 mls of CMC/TPC putty may increase the risk of osteolysis when inserted into the anterior cervical spine.
The aim of this study was to compare long term outcomes of usual surgical advice, involving no formal post-surgical rehabilitation, with a non-aggravating six month gym rehabilitation programme post lumbar discectomy. This study is a prospective randomized controlled trial using a cohort followed for three years.
Mean (95%CI) pre-op Physical Component Summary score (PCS) was 28.1 (26.6–29.5). This increased at last F/U to 39.3 (36.9–41.7, P< 0.0001). Mean Mental Component Summary score (MCS) was 47.8 (45.5–50.1) pre-op and 52.3 (50.2–54.5) at last F/U (P=< 0.0001).
While there was no difference in patient demographics, a significant difference existed in the pre-op SF-12 scores between the patients of the two surgeons (mean PCS: 24.9 (22.7–27.0) vs. 29.6 (27.8–31.5) and MCS: 44.0 (39.3–48.6) vs. 49.5 (46.8–52.1)). No significant difference was found in the improvements in mean SF-12 scores between these two patient groups (PCS: 12.3 (7.6–17.1) vs. 10.8 (8.3–13.3) and MCS: 6.3 (1.8–10.8) vs. 3.0 (0.3–5.6)) or in the SF-12 scores at 12-months (PCS: 37.2 (32.8–41.6) vs. 40.2 (37.2–43.2) and MCS: 52 (48.3–55.7) vs. 52.3 (50.1–54.4)). No significant difference was found between post-op PCS of the less disabled patient group or MCS scores of either group and published SF-12 age-matched population norms (65–74 years: mean PCS of 44.4 (42.7–46.1) and MCS of 53.8 (52.7–55.0)).
Three published series (869 patients) were located providing SF-12 data for TKR surgery. Weighted mean age was 69 years and pre-op PCS was 30 (range:27–34). 12-month improvement in PCS was 7.0 (range:7–8.5). For THR, one paper (147 patients from 3 hospitals) containing SF-12 data was found. Mean age was 68 years (range:36–89). Mean pre-op PCS and MCS of 30.5 and 41.4, increased to 45.6 and 49.7 at one year.
hospital and number of segments of fusion.
In fusions of four and more segments a threefold higher risk of dural tears in comparison to fusions of less than four segments should be taken into consideration. A subgroup analysis on the predictor-variable hospital should be performed assessing further covariates. However, this goes beyond the possibilities of documentation in this international spine registry.
Radiostereometric analysis (RSA) is a technique that can be used to measure in-vivo micro-motion of the components of hip arthroplasty.
86 patients received a titanium custom-made prosthesis. The average age was 64 year (20y –84y). During the study 30 patients out of 86 received a cementless femoral stem. The choice of stem fixation is determined by the quality of the bone. In all cases a 36 mm cobalt chromium head is used. Spherical tantalum markers, chosen because of the proven biocompatibility, were inserted into stable locations in the femoral bone during surgery using a specialized insertion tool, according to the protocol. Evaluation was done 1, 6, 12, 24, 52 weeks after surgery.
Overall subsidence follows a parallel pattern for the cemented and uncemented prosthesis that is slightly stronger in for the uncemented prosthesis. Over the 6 months evaluation period the prosthesis migrates towards the lateral side with 0.25 mm in both groups. An anteroversion of 0.5° to 1° is noted at 6 months follow-up. The varus valgus movement of the prosthesis is similar for both groups at 6 months. At 6 weeks a slight valgus flexion is noted, this is reversed at 3 months. At this point in time the effect is more pronounced in the group with a cemented prosthesis.
Micro motion is difficult to assess on plain radiography. In this study more subsidence is noted in the uncemented prosthesis compared to the cemented. The degree of rotation of the stem measured in our study is comparable with those reported by others. In our primary THR we observe a bi-modal micromotion except for the subsidence the initial movement up till 6 weeks is reversed at 3 months follow-up and at 6 months the prosthesis seems stabilized, though longer follow-up is required to confirm stabilization.
Bone metastases occur in about 15% of all cancer cases. Pathological fractures that result from these tumours most frequently occur in the femur. It is extremely difficult to determine the fracture risk with the current X-ray methods, even for experienced physicians. The purpose of this study was to assess whether the use of a predictive finite element model could improve the prediction of strength in comparison to an clinical assessment.
Eight human cadaver femora, with and without simulated metastases, were CT-scanned. A solid calibration phantom was included in each scan. From the scans, eight finite element (FE) models were generated using brick elements. The non-linear mechanical properties were based on bone density. After scanning, laboratory experiments were performed. The femora were loaded under compression until failure. During the experiments the failure forces and the course of failure were registered. These experiments were simulated in the FE-models, in which plastic deformation simulated failure of the bones. Six experienced physicians, were asked to rank the femora on strength using X-rays (AP and ML) and additional information on gender and age.
The results showed a strong Pearson’s correlation (r2 = 0.92) between the experimental failure force and predicted failure force. The Spearman’s rank correlations between experiment and predictions ranged between ρ=0.58 and ρ=0.8 for the physicians, whereas it was significantly higher (ρ=0.92) for the FE-model
This study showed that femur specific FE models better predicted femoral failure risk under axial loading than experienced physicians. When the model is further improved by adding, for example, other loading conditions, it can be clinically implemented to predict in vivo fracture risk for patients suffering, for example, bone metastases or osteoporosis.
Hip Resurfacing (HR) is nowadays widely used as an alternative to Total Hip Replacement (THR), especially for the young and active patients. Because of the more physiological distribution of the load in the femur, this technique is particularly known to reduce bone loss due to stress shielding behaviour, a major problem encountered with THA. Different computational studies have analysed the performance of HR prostheses. Therefore, the purpose of this study is to apply a computational approach, in fact a bone remodelling analysis, in order to investigate its application to evaluate the bone structure changes postoperatively.
A Finite Element model was developed of a femur with HR prosthesis. The model was reconstructed starting with the femur medical images, and then the prosthesis was positioned in the clinical implantation angle (5° valgus). A cement mantle thickness of 1mm was included. Then a Finite Element Analysis in combination with a bone remodelling model (bone material properties) was performed. The results obtained predict as there is a certain bone loss in the superolateral and inferior medial zone. Additional bone material apposition is locally found with the aim of fixing the implant stem on the medial side, but also a remarkable distal ingrowth around the stem tip. All these findings are in good qualitative agreement with clinical observations.
We conclude that the numerical simulation used in this study is a useful tool in predicting bone remodelling inside a cemented HR prosthesis. This kind of methodologies will help on the design of devices, surgical techniques, etc.
One method of reducing intra-operative complications in revision hip surgery is the cement-in-cement technique. Some concern exists regarding the retention of the existing fatigued cement mantle. It was hypothesised that leaving the existing fatigued cement mantle does not degrade the mechanical properties of the cement in cement revision construct. The aim of this research was to test this hypothesis using in vitro fatigue testing of analogue cement in cement constructs.
Primary cement mantles were formed by cementing a large polished stem into sections of tubular stainless steel using polymethylmethacrylate with Gentamicin. At this stage, the specimen was chosen to be in the test group or the control group. If in the test group, it underwent a fatigue of 1 million cycles. This was carried out in a specifically designed rig and a fatigue testing machine. Into these fatigued and unfatigued primary mantles, the cement in cement procedure was carried out. Both groups underwent a fatigue of again 1 million cycles. Subsidence of the stems and their inducible displacement was recorded. A power calculation preceded testing.
Completion of a Mann Whitney test on the endpoints of the subsidence curves revealed that there is no statistical difference between the data sets (means 0.51, 0.46, n=10 + 10, p = 0.496). This data was also calculated for the inducible displacement. Again, there was no statistical difference in the separate groups for this parameter (means 0.38, 0.36, p = 0.96). This methodology produces a complex 3 dimensional reconstruction of the cement in cement revision which replicates the in vivo structure. This reconstruction has undergone fatigue testing. Neither of these two aspects has been produced for the study of cement in cement revision before.
A fatigued primary cement mantle does not appear to degrade the mechanical properties of the cement in cement revision construct
Aseptic loosening is the most frequent cause of implant failure in total hip arthroplasty (THA). Additionally, failure rate was still found by some authors to be increased in patients with osteonecrosis of the femoral head (ON-FH). It is well evidenced that low initial fixation and early migration precedes and predicts long-term failure rate of both, the acetabular and femoral component in THA.
This independent, double-blind, randomized, controlled study was primarily designed to evaluate whether a single infusion of 4 mg of zoledronic acid is sufficient to prevent implant migration determined by the EBRA-digital method. Fifty patients were consecutively enrolled between July 2002 and March 2005 to receive either 4 mg zoledronic acid (ZOL) or saline solution (CTR) one day after THA (Zweymüller system, cementless). Plain radiographs were performed postoperatively and all parameters were evaluated at each follow-up meeting interval at 7 weeks, 6 months, 1 year, and yearly thereafter during a median follow-up period of 2.8 years (2 years minimum).
In CTR, subsidence increased up to −1.2 mm ± 0.6 SD at 2 years in CTR (P< 0.001). Less, but a near curve-linear shaped migration pattern was found for the ace-tabular component, with an averaged medialization of 0.6 mm ± 1.0 SD and a cranialization of 0.6 mm ± 0.8 SD at 2 years (P< 0.05, Friedman ANOVA) at 2 years. In ZOL, a significant reduction in bone turnover markers was accompanied by a complete prevention of cup migration in both, the transverse and vertical direction (P< 0.05, ANOVA), while there was only a trend to a decreased subsidence in stems.
The study provides useful data which are promising and support the suggestions that bisphosphonates may offer significant opportunities to reduce and prevent implant migration of THA, thus increasing long-term durability of THA especially in selected high-risk patients.
Common in vitro protocols for TGF-β driven chondrogenic differentiation of MSC lead to hypertrophic differentiation of cells. This might cause major problems for articular cartilage repair strategies based on tissue engineered cartilage constructs derived from these cells. BMPs have been described as alternate inductors of chondrogenesis while PTHrP and FGF-2 seem promising for modulation of chondrogenic hypertrophy. The aim of this study was to identify chondrogenic culture conditions avoiding cellular hypertrophy. We analyzed the effect of a broad panel of growth factors alone or in combination with TGF-β3 on MSC pellets cultured in vitro and after transplantation in SCID mice in vivo.
Chondrogenic differentiation in vitro was successful after supplementation of the chondrogenic medium with TGF-β3 as confirmed by positive collagen type II and alcian blue staining. None of the other single growth factors (BMP-2, -4, -6, -7, FGF-1, IGF-1) led to sufficient chondrogenesis as indicated by negative collagen type II and alcian blue staining. Each of these factors, however, allowed chondrogenesis in combination with TGF-β without suppressing collagen type X expression. Combination of TGF-β with PTHrP or FGF-2 suppressed ALP activity, induced MMP13 expression, and prevented differentiation to chondrocyte-like cells when added from day 0. Delayed addition of PTHrP or FGF-2 stopped chondrogenesis at the reached level and repressed ALP activity. The treatment of MSC constructs with FGF-2 or PTHrP in the last 3 weeks before transplantation did not prevent hypertrophy and calcification in vivo.
FGF-2 and PTHrP were potent inhibitors for early and late chondrogenic differentiation in contrast to BMPs. As soon as a developmental window of collagen type II positive and collagen type X negative pellet cultures can be created in this model, both seem to be potent factors to suppress hypertrophy and to generate stable chondrocytes for transplantation purposes.
The use of mesenchymal stem cells (MSCs) for cartilage and bone tissue engineering needs to be supported by scaffolds that may release stimuli for modulate cell activity.
The objective of this study was to asses if MSC undergo differentiation when cultured upon a membrane of nanofibers of poly-L-lactic acid loaded with hydroxyapatite nanoparticles (PLLA/HAp).
The PLLA/HAp nanocomposite was prepared by electrospinning. Membranes microstructure was evaluated by SEM. MSCs were seeded on PLLA/HAp membranes by standard static seeding and cultured either in basal medium or Chondrogenic Differentiation Medium. Cell attachment and engraftment was assessed 3 days after seeding and MSC differentiation was evaluated by immunostaining for CD29, SOX-9 and Aggrecan under a confocal microscope after 14 days.
PLLA/HAp membrane obtained was composed by fibers (average diameter of 7μm) with nano-dispersed hydroxyapatite aggregates (average diameter of 0.3μm). 3 days after seeding, MSCs were well adhered on the PLLA/HAp fibers with a spindled shape. After 14 days of culture all MSCs were positive for SOX-9 in both basal and chondrogenic media groups. Aggrecan was present around the cells. MSCs were either CD29 positive or negative.
We demonstrated that PLLA/HAp nanocomposites are able to induce differentiation of MSCs in chondrocyte-like cells. Since HAp has osteoinductive properties, the chondrogenic phenotype acquired by the MSCs may be either stable or an intermediate stage toward enchondral ossification. The presence of CD29 and SOX-9 double positive cells indicate intermediate differentiation phases.
This nanocomposite could be a susceptible scaffold for bone or cartilage tissue engineering using undifferentiated MSCs.
Acetabular rim damge due to rim impingement is frequently found on retrievals and may be associated with increased wear and contact stresses, instability, and implant loosening of total hip replacement devices. Large X3 bearings (> 36mm) from Stryker have increased implant range of motion and improved polyethylene material (sequentially crosslinked and annealed). A hip simulator wear study was performed with and without femoral neck to acetabular rim impingement to determine the wear performance of these new bearings under aggressive impingement conditions. Two sizes of these new components were tested (36mm with 3.9mm thickness and 40mm with 3.8mm thickness) with two standard sized controls (28mm with 7.9mm thickness in X3 and conventional polyethylene. The 36mm component was chosen to be the largest component utilizing the same shell as the standard 28mm size components while the 40mm component was chosen to be the thinnest bearing currently offered.
Impingement significantly increased wear for all bearings (p< 0.05) but no cracking or failures of the rim occurred. Wear rates for all X3 bearings were statistically indifferent under each testing condition despite bearing size and thickness. Average wear rates for X3 bearings were 0.3mm3/million cycles (mc) under standard conditions and 3.5mm3/mc under impingement conditions. Average wear rates for conventional bearings were 19.5mm3/mc under standard conditions and 48.3mm3/mc under impingement conditions. Overall the X3 bearings exhibited a 93% reduction in wear under impingement conditions and 99% reduction in wear under standard conditions.
Increased bearing range of motion reduces the chance of impingement. This study shows the simulated outcome even if these larger bearings were to impinge. We conclude that these larger X3 bearings exhibits the same wear performance as standard X3 bearings and significantly superior wear performance compared to conventional polyethylene bearings under standard and impingement conditions.
Major drawbacks associated with autologous bone grafting are the risk of donor site morbidity and its limited availability. Sterilized bone allograft, however, lacking osteoinductive properties, carries the risk of graft failure resulting from insufficient osseointegration of the graft.
The aim of this study was to vitalize bone allograft with human osteoprogenitor cells under GMP-conform conditions. For this purpose we investigated proliferation, osteogenic differentiation and large-scale gene expression of human MSCs cultured three-dimensionally on peracetic acid (PAA)-treated spongious bone chips.
MSCs were isolated from healthy donors (N=5) and seeded onto PAA-treated spongious bone samples (~5×5×5 mm, DIZG, Germany) under GMP-conform conditions. Proliferation (total protein assay), osteogenic differentiation (cell-specific ALP activity assay, quantitative gene expression analysis of selected osteogenic marker genes), and morphology were assessed. RNA was isolated and microarray analysis was performed using the PIQORTM Stem Cell Microarray system (Miltenyi Biotec) including 942 target sequences.
Increasing cellularity was observed during the 42 d observation period while cell-specific ALP activity peaked at day 21. Effective proliferation and adhesion of human MSCs on PAA-treated spongious bone was confirmed by histology, scanning electron and confocal laser scanning microscopy. Gene expression of early (Runx-2), intermediate (ALP), and late (osteocalcin) osteogenic marker genes was present during 42 days of cultivation. Microarray analysis of MSCs cultivated on bone allograft versus 2-D tissue culture demonstrated temporal upregulation of genes involved in extracellular matrix synthesis (e.g., matrix metalloproteases, collagens), osteogenesis (e.g., BMPR1b, Runx-2) and angiogenesis (angiopoietin, VEGF).
PAA-treated spongious bone allograft is a biocompatible carrier matrix for long-term ex vivo cultivation of MSCs as observed by favorable proliferation, cell distribution, gene expression profile, and persisting osteogenic differentiation. GMP-grade vitalisation of bone allograft by cultivation with autologous MSCs represents a promising clinical application for the treatment of osseous defects.
Mesenchymal stem cells (MSC) are suitable candidates for the cell-based cartilage reconstruction and have been isolated from different sources such as bone marrow (BMSC), adipose tissue (ATSC) and synovium (SMSC). The aim of this study was to analyse the tendency of BMSC, ATSC and SMSC to undergo hypertrophy during chondrogenic induction in vitro and to evaluate their in vivo development after ectopic transplantation into SCID mice in order to determine which cell source is most suitable for cartilage regeneration.
Human BMSC, ATSC and SMSC were cultured under chondrogenic conditions for five weeks. Differentiation was evaluated based on histology, gene expression, and analysis of alkaline phosphatase activity (ALP). Pellets were transplanted subcutaneously into SCID mice after chondrogenic induction for 5 weeks and analysed 4 weeks later by histology. Similar COL2A1:COL10A1 mRNA ratios were found in BMSC, ATSC and SMSC. BMSC displayed the highest ALP activities, SMSC had lower and heterogenic ALP activities in vitro which correlated with calcification of spheroids in vivo. Most SMSC transplants specifically lost their collagen type II in vivo or were fully degraded. BMSC and ATSC pellets always underwent vascular invasion and calcification in vivo. Single BMSC samples had the capacity to develop into woven bone or fully developed ossicles with hematopoietic tissue surrounded by a bone capsule.
Neither BMSC nor ATSC or SMSC were able to form stable ectopic cartilage. While BMSC and ATSC underwent developmental processes related to endochondral ossification instead of stable ectopic cartilage formation, SMSC tended to undergo fibrous dedifferentiation or degradation. Besides appropriate induction of chondrogenesis, locking of cells in the desired differentiation state is, thus, a further challenge for adult stem cell-based cartilage repair.
The clinical application of bone morphogenetic proteins (BMPs) offers solutions to many challenging problems in orthopaedics. However, a practical clinical problem is to obtain a controlled release of the BMPs. The attachment of heparin to biomaterials may result in an appropriate matrix for the binding, and sustained release of BMPs. Binding of growth factors to heparin stabilizes these growth factors, protects them from proteolytic degradation, and prolongs the half-life of BMPs in culture media 20-fold. We created a carrier based delivery system with a localized sustained release by loading a tricalciumphosphate/hydroxyapatite (TCP/HA) bone substitute coated with cross-linked collagen and heparin, with BMP-7.
TCP/HA granules (BoneSave™, Stryker Orthopaedics) were coated with collagen, and subsequently the collagen was cross-linked in the presence (TCP/HA-Col-Hep) and absence (TCP/HA-Col) of heparin. BMP-7 was loaded onto the coated TCP/HA granules. Morphology of the coated collagen with and without heparin, and release kinetics of BMP-7 from the granules were analyzed. TCP/HA granules without coating were used as controls.
Analysis showed a highly porous collagen network on both TCP/HA-Col and TCP/HA-Col-Hep granules. Immersion of the granules in BMP-7 solution, resulted in the binding of 54±3% (62.9±5.4 ng BMP-7/mg granule) to the TCP/HA granules, 64±8% (69.0±9.6 ng BMP-7/mg granule) to the TCP/HA-Col granules, and 78±1% (92.9±4.8 ng BMP-7/mg granule) to the TCP/HA-Col-Hep granules. TCP/HA granules showed a burst release of BMP-7 within the first 4 h. TCP/HA-Col granules showed an initial burst release, followed by a more gradual release. In contrast, BMP-7 release from the TCP/HA-Col-Hep granules was sustained up to 21 days.
The sustained delivery system for BMP-7 developed in this study may provide a powerful tool for bone regeneration. This system could probably also be applied to deliver multiple growth factors that have affinities for heparin, which could for instance synergistically enhance osteogenesis by increasing vascularity.
Metallic implants are widely used in orthopedic, oral and maxillofacial surgery. Durable osseous fixation of an implant requires that osteoprogenitor cells attach and adhere to the implant, proliferate, differentiate into osteoblasts, and produce mineralized matrix. We previously observed that human mesenchymal stem cells (MSCs) adherent to smooth tantalum (Ta) surfaces demonstrated superior biocompatibility compared with titanium (Ti) coatings.
The aim of the present study was to investigate the interactions between MSCs and smooth surfaces of Ta and by means of whole-genome microarray technology.
Immortalized human mesenchymal stem cells were cultivated on smooth surfaces of Ti and Ta. Total RNA was extracted after culturing for 1, 2, 4, and 8 days and hybridized to Affymetrix whole-genome microarrays (N=16). Replicate arrays were averaged and the ratios of gene expression by MSCs cultivated on Ta versus Ti coating were calculated. Absolute fold differences were also calculated and lists of upregulated genes were generated. Moreover, gene Ontology (GO) annotation analysis of differentially regulated genes was performed.
For both Ta and Ti coatings, the vast majority of genes were upregulated after 4 d of cultivation. Genes upregulated by MSCs cultivated on Ta coating for 4 d were annotated to relevant GO terms. Ti-regulated GO annotation clusters were predominantly transcription-related. By using the K-means clustering algorithm, 10 clusters containing more than 5 genes were identified. Moreover, various genes related to osteogenesis and cell adhesion were upregulated by MSCs exposed to Ta surface.
Microarray analysis of MSCs exposed to smooth metallic surfaces of both Ta and Ti generally showed a huge increase in transcriptional activity after 4 d of cultivation. According to GO annotation analysis Ta coating may induce increased adhesion and earlier differentiation of MSCs compared to Ti surface making Ta a promising biocompatible material for bone implants.
The induction of differentiation is a highly programmed lineage-specific process and several studies have provided great insight into the microenvironment affecting differentiation of multipotential hMSCs. In this regard, the importance of physical factors has been recognized for many years, but only little is known about its effects on undifferentiated hMSCs. The study aimed to determine the early osteogenic differentiation response to physiologically-based mechanical tensile strain with possible contributions to donor-specific physiological conditions.
MSCs of ten donors were expanded under standard culture conditions, and the individual response to cyclic tensile strain (CTS) was determined in a two-armed study design (strained versus unstrained (CTR)). CTS was applied with a maximum of 3,000 μstrain. Genotypic characteristics (RUNX2, ALPL, SPARC, SPP1; COL1A1, MKI67, etc) as well as phenotypic effects (cell numbers, cell viability and ALP activity) were compared between CTR and CTS, and possible relations to donor-specific physiological characteristics including anthropomorphometric and biochemical variables were determined.
We found a significant up-regulation of the osteogenic marker genes due to CTS, which was accompanied by an increase in cell-based ALP activity (plus 39.6 ± 9.8% SEM, P< 0.05). Cell density as well as XTT were significantly lower following CTS (minus 20.0 ± 4.7% and minus 17.8 ± 5.6%, respectively, P< 0.05). As a consequence, the ALP activity w/o normalization ranged widely from minus 30.8% to plus 60.1% between individual donors and was a function of donor’s BMI (r=−0.91, P< 0.0001), weight (r=−0.73, P=0.016), and age (r=−0.65, P=0.041).
The findings demonstrate that
the application of CTS provides an inherent osteogenic differentiation stimulus for undifferentiated hMSCs in vitro, and the functional response of hMSCs to CTS was found to be highly related to donor’s BMI/fat mass, thus suggesting an upstream imprinting process of the hMSCs within bone marrow
This bone preserving procedure is less well described in the much older population over 65 years of age. Despite good bone quality, independence and active lifestyle, older age seems to be a deterrent for hip resurfacings among most orthopaedic surgeons.
Analysis of 111 Birmingham hip resurfacings in 105 consecutive patients from 1999 to 2007 performed by a single surgeon was carried out to determine radiological and clinical outcome. The unique selection criteria looked at joint disease, activity levels, general health, imaging (Xray/CT/MRI) and Bone density studies.
28 females and 77 males with mean age of 69.5 years (65–87 years, SD +/− 4), body mass index of 27.2 (19–40.4, SD +/− 3.8) underwent resurfacings. 8 patients had bilateral, consecutive 2 stage procedures. Mean Follow up was 3.8 years ranging from 3 months to 7 years. 62 resurfacings were performed in the age group 65–69 yrs, 32 resurfacings in the 70–74 age group, 12 resurfacings in the 75–79 age group and 4 resurfacings in the 80–89 age group. 77 patients (71.3%) stayed one night or less in hospital. 4 patients (3 males and 1 female) had postoperative fracture neck of femora.
Radiographic review at the most recent follow up revealed non of the patients (101) who had the original hip resurfacing components had any evidence of gross loosening, migration or subsidence requiring revision of either the cup or the femoral components. No patients complained of localised hip pain and at the most recent follow up they had very good to excellent function with no report of dislocations.
Hip resurfacing is a challenge in patients who are over the age of 65 years. Using our selection criteria, it may be offered to active, independent patients with good bone quality as this age group in the population becomes larger with time.
The potential for bone remodeling in the proximal femur may be detrimental to the long term survival of resurfacing prosthesis.
A retrospective analysis of radiological changes in the femoral neck was undertaken for 96 patients (100 hips, 76 males and 24 females), with a minimum of 5 years following hip resurfacing. The mean age at surgery was 53.8 years. Femoral neck diameter was measured post-operatively, at 2 and 5 years. Pre and post-operative head to neck ratios, femoral head-shaft offset, femoral neck and implant stem-shaft angles were also measured.
Two groups of patients were identified with differing rates of reduction in their femoral neck diameter. Over the first 2 years, Group A (24%) mean reduction was 2.02mm/year while Group B (76%) mean reduction was 0.33 mm/year. At 5 years, the Group A mean reduction was 5.64mm (sd±2.03mm) while Group B reduction was 1.16mm, (sd±0.97mm). The difference was significant at both time points (p< 0.01). Larger head-neck ratios were observed in the group A, both pre and post operatively (p< 0.01).
Finite Element Analysis has predicted stress shielding underneath the femoral head and loading of the mini stem. This may explain bone resorption underneath the shell and remodeling around the mini stem. Compromised blood supply of the retained epiphyseal remnant may also play a part in femoral head resorption. Group A with a larger proportion of females and femoral heads will potentially have a larger proportion of epiphyseal remnant retained. A further mechanism that could be influential in the development of neck thinning and bone resorption may be due to fluid pumping mechanism causing osteolytic erosion at the bone cement interface.
In conclusion, femoral neck thinning is a phenomenon of unproven aetiology which is affecting almost 25% of our resurfacing cases. Further investigations are needed to determine its aetiology and remedy.
Flock technology is well known from textile industry. Short fibres are applied vertically on a substrate, coated with a flocking adhesive. Until now this technology has not been used in the field of biomaterials although it offers the possibility to create anisotrophic matrices with a high compressive strength despite of high porosity. Matrices presently used in matrix assisted autologous chondrocyte implantation do not show any orientation of the embedded chondrocytes. However column orientation and anisotropic direction of embedded cells and collagen fibers are thought to be necessary for proper cartilage matrix biomechanics. Combination of matrices as a guiding structure and chondrogenically differentiated mesenchymal stem cells (MSC) could offer new possibilities in the treatment of cartilage defects. Our aim was to evaluate whether anisotropic scaffolds are capable to support a cellular cartilaginous phenotype in vitro.
Electrostatically flocked matrices consisted of a collagen substrate, gelatine as adhesive and polyamide flock fibres. Chondrogenic cells and MSC were embedded in the scaffolds. Adherence, vitality and proliferation was assessed using confocal laser-scan microscopy (cLSM). Chondrogenic induction was performed in the presence of TGF-beta 3. Accumulation of proteoglycans was quantified by alcian-blue stain and collagen type II synthesis after extraction of the newly synthesized matrix.
cLSM showed proliferation of embedded MSC as evidenced by DAPI/Phalloidin stain. Vitality of embedded cells remained high over time. Articular chondrocytes and nucleus pulposus cells synthesized proteoglycans and collagen type II in the scaffolds. Also MSC embedded in the flock scaffolds differentiated and increased their chondrogenic phenotype over time.
Using cLSM and biochemical analyses we demonstrated that cells adhered and proliferated well in the new scaffolds. Furthermore we showed that the scaffolds are capable to support induction and maintenance of the chondrogenic phenotype. We conclude that flocking technology is suitable for fabrication of scaffolds for cell cultivation and cartilage tissue engineering.
Irreparable tendon ruptures constitute a grave clinical problem. Especially for large rotator cuff tears, there often is no primary causal therapy available. As a sad result, the development of a rotator cuff tear arthropathy is more often than not inevitable. Our study investigates the effects of scaffold based tendon regeneration with special focus on mesenchymal stem cells in a rat model.
We used ‘native’ bone marrow stromal cells and cultivated mesenchymal stem cells from male rats that were implanted into female rats. As scaffolds polyglycol acid (PGA) and a collagen I were used. A full-thickness-defect of 2–3 mm in the middle third of the rats achilles tendon was created, which was then filled, with either cell-seeded or not cell-seeded scaffolds and, due to the low primary stability of the scaffolds, fixed with a 4-0 suture. After 12 weeks, a DNA PCR was conducted to verify the existence of male Y-chromosomes in the female regenerated tissue. We determined the maximum tensile load of the regenerated tissue and also did a histological evaluation.
Macroscopically the regenerated tendons were much bigger in diameter, much firmer and also much less elastic than a normal tendon. In the ‘mesenchymal stem cells’ group the implanted cells could be clearly identified after 12 weeks by DNA PCR. The collagen I scaffold yielded better results in the biomechanical study than the PGA scaffold. No evidence of positive influence of the cells on the mechanical stability of the regenerated tissue was found. Collagen I and the use of BMSC histologically lead to increased ossification of the regenerated tissue. In the PGA scaffold group a significant inflammatory reaction was found.
Both scaffold/cell combination seem to be unsuitable for tendon replacement. in-vitro studies on the influence of scaffold material on cell differentiation needs to be done.
Femoral neck fracture is a serious complication in hip resurfacing arthroplasty and reducing its risk is a major challenge. From a biomechanical point of view changing the geometrical characteristics in surgery could affect the stresses in the femoral neck. We analysed standing AP X-rays of 85 randomly selected patients having pain in the pelvic region in order to gain better understanding of the geometrical influences. Patients were selected on age, weight, pelvis visibility and no deformations of the proximal femur. A variety of geometrical characteristics has been measured and analysed using the two-sided t-test.
A significant difference was found between men and women, which was compared to previous publications in order to verify the measurement method. Statistical indication could not be found for leg-dominancy influencing geometrical dimensions. This is not mentioned in literature, but it is mentioned that the BMC and BMD differs between the legs. Several linear relations have been found between geometrical characteristics and demographics. The average head-neck ratio for both left and right was about 1.4 and the ratio of the abductor moment arm and body moment arm was about 2.1. The linear relation between femoral head diameter and femoral neck diameter indicates that the femoral component should be chosen according to the natural head diameter. The ratio between the abductor arm and body arm in combination with the bodyweight determines the static stresses in the femoral neck and can be changed in surgery by altering the hip axis length and neck shaft angle.
The cement-in-cement femoral revision is a possible method of reducing complications. During recent research on this revision it was observed that a number of the inner cement contained macropores. It was hypothesized that porosity of the mantle influenced the subsidence and inducible displacement of the revision stems. The aim was to calculate the porosity and assess its relationship to the above factors.
Primary cement mantles were formed by cementing a stem into sections of tubular steel. At this stage, the specimen was chosen to be in a test or a control group. If in the test group, it underwent a fatigue of 1 million cycles. This was carried out in a fatigue machine mounted with a specifically designed rig. If in the control group, no such fatigue was undertaken. Into these fatigued and unfatigued mantles, the cement-in-cement procedure was performed. Both groups underwent a fatigue of again 1 million cycles. Subsidence and inducible displacement was recorded. The composites were then sectioned and photographed. The images underwent image analysis to calculate the porosity.
Multiple regression and a general linear model showed subsidence was inversely correlated to the porosity of the “fresh cement” in Gruen zones 3 and 5 (p = 0.021, R2 = 0.36). This relationship was not expected. The reason could be related to the fact that the migration of the stems in each separate direction was not monitored. Inducible displacement was inversely correlated to porosity of the inner cement, again in Gruen zones 3 and 5 (p = 0.001, R2 = 0.61). A possible explanation is that the stem was able to subside more due to the higher porosity and find a more stable position.
The subsidence and inducible displacement of these stems is influenced by porosity, specifically by the porosity of the distal inner cement.
We present the results of a prospective longitudinal follow-up study of Dual X-ray Absorptiometry (DXA) measurements of the evolution of bone mineral density (BMD) of acetabulum and femur in 86 patients who underwent total hip arthroplasty (THA). A standard uncemented cup and intra-operatively manufactured stem prosthesis was used in all patients. Stem fixation was determided by the bone quality Thirthy patients received cementless and 56 patients received cemented stem prosthesis. Post-operative DXA scans were obtained in peri-prosthetic bone at 10 days, 6 weeks, 3, 6 and 12 months after THA. Peri-prosthetic BMD values in the proximal femur were obtained in the 7 Gruen zones. In the acetabulum a 4 region of interest model (ROI) was used.
Bimodal significant femoral BMD changes are found in all Gruen zones except for zone 1 of the cemented group where an immediate recovery is observed. The recovery mostly starts after 6 months of follow-up and the highest remodelling is found in the calcar region reaching even values of −16% at 6 months but no statistical significance was observed between the two groups. Significant linear losses (p< 0.0001) are observed in the pelvis region independent of type of fixation except the opposite change (p< 0.01) in the inferior region observing an immediate recovery in the uncemented group.
We compared the impact of a cemented stem with a non cemented stem on the bone remodelling of the cup and found that there was a correlation between the type of fixation and the mode of remodelling at the acetabular level. This suggest that a parameter such as the flexibility my have an influence on the bone remodelling at the acetabulum level. The pattern of bone remodelling observed on the different Gruen zones reflects the local load transfer to peri-prosthetic bone.
In a previous report from a randomised study we reported excellent fixation and less proximal periprosthetic bone mineral loss around the Epoch design at 2 years follow-up when compared with a solid stem of similar design. We now present the 7 years follow-up.
Forty consecutive patients (20 men, 10 women, mean age 57, 41–74) with non-inflammatory osteoarthritis were randomised to receive either a cementless porous-coated composite stem with reduced stiffness (Epoch) or a cementless stiff stem with a porous coating (Anatomic). Patients were followed for 7 years with repeated evaluations using radiostereometry, DXA, conventional radiography and Harris Hip Score (HHS).
At 7 years 1 stem had been revised (Anatomic) due to late infection. Subsidence and stem rotations were close to zero without any difference between the two groups (p> 0,12). Median wear rates were lower than expected (0.4mm up to 7 years) for both stem designs. At 2 years loss bone mineral density was less in Gruen regions 1, 2, 6 and 7 for the Epoch stems (p< 0.04), but this difference tended to disappear with time. At 7 years only the calcar region (Gruen region 7) had significantly denser bone in the Epoch group (p< 0.001). The HHS scores did not differ (median 98, 51–100). No stem was radiographically loose.
The Epoch stem achieved excellent fixation. Wear rates were low despite use of conventionally gamma-sterilised polyethylene. This low modulus stem had positive effects on early proximal bone remodeling, but this effect decreased with time.
Earlier reports have shown that surface treatment influences the survivorship of tapered hip implants. To assess the role of surface finish for other stem shapes we evaluated three modifications of the Lubinus SP2 stem.
Eighty patients (31 male, 49 female, 68 (46–78 years), 84 hips) with non-inflammatory arthrosis randomly received either stem type: cemented matte (M, standard design), polymethylmetacrylate-coated (PC) or polished (P, collarless). Component fixation and wear were studied with radiostereometric analysis and the bone mineral density was measured around the stem in 40 patients at 6 months, 1, 2 and 5 years.
The polished design showed increased distal migration at 6 months (Mean and range) P: −0.21mm(−0.52 to 0.09), M: −0.07mm (−0.34 to 0.26), PC: −0.03 (−0.18 to 0.18) and at 5 years P:0.49mm (−1.46 to 0.16), M: −0.18mm (−0.80 to 0.33), PC: −0.12mm (−1.40 to 0.12 (p< 0.0001). This increased subsidence occurred inside the cement mantle. The rotations of the stem did not differ (p> 0.4). Neither did the migration and the wear (p> 0.1). After 1 and 2 years the polished stems had lost significantly less bone mineral in Gruen zones 1, 2, 6 and 7 (p 0.004 to 0.03). After 5 years this difference had disappeared. The Harris Hip Scores did not differ.
A polished surface without collar on an anteverted stem design resulted in increased subsidence of the stem inside the cement mantle. The improved bone remodeling around the polished version seemed to be transient.
The development of metalosis is a not commonly reported complication after THR. The exact reasons are still unknown, but hypersensitivity reaction is favored ahead of toxic effects, immune defects and exogen causes. The phenomenon of metalosis occurred at an unpredictable time in situ and is often misinterpreted as a low grade infection.
In a retrospective study, we analysed all 173 (102 women and 71 men) primary and single cement less PPF THR (STRATEC®) with metal-on-metal (low carbide 0.08%) articulation of 1995. One patient was lost to follow-up, 18 patients were deceased. The average age at the time of surgery was 63.3 years and the follow-up time was 115 months.
40 (23.1%) metalosis cases were observed. Revision was done in 29 (16.8%) patients: three femur fractures, five cases of infection and 21 cases of metalosis. The median HHS at follow-up was 95. 18 cases (10.4%) had metalosis signs: six patients (3.2%) had periprosthetic osteolysis and pain, 16 patients (9.2%) had osteolysis without pain and nine patients (5.2%) had pain without osteolysis in the radiographs. Pain caused by metalosis typically occurred inguinal and at an average time of thirty months postoperatively. Dislocation was observed in 13 cases at an average time of 44 months with an average cup inclination of 48°. Extensive necrosis and diffuse lymphoplasmacytic infiltrates were noted. In most cases the bursa ileopectinea was highly filled and in this synovial fluid extremely elevated levels of chrome (32 – 46095 μg/l) and cobalt (30 – 67410 μg/l) were detected.
Since 2003, we do not implant or recommend metal-on-metal for THR anymore. Close radiographic and computertomographic monitoring with high mark on typical osteolysis and exact clinical evaluation is recommended for metal-on-metal THR. Patients without symptoms with severe osteolysis must be detected, and head and inlay changes must be performed.
The anterior supine intermuscular (ASI) approach enables total hip arthroplasty (THA) without dissection of muscles or insertions. This could be beneficial in patient recovery and satisfaction. Study-aim was to assess the learning-curve for the ASI-approach and show short-term results.
Two surgeons performed uncemented THA on 23 (17 and six respectively) consecutive patients. The Taperloc stem, Recap-cup and Magnum head (Biomet, Warsaw, USA) were used. THA was performed without the use of a traction-table. Data was gathered till 3 months follow-up.
Average patient age was 61 years (36–74), ASA-classification was two (one-four). There was a decrease in surgical time from 140 at the beginning to 80 minutes at the end of our series. Average blood-loss was 788 ml. Three patients received erythrocyte-transfusion. Minor non-orthopaedic complications all resolved within 48 hours. Average length of stay was five-and-a-half days. Functional score-lists showed improvement comparing pre-operative scores with scores on 12 weeks follow-up: Harris-Hip-Score from 56 to 94, Oxford-Hip-Score from 43 to 19, Hip-disability-and-Osteoarthritis-Outcome-Score from 109 to 18. On six weeks follow-up 65% and on 12 weeks 100% of patients showed unaided mobilisation. At follow-up we saw one superficial wound-infection, one partial non-disabling sartorius-lesion, one paraesthesia and one transient anaesthesia of the lateral femoral cutaneous nerve area.
ASI-approach for uncemented THA showed good results and rapid patient-mobilisation. This may in part be due to the non-dissecting of muscles or insertions, thus non-compromising the propriocepsis. Off course tissue-damage occurs, though this is likely to be of a fast reversible nature. There were no serious adverse events. We saw a rapid decline in session-duration suggesting a moderate learning-curve. Further research will have to prove the beneficiality of the ASI-approach.
SBA-15 is a siliceous mesoporous ordered material with hexagonal arrangement of 9-nm tubular pores connected by micropores, high pore volume and abundance of silanol groups. This functionalised material could thus tailor the release kinetics of specific biomolecules to the clinical needs. Non-functionalized SBA-15 and its C8- or C3-alkyl-derivatives were coated with parathyroid hormone–related protein (PTHrP)(107–111) to assess their relative effects on osteoblastic cell growth and function.
SBA-15 was functionalized with either octyl or propyl trimethoxysilane (C8 or C3 precursor, respectively) in ACN for 24h and then were coated (or not) by dipping in 10 nM PTHrP (107–111) solution for 24 h at 4°C. After air drying, biomaterials were transferred to culture dishes. MC3T3-E1 cells were cultured in differentiation medium with SBA-15, C3-SBA-15 and C8-SBA-15, loaded or not with the peptide. Cell viability and proliferation were evaluated by trypan blue exclusion and a proliferation kit (Promega), respectively. Alkaline phosphatase (ALP) activity and collagen secretion were determined by colorimetric methods. Gene expression was analyzed by real-time PCR. Mineralization was assessed by alizarin red staining.
PTHrP(107–111)-coated SBA-15 increased cell proliferation (50%), cell viability (20%), and ALP activity (15%) over control values within 2–4 days. At day 2, collagen secretion increased (20%), and also the gene expression of ALP, PTHrP, and VEGF, which normalized at day 8, in these cells. An increase (by 30–40%) in all of these parameters was induced by peptide-coated C3-SBA-15 at day 4. Similar stimulatory effects were also observed with PTHrP(107–111)-coated C8-SBA-15 but only at day 8. At day 10, collagen secretion slightly increased (10–15%), and also mineralization (30–40%) with both functionalized materials coated with the PTHrP peptide.
In conclusion, PTHrP(107–111)-coated SBA-15 stimulates osteoblastic function in vitro; an effect delayed by C3- or C8-functionalization. These data further support the clinical impact of this bioceramic as functionalized implants in vivo.
Posterior dislocation of replacement hips may occur during hip flexion and adduction. Whilst hip braces can restrict hip movement, they are cumbersome and have a low patient compliance. Knee braces are more comfortable to wear and also restrict hip movement by tightening the hamstrings. This study investigated the effect of a knee brace on hip flexion and adduction.
The movement of 20 normal hips in 20 healthy volunteers aged 25–62, were assessed using a magnetic tracking system (Polhemus Fastrak). Tracking sensors were attached over the iliac crest and lateral thigh. Subjects were asked to lie on a couch and flex and adduct their hip three times with their knee bent. A knee brace was then applied and the hip movements were repeated with the knee extended. During each movement the tracker recorded hip flexion and adduction angles with an accuracy of 0.15 degrees.
When the knee was flexed, the mean hip flexion angle was 66.00 (CI95 = 61.1, 70.8). When the knee was braced, the mean hip flexion angle was 35.30 (CI95 = 28.5, 42.1). Hence the knee brace reduced hip flexion by 46 % (30.70). A paired t-test found this highly significant (P < 0.001).
When the knee was flexed, the mean hip adduction angle was 23.70 (CI95 = 20.6, 26.9). When the knee was braced, the mean hip adduction angle was 21.60 (CI95 = 19.2, 24.1). Hence the knee brace reduced hip adduction by 9 % (2.10). A paired t-test found this was not significant (P = 0.3).
These results indicate that a knee brace can restrict hip flexion by almost 50%. This information may be useful for patients in whom restriction of hip flexion provides hip stability. As the knee brace is more comfortable than the hip brace, a better patient compliance can be expected.
To investigate whether stopping clopidogrel on admission and subsequently delaying surgery in patients with hip fracture increases the risk of cerebrovascular complications and in-hospital mortality.
Retrospectively studied patients with hip fractures on clopidogrel admitted to our trauma unit between January 1, 2006 and May 31, 2007. Fifteen patients aged over 65 years with intra-capsular and extra-capsular hip fracture were reviewed. Demographic details of patients were recorded including the primary diagnosis on admission, timing of surgical intervention performed, pre-and post-operative haemoglobin and classification according to the American Society of Anesthesiologists (ASA) and in hospital mortality.
Eight fractures were intra-capsular and seven extra-capsular. The mean preoperative haemoglobin levels were 12.4 (range 9.9 to 14.1), the mean postoperative haemoglobin level were 9.7 (range 8 to 12.3). Four patients required blood transfusions, 8 unit of blood were transfused in total postoperatively. The mean delay in surgery were 9.1 days (range 7 to 14 days). The mean duration of hospital stay was 21 days (range, 8 to 45 days). The 30-day mortalities were 3/15 (20%). Mortalities were secondary to cerebrovascular events.
In summary, we found increase mortality and requirement for blood transfusion in patients on clopidogrel in whom surgery were delayed. A well designed research is needed to achieve evidence based management, but this may require several years due to the small, but increasing, number patients seen at present. We suggest early surgery for elderly hip fracture patients on clopidogrel. Patients on clopidogrel should be cross matched pre-operatively for red blood cells and platelets and experienced surgeon should perform the procedure.
Although effects of mechanical stimulation with high frequency, low magnitude vibrations on bone mass and bone mineral density in animal and clinical studies have been proven effective, its effects on fracture healing is less well described.
20 Sham and 20 ovarectomised (Ovx) Sprague Dawley rats at 22 weeks of age, had intra-medullary k-wire fixation followed by controlled mid-shaft fractures.
The animals were divided into subgroups of 3 week Sham and Ovx treated and non-treated and 6 week Sham and Ovx treated and non-treated groups.
The treated animals were vibrated for 20mins daily on a DMT (dynamic motion therapy) platform which had a frequency of 30hz, 8-micron vertical displacement and 3g force, the non treated animals allowed to move freely. Xrays, DEXA studies, micro computed tomography, Histological analysis and Mechanical studies performed at the end point.
DMT treated animals had more bridging callus on radiographic and micro computed tomographic analysis compared to non-treated groups especially the OVX groups at 3 weeks compared to controls or Shams (using Image J software). DEXA studies showed increased bone mineral density and bone mineral content in the treated animals compared to the controls. Histological analysis showed increased callus and woven bone being laid down in the treated OVX groups.
In the 6-week groups, the treated OVX groups had healed, remodelled fractures compared to the non-treated groups or Sham controls where the fracture gaps were still visible. Although significance was not achieved on mechanical analysis due to small sample size, in the OVX non-operated femora group that were treated with DMT there were indications that they were stronger than the control counterparts.
High frequency low magnitude vibrations with the Juvent DMT device enhances fracture healing in oestrogen deficient models and this model could be used as a platform for clinical studies in future.
The osteoclastogenesis is regulated by a complex signaling system between the pro-apoptotic factors (Bax-Cyclin E2-Cdk2) and the tumor necrosis factor family (RANKL-RANK-OPG).
Extracorporeal Shock Waves Therapy (ESWT) have recently been used in orthopaedic treatments to induce bone repair, but their mechanisms of action are not sufficiently investigated. So we studied the effect of shock-waves on murine osteoblastic cells.
Osteoblast cultures were subjected to a single shock-wave with combinations of low energy intensities (0.05mJ/mm2) and 500 number of shocks (impulses), whereas control cells received no treatment. We valued the cell viability quantifying the expressions of Bax and Opg by PCR.
We found an immediate negative effect on cell viability, that occurs with an increase of Bax protein expression after 3 hours of treatment. After a longer time lapse a stimulatory effect on cell proliferation, as reflected by the increase of a G(1)-S phase marker, was observed. In fact, in the following 24, 48 and 72 hours after ESW treatment, we found a stronger association of Cyclin E2 and Cdk2, forming active cyclin E-Cdk2 kinase, compared to untreated cells at the same times.
We further explored the molecular mechanism for the ESW induction of osteogenesis: by Real Time PCR an enhancement of Runx2 mRNA, evident 48 hours after the treatment, was found. A link between physical ESW and Runx2 activation has been already demonstrated. ESW-induced
O2- production, followed by tyrosine kinase mediated ERK activation and Runx2 activation, resulted in osteogenic cell growth and maturation. Moreover, we analyzed the cytokines RANK-L and OPG osteoblast expression, involved in regulation of osteoclastogenesis. A decrease in RANK-L/OPG ratio was found, perhaps leading to a reduced osteoclastogenesis.
The Shock waves have a repair action on bone and it can been explained by the regulation on osteoclastogenesis by the apoptoic pathway of BAX and OPG.
In the last years there is an increase in the interest in the study of growth factors that take part in the process of consolidation of the fracture to be used as treatment. The different types of fixations modify the natural process of the fracture healing and the production of growth factors could also be affected. There is not evidence in the literature of the effect that the intramedullary reaming has on the osteogenesis. We did a study to analyse the effect of intramedullary reaming on the production of growth factors during the process of fracture healing in the femur of rats. We did a pospective study in San Carlos Clinical Hospital from Madrid in which was made a fracture on the femur of 64 adults rats type Sprague-Dawley. The rats were divided in two main groups; each group received one different treatment: 30 rats with intramedullary nail and 34 rats did not receive any treatment. The rats of each group were sacrificed in 4 different moments: at the 24th hour, 4th, 7th and 15th days after the fracture was done, and we measured the amount of growth factors that appeared in the callus fracture, by anatomopathology study. The group in which was done the intramedullar nailing recovered normal walk after surgery. In this group were found more production of BMP and PDGF compared to the control group but did not reveal any significant difference between the groups (p> 0,05). Differences about other growth factors as TGF were not found. We conclude that in the results we have taken, the increase on BMP and PDGF could be produced by the intramedullary reaming by the surgery technique but we would need more studies.
The influence of the mechanical environment on tissue differentiation has been widely investigated. However many questions remain about the actual process and the parameters that govern it. It has been proposed that tissue differentiation is driven by a biophysical stimulus which is a combination of fluid flow and octahedral shear strain. In order to further investigate the influence of the mechanical environment on tissue differentiation we have tested this hypothesis within a mechanically controlled bone chamber.
The bone chamber consists of a titanium cylinder with two bone ingrowth openings at one end which allow tissue to grow in from the subcortical cancellous bone. It is equipped with a piston protruding into the chamber for the application of a known pressure to the ingrowth tissue.
A 3D poroelastic finite element model of the inside of the bone chamber was developed. To model the dispersal of the various cell populations inside the tissue a lattice was created within each finite element, representing a space for both the cell and extracellular matrix. The differentiation process was ruled by fluid flow and shear strain. The change in tissue phenotype was implemented through a change in mechanical properties. Loading conditions corresponded to those applied during conducted experiments
High fluid flow and shear strain at the top and bottom of the chamber favoured tissue differentiation towards fibrous tissue. In the middle region, bone formed. A cartilage layer between the bone and the fibrous tissue was predicted, which is qualitatively in agreement with the experiments.
Although acceptable simulation/experiment comparison is achieved, in reality great variation is found in experiments, whereas our simulations are deterministic. It is clear that deterministic simulations can not capture the nature of tissue differentiation in this chamber. Nonetheless, tissue differentiation algorithms based on fluid/strain stimuli and using lattice models for biological activity are a promising tool in their ability to predict tissue differentiation inside a mechanically-controlled bone chamber.
Spastic muscles show permanent contraction but also paradoxical muscular weakness. Compartmental muscular pressure in normal subjects oscillates between 0 and 5 mmHg.
To study compartmental pressure in the posterior superficial compartment of the leg in children with spastic paralysis, to identify its variations after a percutaneous tenotomy of the Achilles tendon, and to find any possible connection with arterial pressure or weight.
Twelve patients who had undergone a percutaneous tenotomy of the Achilles tendon were studied. Six of them were tetraplegic and three hemiplegic, with bilateral and unilateral tenotomies respectively. The following variables were taken into consideration: age, weight, systolic and diastolic arterial pressure and pressure of the superficial compartment of the leg, both pre- and post- tenotomy. The measurement of the compartmental pressure was taken using an automatic calibration monitor with an error of measure of ± 1 mmHg. Statistics: descriptive, non-parametric tests (Wilcoxon, Kruskall- Willis).
The average age was 9.3 years old, 11 in men and 7.5 in women. 89.5% of the total population was male and 10.5 % female. The average weight was 27.2 Kilograms, 28.1 Kg. in men and 20.5 Kg. in women. Systolic pressure was 94.1 mmHg and diastolic pressure 41.3 mmHg. Pre-tenotomy compartmental pressure was 12.1 mmHg and 7.9 mmHg post-tenotomy, decreasing 34.5 % (p= 0.08, N.S.). Systolic pressure had no relation to pre-tenotomy (r = −0.16) o post-tenotomy (r = −0.13) compartmental pressure. Diastolic pressure had no relation either (p =0.2 and r=−0.36), respectively. The pressure of the superficial compartment of the leg is higher than normal in spastic patients, decreasing, although not significantly, after a percutaneous tenotomy of the Achilles tendon is performed.
There is a great need for suitable large animal models that closely resemble osteoporosis in humans, and that they have adequate bone size for bone prosthesis and biomaterial research. This study aimed to investigate effects of a 7 month glucocorticoid (GC) treatment alone without ovariectomy on the properties of sheep cancellous bone.
Eighteen female sheep were randomly allocated into 3 groups: group 1 (GC-1) received GC (0.60mg/kg/day methylprednisolone) 5 days weekly for 7 months; group 2 (GC-2) received the same treatment regime for 7 months, and further observed for 3 months without GC; and group 3 served as the control group, and left untreated for 7 months. The sheep received restricted diet.
After 7 months of GC treatment. Cancellous bone volume fraction of the 5th lumbar vertebra in the GC-1 group was reduced by −35%, trabecular thickness by −28%, and changed from typical plate structure to a combination of plate and rod structure with increased connectivity by 202%. Bone strength was reduced by 52%. Bone formation marker, serum osteocalcin of GC-1, was reduced by 71% at 7 months, but recovered with an increase of 45% at 10 month in the GC-2 group. Similar trends were also seen in the femur and tibia. At 10 months, the GC-2 group had microarchitectural and mechanical properties similar to the level of the control sheep.
We have demonstrated in this study that 7 month high-dose GC on bone density and microarchitecture are comparable with those observed in human after long-term GC treatment. Moreover, we have shown that the bone quality with regard to strength and microarchitecture recovers after 3 months further observation without GC. This suggests that a prolonged administration of GC is needed for long-term observation to keep osteopenic bone. The model will be useful in pre-clinical studies.
Healing of tendons is sensitive to mechanical loading, and the callus strength is reduced by ¾ after 14 days, if loading is prevented. Exogenous GDFs stimulate tendon healing. This response is influenced by loading: without loading, cartilage and bone formation is initiated. This suggests that BMP signalling is crucial during tendon healing, and that it is influenced by mechanical loading. We investigated if mechanical loading influences BMP signalling in intact and healing tendons, and how BMP gene expression changes during healing.
The Achilles tendon was transected in rats and left to heal. Half of the rats had one Achilles tendon unloaded by injection of Botox in the calf muscles. Ten tendons were analyzed before transection and for each of four time points. Gene expression for OP-1, GDF-5, -6, -7, Follistatin, Noggin, BMP-receptor 1b and BMP-receptor 2 were analysed with real-time PCR.
Loading had no detectable effects on intact tendons. During repair, loading decreased follistatin by more than half (p=0.0001), and increased GDF-5 (p=0.02). All genes showed changes during repair (p=0.0001), but the time sequences differed. GDF-5 and GDF-7 were generally more expressed than OP-1 and GDF-6. GDF-5 and GDF-7 were more expressed in normal tendons than during repair. Noggin was never detected.
Our results suggest that GDF-5 is specific for the mature tendon, and not much involved in repair. This contrasts to GDF-7, which is involved in both. OP-1 and GDF-6 seem to be involved in early healing. There was less expression of follistatin in loaded tendons during healing. The mechanosensitivity is likely of most importance at day 14 and 21 since the difference in strength between loaded and unloaded tendons is huge. An Anova with only these time points reveals effects of loading on GDF-5 and follistatin (p=0.0001 for both) and significant differences between the days for most variables.
Computational modelling has the potential of becoming a useful tool in assessing revision risk on a patient-specific basis. However, there are many difficulties encountered in generating subject-specific computational models that have unknown influences on such predictions, e.g. accuracy of the anatomical geometry and material properties of the patient. This study compares the influence of these two patient-specific parameters on predictions of revision risk due to aseptic loosening.
First, X-rays from seventeen patients were processed using previously developed technique utilising rigid scaling of a generic femur to match selected dimensions from each patient’s post-operative X-ray and, then, the same set of 3D models was obtained by using an automated technique that generates 3D extra-cortical geometries from planar X-rays using a combination of 2D contour extraction and 3D warping of a generic model to match the extracted contour.
A cement and cement-metal interfacial damage accumulation algorithm developed previously was used. For each geometric set two types of simulations were performed. First, constant cortical and cancellous bone apparent Young’s moduli were assumed. A second set of simulations used age-dependent Young’s moduli for each bone type. Walking and stair-climbing activities were simulated. Resultant migration of the prostheses was used to indicate revision risk.
Factorial analysis has shown that the geometry has a larger influence on resultant migration magnitude for each case; however, unexpectedly, using more realistic geometry weakened the strength of predictions. This is most likely to be due ongoing mesh-induced contact problems.
Ultrasound has been shown to have positive biological effects, including increased angiogenic, chondrogenic, and osteogenic activities.
The aim of our study was to evaluate the evidence available in the scientific literature for the ultrasound treatment for tendon healing.
To identify “best evidence” published research a computerized literature search of Medline, Cochrane, PEDro, IME, IBECS and ENFISPO. Keywords used to identify the study population and interventions were: ultrasound, low intensity pulsed ultrasound, physiotherapy, clinical trial, meta-analysis, practice guideline, randomized controlled trial, repair tendon and tendon healing.
The scientific evidence of the group of selected documents were measured using the scale described by the US Preventive Task Force. The assignment of the evidence level to each study was evaluated independently by two reviewers without communication among them. To determine inter-rather reliability Kappa index it was used (K) with a value of CI of 95%.
The study populations were 39 pertinent recovered documents. The findings suggest that therapeutic ultrasound can increase in collagen synthesis and enhance the maturation of collagen fibrils of repairing tendons. Researchers have reported that therapeutic ultrasound could facilitate tissue recovery and US with dosages between 0.125–3 W/cm2 have been used in the treatment of tendon ruptures reported an improvement in both strength and energy absorption capacity of repairing rabbit or rat tendons with 1-MHz continuous US. Best results were: continuous US at 1 MHz, 0.5w/cm2 starting from day 5 after injury, 20 treatment sessions, 4 mi each session. There is not a general consensus on the choice of parameters for US treatment and the evidence for efficacy of therapeutic.
Limits of studies: The time needed to develop such an interface in humans was reported to be much longer than that reported in animal models.
Continuous and low-intensity pulsed ultrasound was able to accelerate tendon healing and facilitating earlier physiotherapy.
Aseptic loosening can be considered as a combination of both mechanical and biological failure scenarios. This study investigated the influence of including bone remodelling in the simulation of aseptic loosening of cemented hip prostheses.
A combined strain and damage stimulated bone adaptation algorithm (Mulvihill et al., Proc. ESB Summer Workshop, p.114–115, 2007) was modified for use on an apparent tissue level. Constant rate resorption or deposition occurs if local strain falls outside a quiescent reference strain range. Furthermore, damage accumulates as a function of tensile stress. Resorption and simultaneous repair is activated above a critical damage level. Model parameters are related to specific surface area expressed as a function of apparent tissue density. Elastic modulus was also a function of accumulated damage. This algorithm was applied in conjunction with a bone cement and cement-metal interfacial damage accumulation algorithm to simulate aseptic loosening for a retrospective dataset of early revision and long-term-unrevised patients (Lennon et al. JOR, 779-88, 2007). One year of walking activity was simulated and resultant migrations of the prostheses were used to indicate revision risk.
The current implementation demonstrated increased migration for simulations with bone remodelling (p= 0.01). Variability was increased but mean predicted migration for early revisions was significantly higher than for the unrevised group (p= 0.03). Bulk bone remodelling was predicted primarily in the proximal regions. Interfacial bone remodelling demonstrated oscillation in damage at the interface due to alternate resorption-repair and deposition cycles. Interfacial bone density changes were more prominent in proximal regions but some models did show small amounts of resorption in more distal Gruen zones.
We conclude that bone remodelling has potential to predict more realistic migration patterns but further development and assessment is needed to identify the correct parameters for the bone adaptation algorithm.
Local dysregulation of the proteolytic matrix metalloproteinases (MMPs) and their tissue inhibitors of metalloproteinases (TIMPs) is a feature of tendon degeneration and rupture.
At three years after injury, we measured serum MMP-1, -2, -3, -7, -8, -9 and -13 and TIMP-1 and -2 in eight patients who had suffered Achilles tendon rupture. Serum was also obtained from 12 blood donors with similar age and sex distribution. In another eight patients, MMPs and TIMPs were followed over time, with samples taken at the time of Achilles tendon injury, and after 4, 8 and 24 weeks. MMPs were determined using Fluorokine Multi Analyte Profiling kits while TIMPs were analysed using ELISA (R& D systems). The study was approved by the ethics committee and written informed consent was obtained from all patients.
Patients who had previously suffered tendon rupture had increased levels of MMP-2 (median difference (m.d.) 10 %; p = 0.01), MMP-7 (m.d. 15 %; p = 0.02) and TIMP-2 (m.d. 36%; p = 0.02), as compared to controls. In patients with acute tendon rupture, MMP-2 was the only MMP or TIMP to change significantly over time (p = 0.009). MMP-7 appeared to be higher than control values already at the time of rupture. MMP-13 could not be detected in any sample.
In conclusion, patients with a history of tendon rupture had elevated serum levels of MMP-2, MMP-7 and TIMP-2. Changes in MMP-7 might be present already at the time of rupture. This suggests that disturbances in proteolytic control might render tendons prone to rupture.
Resurfacing THA is claimed to transfer stress naturally to the femur neck and preserve proximal femoral bone mass postoperatively. DXA is an established method in estimating BMD around a standard THA, but due to the anteversion of the femur neck, rotation could affect the size of the neck-regions and thereby the BMD measurements around a RTHA. To our knowledge, this is the first study to analyze the effects of hip rotation on BMD in the femoral neck around a RTHA.
We scanned the femoral neck of 15 patients twice in each position of 15° inward, 0° and 15° outward rotation, and analyzed BMD in a single and a six-region model. CVs were calculated for BMD in the same position as well as between different positions.
For double measurements in the same position we found mean CVs of 3.1% (range 2.5% – 3.7%) and 4.6% (range 2.2% – 8.6%) in the one- and six-region models, respectively. When the 15° outward position was excluded, the CVs decreased to 2.8% and 4.0%. With rotation, the mean CVs rose to 5.4% (range 3.2%–7.2%) and 11.8% (range 2.7% – 36.3%). This effect was most pronounced in the 6-region model, predominantly in the lateral and distal parts of the femoral neck, where the change was significantly different from the fixated position. For the single-region model 15° rotation could be allowed without compromising the precision.
We conclude that rotation adversely affects the precision of BMD measurements around a RTHA, but in the single-region model smaller rotations can be allowed.
With the hip fixated the six-region model produces low CVs, acceptable for longitudinal studies. For maximal topographical detail we prefer the six-region model and recommend that future longitudinal DXA studies, including RTHA, be performed standardised, Preferably, with the hip in the neutral or internal rotation.
Biomechanical models have been successfully applied to screen potential risk factors for injuries and to plan and evaluate the effects of orthopedic surgical procedures.[
In order to determine the muscles of the shoulder girdle, ultrathin flexible metallic markers were sutured from origin to insertion according to the fiber directions in all muscles involved in shoulder movement on a total of ten different cadaver shoulders. The plexus brachialis and upper limb nerves were dissected and injected with a iodium contrast containing mixture. A Ct multi-slice image reconstruction was performed from occiput to the hip joint. The software package Mimics® (Materialise NV, Heverlee, Belgium) was used to segment and reconstruct the different anatomical models that included bone, muscle features, nerves and vascular structures. A clustering method algorithm, was used to filter interruptions of the different masks, scattering rustle and small irregularities due to the different contrasting markers used. Vascular tissue could be reconstructed and segmented as air filled structures. We were able to accurately reconstruct nerve tissue in an highly complex configuration such as the plexus brachialis.
Analysis of the representations showed that the different morphologic parameters were within the normal anatomical ranges and that our method is suitable to create complete anatomical models based on Ct-imaging alone.
Aseptic loosening of the total TMC joint prosthesis occurs frequently and may depend on the design of the prosthesis. Numerous TMC prosthesis designs are available, and new designs are being developed and tested. One of the problems in the clinical studies of TMC prostheses is identifying and predicting prosthetic loosening at an early stage. Roentgen Stereophotogrammetric Analysis (RSA). allows assessment of three-dimensional micromotion of orthopaedic implants with high accuracy. Early micromotion (in the first two postoperative years) of most prostheses is strongly correlated with the development of aseptic loosening. We studied if RSA assessment was possible after total TMC joint arthroplasty.
In five cadaveric hands the TMC joint was replaced by the SR-TMC prosthesis. Tantalum beads of 0.8 mm were implanted in the trapezium and first metacarpal bone without extending the standard surgical exposure. The metacarpal prosthesis component was provided with 0.5 mm beads. A three-dimensional surface model of the trapezium component of the SR-TMC prosthesis was prepared to facilitate model-based RSA. After the surgical procedure, RSA radiographs were made of all hands in two commonly used positions for imaging of the TMC joint. The number of visually detected markers for each bone/implant was recorded. Of one cadaver hand, RSA radiographs were made in ten different positions to calculate the measurement error of the performed technique.
For the metacarpal bone, all beads were visible in all positions and both (L+R) RSA radiographs. For beads in the polyethylene metacarpal prosthesis component three beads seem sufficient, however in exceptional cases the most proximal placed bead might be invisible due to overprojection by the metal trapezium prosthesis component. Therefore the X-rays should be carefully checked at the radiology department before the patient leaves the ward. Alternatively, an extra bead can be placed in the prosthesis, although this is a lesser option due to possible weakening of the component caused by the placement of the beads. The use of different sizes of beads (0.5/0.8 mm) in the metacarpal bone and metacarpal prosthesis made the interpretation for the analyser easier
The accuracy analysis is currently carried out. First results of these measurements are promising and placement of tantalum beads for RSA analysis during TMC-joint replacement seems feasible.
Since the approval of parathyroid hormone (PTH) as an anabolic treatment for osteoporosis, PTH has increasingly been investigated for other potential clinical uses such as bone repair and regeneration. The microstructure of newly formed bone during distraction osteogenesis enhanced by PTH treatment has yet to be studied. Therefore, the purpose of the study was to investigate the effects of intermittent parathyroid hormone PTH (1–34) treatment on the microstructure of regenerated bone during distraction osteogenesis in rabbits. After tibial mid-diaphyseal osteotomy the callus was distracted 1 mm/day for 10 days. The rabbits were divided in to 3 groups, which daily received a PTH injection for 30 days, a saline injection for 10 days and a PTH injection for 20 days, or a saline injection for 30 days. The new-trabecular structure of the regenerate callus was assessed by micro computed tomography (μCT). In all 51 specimen obtained from the lengthened tibia were scanned and evaluated morphometrically using three different volume of interests. The investigated μCT parameters included trabecular number Tb.N*, trabecular thickness Tb.Th*, trabecular separation Tb.Sp*, bone volume fraction (BV/TV), bone volume (BV), connectivity density (CD), and degree of anisotropy (DA). The results showed that intermittent treatment with PTH during distraction osteogensis resulted in a significantly higher Tb.N*, a more isotropic trabecular orientation, a higher connectivity density, and a higher bone mass. We also found preliminary evidence suggesting that the newly regenerated calluses treated with PTH were more mature than the non-treated calluses. In conclusion: the study demonstrated that treatment with PTH resulted in an enhanced microstructure of the newly regenerated bone indicating that PTH has a potential role as a stimulating agent for distraction osteogenesis.
An ample number of radiographic hip parameters on anteroposterior (AP) pelvic radiographs vary significantly with individual pelvic tilt and rotation. We developed specific computer software Hip2Norm to perform 3D analysis of the individual hip joint morphology using 2D AP pelvic radiographs. Twenty-five parameters 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. The validation comprised three steps:
External and internal validation; and intra-/interobserver analysis.
A series of x-rays of 30 cadaver pelves were available for step 1 and 2. External validation comprised the comparison of radiographical parameters of the cadaver hips when determined with Hip2Norm in comparison with CT-based measurements or actual radiographs in a neutral pelvic orientation. 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-/interob-server analysis investigated the reliability/reproducibility of all parameters with the help of 100 randomised, blinded radiographs of a consecutive patient series.
All but two parameters (acetabular index, ACE angle) showed a good to very correlation with the CT-measurements. Internal validity was good to very good for all parameters. There was a good to very good reliability and reproducibility of all parameters except five parameters.
The software could be shown to be an accurate, reliable and reproducible method for correction of AP pelvic radiographs. This computer-assisted method allows standardised evaluation of all relevant radiographic parameters for detection of anatomic morphologic differences. It will be used to study the influence of pelvic malorientation on the radiographic appearance of each individual parameter and the clinical significance of standardising pelvic parameters.
X-ray is the standard method for monitoring fracture healing however it is not ideal; signs of healing are not normally visible on X-ray until around 6–8 weeks post fracture. Ultrasonography allows the detection of both the initial haematoma, usually formed immediately after fracture, and the small calcium deposits laid down between broken bone ends in the first stages of fracture healing. It has been reported that these early indicators of the healing process are visible as early as 1–2 weeks after fracture. We use Freehand 3D Ultrasound to monitor the early stages of fracture healing as both the bone surface and surrounding soft tissues can be imaged simultaneously.
The Freehand 3D Ultrasound system consists of a standard Ultrasound machine, a PC running STRAD-WIN (Medical Imaging Group, Cambridge University) 3D software, and an optical tracking devise (NDI Polaris) to record the position and orientation of the Ultrasound probe during scanning. Images are transferred from the Ultrasound machine to the PC using RF capture through out a scan. Calibrating the system matches up the correct image with the correct probe position to produce a 3D dataset.
We segment features of interest on the sequence of 2D images to construct a 3D model. These models are rotatable and provide views of the scanned anatomy that are not otherwise achievable using conventional Ultrasound or X-ray. The 3D data set can also be resliced through any plane to provide further views.
To conduct a 3D Ultrasound scan takes the same amount of time as a conventional 2D scan. The production of the 3D model takes between 15–60 minutes depending on the level of detail required. Distances are measurable to within ±0.4mm meaning fracture gaps of sub-millimeter width can be resolved. The system has already been evaluated on healthy volunteers and a clinical study currently underway.
Posterior internal fixation systems undergo internal constraints resulting in high load bearing requirement for the pedicular screw/bone interface. Only few studies deal with the impact of the vertebral augmentation on the migration of pedicular screws. In this study, the impact of the pedicular screw augmentation has been investigated under physiological load for osteoporotic vertebras. The data have been proceeded to reduce the influence of vertebral geometry, which generally leads to results devoid of statistical meaning
In 8 osteoporotic vertebrae, two screws have been inserted in each vertebra: a non-augmented on one side and an augmented one on the contralateral side.
Compression tests have been performed (two consecutive 50 cycles load steps -100N and 200N-) to observe the displacement of the screw’s head. Two different setups have been employed: a free connection (FC) and a blocked connection (BC). A load step is successful if the migration between two consecutive cycles tends to zero. To reduce the impact of the vertebras’ geometry, the screws’ migration have been compared contra-laterally using the migration ratio (MR). MR of vertebrae is defined as the division of the augmented screw’s migration with the non-augmented screw’s migration.
All the augmented screws survived both test setups whereas the non-augmented failed the 200N FC load step. Significant differences are observable only for the highest successful load steps for each test setup: T-tests (P=0.039 and P=0.007 respectively) put into evidence that the results are statistically smaller than one. It is observable as well, that the BC induced fewer loads into the vertebrae: even non-augmented screw can withstand 200N load step.
As expected, augmentation of pedicular perforated screws increases their stability in osteoporotic vertebras undergoing large physiological load. This could be explained by the fact that the presence of PMMA increases the load transfer interface improving screw/PMMA complex bearing capacity. Smaller loads induce only small differences that are not significant.
The safety of nucleus implants remains an open issue in the treatment of intervertebral disc degeneration. Post-operative migration and subsequent extrusion represent a high risk of potential unsatisfactory outcome. The effectiveness of additionally sewing a biointegrative nucleus implant into an annulus defect was investigated therefore in this experiment.
Laminectomy preserving the facet joints was performed on seven human functional spinal units (FSU’s). A reproducible annulus defect of 6×6 mm was incised, followed by a standard nucleotomy procedure and subsequent introduction of the implants. These woven patches consist of biointegrative, absorbable polyglycolic acid (PGA), lyophilized with hyaluronic acid. The annulus sealing technique requires placing a PGA-patch adjacent to the inner annulus, fixed by sutures (Polysorb 3-0, Syneture) at its four corners. Unsealed annulus defects served as a control group. FSU’s were loaded with a bending torque of 5 to 7.5 Nm. Continual revolution of the specimen around its vertical axis resulted in a combination of lateral, dorsal and flexural bending. During application of loads, implant herniation level was determined every 1 000 cycles according to predefined criteria. Tests were stopped after reaching 20 000 cycles.
Five of totally six sewed specimens withstood 20 000 load cycles, whereas only one of five not sewed specimens terminated successfully. Based on the Mann-Whitney test, significant increase in stability can be detected for the sewed procedure.
Sewing a biointegrative annulus implant into an annulus defect improves nucleus implant containment. It remains to be shown whether this annulus sealing technique is also effective in highly degenerated annulus tissue. Furthermore, a minimally invasive implantation device is crucial for application in a clinical setting.
Neurodynamic tests are daily regarded as important in orthopedic physical assesment. Changes in neural tension provoked by these tests over differents nerve trunks in lumbopelvic region may alter the nociceptive responses of nearby tissues.
The aim of our study was to evidence changes in mechanical nociceptive thresholds (MNTs) of lumbopelvic muscles in different neurodynamic positions.
Cross-sectional study. Fifty asymptomatic volunteers were evaluated with algometer in three neurodynamic positions:
Contralateral side-lying position with knees at 90° of flexion, hips at 70° of flexion and spine in neutral; initial position with the homolateral knee in complete extension to add neural tension of sciatic nerve; initial position incorporating maximum craniocervical flexion to add neural tension within vertebral canal.
The pressure algometry was tested at one anatomical site on gluteal region 2.5 cm. below iliac crest bone and behind iliotibial band.
One physiotherapist (PT) measured MNTs unilaterally over gluteus medius. Three consecutive measurements was evaluated in the three described positions, while a second PT reported the data in kilograms (kg). A third PT was responsible for modifying the knee and craniocervical range of motion.
The findings revealed significant mean differences (SMD) (0.522 kg; 95% IC: 0.385–0.659 kg) in algometry measurements (P < 0.0001) betweeen position 1 (mean 3.632 kg; SD 1.235 kg) and position 2 (mean 3.110 kg; SD 1.233 kg), SMD (0.590 kg; 95% IC: 0.412–0.768 kg) (P < 0.0001) betweeen position 1 and position 3 (mean 3.042 kg; SD 1.136 kg). Furthermore, no SMD between the two different neural tension positions (P < 0.420).
We concluded that MNTs of lumbopelvic muscles decrease with neural tension positions. MNTs decrease is similar with sciatic nerve and vertebral canal neural tension positions. So, neurodynamic positions are important procedures to be taken into account in clinical reasoning, both physical therapy diagnosis and treatment.
Mechanical tests that have been carried out to validate finite-element models predicting vertebral strength concern vertebral bodies under axial compression. But in standing position gravity loads can induce a flexion component, especially for the last thoracic and first lumbar vertebrae. The aim of the study was to evaluate the strength of complete vertebrae under anterior compression.
15 isolated vertebrae T11-L2 (four women, one man, 88 ± 14 years old) were tested to failure. The load was applied at the one third of the vertebral body depth through a ball constrained in a hole. It was homogeneously distributed on the vertebral endplate through a polymetylmetacrylate (PMMA) layer which completely fills the concavity. The solid composed by the PMMA layer and the steel plate containing the hole for the ball was called “upper plate”. Its 3D orientation was assessed using the Polaris® motion capture system (accuracy: 0.6 mm, 0.6°) thanks to tripods. Before testing, the position of the marker-frames was assessed using 3D reconstructions (obtained by bi-planar X-rays) to express all the movements relatively to the vertebral frame.
The outcome data was the position of the upper plate. The load was calculated from the measurement of the vertical load (using the testing machine sensor) and the orientation of the upper plate (using the Polaris® system).
The mean flexion of the upper-plate is equal to 1° (± 0.7°) before the vertebra collapses. As this value is weak, the optoelectronic assessment could be removed during the test if the initial 3D orientation of the upper plate relatively to the vertebral frame is assessed.
This protocol allowed collecting with accuracy all the data necessary to validate models.
Spinal fusion for degenerative disc disease is known to have inconsistent outcomes. One concern is the possibility of AASDD as a result of the altered kinematics. The Dynamic Neutralisation System (Dynesys) appears to offer an advantage in that it restricts, rather than abolishes movement at the treated segment, and should thereby reduce the problem of AASDD, In the event of failure, it can in addition be removed, returning the spine to the former status quo. Various biomechanical studies confirmed flexibility of Dynesys.
Extension of Dynesys10 Dynesys combined with MIF2 Dynesys combined with PLIF2
There was no caudal ASD in our cohort.
A recently developed parametric geometrical finite element model (p-FEM) was adapted to the specific hip geometric measurements of a group of patients with slipped capital femoral epiphysis (SCFE). The objective was to analyze the stress distribution in the growth plate of these patients and to evaluate differences for those patients who developed bilateral disease.
Different geometric parameters were measured in the healthy proximal femur of 18 adolescents (mean age, 12,1 yr) with unilateral SCFE and in 23 adolescents matched in age without hip disease (control group). Five patients developed SCFE in the contralateral side during follow-up. Different geometric measurements were taken from hip conventional X-ray studies. The p-FEM of the proximal femur permits modifications of different geometrical parameters, therefore the X-ray measurements taken from each patient were applied to the model obtaining a subject-specific model for each case. In each model, different mechanical situations such as walking, stairs climbing and sitting were simulated by applying loads on the femoral head corresponding to each own weight. The risk for growth plate failure was estimated by the Tresca, von Misses and Rankine stresses.
In summary, the models shows important differences between the stresses computed at the healthy femurs of patients with unilateral SCFE and femurs that further underwent bilateral SCFE. So, the 95% confidence interval of the percentage of volume of the growth plate subjected to stresses higher than 2MPa was almost similar for the control group and patients with unilateral SCFE. However, those patients who developed bilateral disease had statistically significant large physeal areas with more than 2.0 MPa (p< 0.005). Stresses were also strongly dependent on the geometry of the proximal femur, especially on the posterior sloping angle of the physis and the physeal sloping angle.
In spite of simplifications of the developed p-FEM, this tool has been able to show the influence of femur geometry in growth plate stresses and to predict the sites where growth plate starts to fail.
The continuous leakage of cerebrospinal fluid in the mielomeningocele (MMC) area produces the Chiari II malformation. The aim of our study was to assess the effect of preterm delivery and prenatal corticosteroids administration in the degree of Chiari malformation.
Seventy-five out of 148 foetuses from 17 pregnant New Zealand White rabbits underwent lumbar three-level laminectomy and wide opening of dura-mater (surgical MMC). Animals were distributed in five groups: group T, foetuses with MMC, delivery at term and no other treatment; group TC, foetuses with MMC, delivery at term and prenatal administration of corticosteroids; group P, foetuses with MMC, delivery preterm and no other treatment; group PC, foetuses with MMC, delivery preterm and prenatal administration of corticosteroids; group C, controls. The degree of herniation was measured in percentage of decrease of the cerebellum between the inferior limit of the skull and the superior limit of the first vertebra, and compared among groups.
We obtained 7T, 5TC, 10P, 6PC, and 28C alive newborns. All groups with prenatal delivery or prenatal corticosteroids showed statistically significant minor degree of herniation than T-group: group TC IC 95% between 25.7 and 47.2% minor (p=0.000), group P IC 95% between 30.4 and 47.7% minor (p=0.000), group PC IC 95% between 32.6 and 55.4 minor (p=0.000). There were no statistically significant differences among groups TC and P (p=0,577), TC and PC (p=0,227) or P and PC (p=0,311).
Preterm delivery and prenatal administration of corticosteroids, together or separately, result in lower degree of Chiari malformation in a model of surgical MMC in rabbit fetuses.
Open fetal surgery for reparation in myelomeningocele reverses Chiari II malformation and protects exposed neural elements from secondary lesion, but the technique is associated with a high rate of complications. The aim of our study was to assess whether a simple and fast technique of coverage produces the same results as a complete and longer technique of reparation in terms of neural protection.
Twelve sheep’s foetuses underwent lumbar three-level laminectomy and opening of the dura-mater on the 75th day of the gestation. Four of them were not-repaired (NR group). Eight of them underwent coverage with inert material sheet and synthetic surgical sealant on the 95th day (R group). At birth, clinical and histological examination and comparison between groups was performed.
None NR animal were able to stand or to walk nor had sphincter continence; all of them showed a wide defect of closure in the lumbar area, continuous leakage of cerebrospinal fluid (CSF), and histological neural damage; the mean vermis herniation was 75%. All R animals were able to stand and to walk and all of them showed sphincter continence; none of them showed leakage of CSF and showed coverage of the 93% of the defect; all of them showed regeneration of dura-mater, muscle and skin; the mean vermis herniation was 10%.
A simplified technique of coverage produces the same clinical results than a more complex reconstruction in a model of surgical MMC in sheep and the histological study reveals the regeneration of several layers of soft tissues.
The Acetabular Index and the Physeal Angle of the proximal femur are a radiographic assessment of the morphology of the acetabulum and the proximal physis, respectively. Their values to decrease with age and it remains unknown whether any correlation exists between them or if weightbearing has any influence. X-rays belonging to 30 infants (60 hips), 4 boys and 26 girls, were studied between 2003 and 2006, measuring the Acetabular Index (AI) and the Femoral Proximal Physeal Angle (PPA). Measurements were taken using a goniometer (error ± 1°). All the cases had ultrasound scans at 4 months of age, with alpha angles smaller than 50° (Graf type IIa) and cephalic coverage between 33% and 50%. Anteroposterior hip X-rays were taken at 3 months (pre-weightbearing) and 4–10 months (post-weightbearing). Statistics: t-Test and correlation.
The AI was 21.5° (19.5° boys, 21.8° girls) pre-weightbearing and 20.9° (20.8° boys, 21° girls) post- weightbearing. The PPA was 76.5° (75.9° boys, 76.6° girls) pre-weightbearing and 74.9° (75.5° boys, 74.8° girls) post-weightbearing. AI and PPA decreased pre- and post- weightbearing, 2′8% and 2′1% respectively. The decrease was considered significant in the PPA (p = 0.02), especially in girls (p = 0.009), and not significant in the IA. Differences were found between sexes: the AI increased in boys (+6.3%) and decreased in girls (−8.3%), and the PPA decreased in both boys (−0.5%) and girls (−2.3%). The side had no influence. No relevant correlation was found between AI and PPA, both pre- (r = − 0.15, p = 0.27) and post- weightbearing (r = − 0.24, p = 0.07).
We did not find any relevant correlation between IA and PPA values, neither previous to weightbearing, nor in the months after weightbearing occurs. The measured angles suffered a decrease after weightbearing but the only significant decrease was in the PPA.
This work was aimed at study the role of paraspinal muscles on spinal tensegrity. Four different models of spinal tensegrity breakage with and without injury of the posterior spinal muscle were investigated.
Fifteen minipigs (mean age 6-week) underwent costotransversectomy (CTT) at 5 consecutive vertebral segments. In 4 animals ribs and transverse processes (T7–T11) were removed through a posterior midline approach with complete desinsertion of paraspinal muscles. In other 3 animals, CTT was performed by a posterolateral approach (T6–T10) without detachment of paraspinal muscles. Other 4 minipigs underwent rib resection (T7-T11) throughout a thoracoscopic approach avoiding damage of posterior spinal muscles. A final group of 4 animals, a complete detachment of the paraspinal muscles was performed from T7 to T11 without removing bony structures and leaving in deep surgical wax attached to the spinous and transverse processes to avoid reinsertion of the muscles after surgery. Anatomic specimens were radiologically and macroscopically studied just at sacrifice 5 months after surgery
All 4 animals operated on of CTT by midline posterior approach developed structural spinal deformity with curve convexity at the side of rib removal (mean Cobb angle 34,6°). Animals undergoing CTT by posterolateral approach without paraspinal muscle detachment did not develop any significant spinal deformity. Absence of spinal deformity was also found in those animals in which rib resection was performed by thoracoscopy without injury of the posterior spinal muscles. All 4 animals undergoing detachment of the paraspinal muscles without CTT and application of the surgical wax developed scoliotic curves (mean Cobb angle of 28°).
In conclusion, a new insight on the underlying pathogenic mechanisms of scoliotic curves is given by using this spinal tensegrity model. Isolated damage of the posterior muscle-ligamentous structures around the costotransverse joints breaking muscles spine tensegrity seems to be mandatory to induce scoliotic deformity. Rib removal alone appeared to have less scoliotic inductive implication. The finding questions previous knowledge on scoliosis etiopathogeny.
Recently, many mathematical descriptors were proposed to quantify 3D motions of the foot and ankle complex. However, since the ranges of rotation in foot joints are rather small, the reliability of these kinematic assessments is questionable. Particularly, achievement of acceptable results for clinical decision makings demands to extract repeatable features. In this study, repeatability of kinematics assessment of multi-segment foot by means of different mathematical descriptors was investigated.
25 tiny markers were mounted on dominant anatomical landmarks of the foot and ankle complex. Six young healthy subjects were asked to walk over a forceplate surrounded by six infra-red cameras. Marker trajectories were captured during one stance phase and several trials per subject were recorded. Foot and ankle complex was considered as six rigid segments:
Shank, Hindfoot, Mid-foot, Medial forefoot Lateral forefoot Toes.
3D angles between each pair of segments (i.e., 1~2, 2~3, 3~4, 3~5 and 4~6) were calculated based on three common mathematical descriptors:
helical angle, joint coordinate system and projection angles.
Then, the coefficient of multiple correlations (CMC) was used to estimate the degree of similarity among joint angle patterns for intra-subject and inter-subjects trials.
It was observed that the three angle calculation methods had comparable repeatability for both intra-subject and inter-subjects kinematics. No significant difference among their repeatability was noticed. Most of angles showed good pattern repeatability intra-subject and acceptable pattern repeatability inter-subjects. In conclusion, all three calculation methods for foot joint angles can be reliably applied. Further studies enrolling patients with foot and ankle pathology are necessary to investigate the relevance of these measurements for clinical evaluations.
In joint arthroplasty the currently used patient assessment scores suffer from subjectivity, a low ceiling effect and pain dominance. These effects mask functional differences which are important for today’s demanding patients. Functional assessment tools are needed which can objectively monitor patient outcome. This study investigates whether an acceleration based gait test is able to assess TKR patients.
A cohort of 24 patients (11m, 13f) operated for osteoarthritis receiving unilateral TKR (Stryker Scorpio) were monitored for 3 months post-operative. Classic scores including subscores (KSS, Womac, VAS, PDI) and a gait test were measured pre-operative, at 2 weeks, 6 weeks and 3 months post-operative. Gait was analyzed using a triaxial accelerometer fixed to the sacrum while walking 6 times a 20m distance at preferred speed. Movement parameters like step frequency, step time, step number, vertical displacement, asymmetry and irregularity were calculated based on a peak detection algorithm.
All classic scores were significantly intercorrelated (e.g. KSS and Womac, R=−0.73) indicating a degree of redundancy. Significant correlations were shown between several gait parameters and the KSS, PDI and VAS. Most correlations between gait parameters and a classical score were found for the KSS function subscore indicating it as the most objective functional assessement amongst the classic scores. In contrast Womac did not correlate with any gait parameter. This lack WOMAC capturing objective function was reported before using functional tests.
The classic scales and the gait test cover different dimensions of surgical outcome supporting their combined use to follow up patients The accelerometer based gait test is clinically valid for the follow-up of TKR patients.
To clinically diagnose and postoperatively monitor the younger or more demanding orthopaedic patients it becomes increasingly important to measure function beyond the capacity of classic scores suffering from subjectivity, pain dominance and ceiling effects. This study investigates whether a stair climbing test with accelerometer derived motion parameters in a group of healthy subjects is clinically feasible and valid to distinguish between demographic differences.
The ascending and descending of stairs (preferred speed, no handrails) was measured in 46 healthy subjects (19m/27f, no orthopaedic pathology) using a triaxial accelerometer attached with a belt to the sacrum. The study group was divided in two age groups: young group (15m/16f; age: 25 [21–38]) and old group (4m/11f; age: 67 [54–74]). Motion parameters were derived by acceleration peak detection algorithms based on step times: tup, tdown, tup-tdown,, step irregularity: irrup, irrdown and asymmetry: asymup, asymdown.
Step times were slightly higher ascending (tup=606ms) than descending (tdown=575ms, p< 0.05). The step time difference between ascending and descending (tup-tdown=31ms) showed a significant difference between the young (47ms) and elderly (−7ms). All subjects with descending times ≥20ms slower than ascending (6/46) were elderly. Irregularity and asymmetry were similar between stepping direction and age groups. Asymmetry identified the dominant leg with equal or faster steps than the non-dominant leg in 43/46 cases. Motion parameters were not correlated to gender, height or BMI.
Slower step times down than up seem a promising parameter to detect general or bilateral orthopaedic pathologies. Asymmetry identifying the dominant leg shall detect unilateral pathologies. The accelerometer assessed stair test seems suitable for routine clinical follow-up complementing classic scores.
Complex foot and ankle surgery and reconstruction require accurate preoperative planning. In the foot procedures are challenging and can be associated with a range of complications. The aim of planning is to correct only the deformity and prevent extensive surgery. Knowledge of foot and ankle morphometry is vital. For comparison between different subjects the coordinate system must be constant. To the authors knowledge there has been no previous description of a coordinate system for the foot and ankle.
CT images of ten anatomically normal feet were segmented in a general purpose segmentation program for grey value images and imported to a shape analysis program for biomechanics. A coordinate frame was defined in a 3 × 3 identity matrix using the inter-malleolar axis and a fibular diaphyseal centroidal axis in the construction. Centroidal vectors were defined in the metatarsals. Correlation of metatarsal length, inter-metatarsal angles, inter-malleolar distance and height was carried out.
The forefoot was examined in relation to the medial and lateral columns. Metatarsal length had a significant correlation within each column and between the two columns notably in the 3rd (0.525 – 0.965) metatarsal at the columns junction. The 3rd metatarsals also correlated significantly (−0.583) with the inter-metatarsal angles. There was a weak correlation between the 1st 3rd and the 3rd 5th inter-metatarsal angles directly however, each had a large correlation with the 1st 5th inter-metatarsal angle (0.734 – 0.950). There was also a large correlation between the individual’s stature and the metatarsal length and the inter-malleolar distance.
We have presented a means defining a coordinate system for three dimensional analyses in the foot and ankle. This coordinate system can be used for meaningful comparison of data between multiple subjects. We have shown that this coordinate system to be effective in practice in the morphometrical analysis of the normal forefoot.
Leg length discrepancy (LLD) is a recognised complication of total hip arthroplasty. LLDs can cause abnormal weight bearing, leading to increased wear, aseptic loosening of replacement hips and pain. To compensate for LLDs the patient can either flex the knee of the long leg or tilt their pelvis. The aim of this project was to investigate how stance affects static limb loading of patients with leg length discrepancy.
A pedobarograph was used to measure the limb loading of 20 normal volunteers aged 19 to 60. A 2 second recording with both feet on was taken to establish their body weight. Readings were taken of the left foot with the right level, 3.5cm lower (simulating a long left leg) and 3.5cm higher. In each case three readings were taken with the knee flexed and three readings with the knee extended.
When both feet were at the same level, the left limb took 54% of the load.
When the right foot was lower and the left knee flexed, the left leg took 39 % of the load (P < 0.001) (paired t-test). When the left knee was extended the left leg took 49 % of the load (P = 0.074).
With the right foot higher and right knee flexed, the left leg took 65 % of the load (P < 0.001). When the right knee was extended the left leg took 58 % of the load (P = 0.069).
These results show that weight distribution is increased in the simulated shorter limb. Loading is greater when the longer limb is flexed. Tilting the pelvis reduced the load. However this may cause pelvic and spinal problems.
Uneven load distribution is likely to lead to early fatigue when standing and may explain why some post arthroplasty patients with limb length discrepancy have poor outcomes.
The performance of ultra-high molecular weight polyethylene (UHMWPE) used in total joint replacement prosthesis depends on its wear resistance, oxidation resistance and mechanical properties. Several studies have now established that radiation crosslinking by applying a dose of 50–100 kGy gamma or electron beam radiation followed by remelting to quench free radicals fulfils the criterion of high wear resistance as well as oxidation resistance. However, post-irradiation remelting leads to a decrease in several mechanical properties of UHMWPE including fracture toughness and resistance to fatigue crack propagation, which are deemed important for components in joints where they are subjected to high stresses, such as in tibial components.
In this study, we used uniaxial compression and high-pressure crystallization to disentangle UHMWPE, expecting that this would assist in increasing its crystallinity since disentangled polymer chains would be more readily incorporated into crystalline lamellae, thereby increasing overall crystallinity. This could then result in an increase in some mechanical properties of irradiated, remelted UHMWPE since high crystallinity is associated with high modulus and yield stress. Uniaxial compression of irradiated, remelted GUR 1050 UHMWPE at 130C to a compression ratio up to 2.5 followed by remelting to recover crystallographic orientation showed no statistically significant increase in crystallinity (p> 0.05, ANOVA). High-pressure crystallization at 500 MPa and temperatures in a range of 130-220C also did not show statistically significant increase in crystallinity of irradiated, remelted UHMWPE. However high-pressure crystallization at 500MPa pressure and 240C, where crystallization occurs via the hexagonal phase, increased the crystallinity from 46.2% to 56.4% (p< 0.05, ANOVA).
We conclude that high-pressure crystallization via the hexagonal phase is more effective than uniaxial compression followed by strain recovery or high-pressure crystallization via the orthorhombic phase in increasing the crystallinity of irradiated, remelted UHMWPE, with potential to recover some mechanical properties.
For orthopaedic implants the adhesive strength of bone cells on implant surfaces is of high interest. In some cases the adherence of cells is desirable, e.g. on endoprosthetic implants, in others, mainly temporarily used implants, e.g. intramedullary nails, it is not favourable for the cells to attach to the implant. Therefore, besides cell spreading and proliferation on surfaces the adhesion strength with which cells bond to the substrate is of high interest. There are different approaches to determine bone cell adhesion, but no easy to operate quantitative methods are available. For this purpose, based on the spinning disc principle, we have developed a new adhesion device in conjunction with an inverse confocal laser scanning microscope (LSM).
Polished disc-shaped test samples made of Ti6Al4V were seeded with bone cells (MG-63), stained with a fluorescent dye, at defined radial positions and were incubated for 18 h with cell medium. After incubation the test samples were placed into the adhesion chamber filled with 250 ml cell medium (DMEM). The test samples were rotated at various velocities until a minimum detachment of 50% was achieved. Using the LSM the detachment of the bone cells at the defined radial positions was determined and the cell count was recorded before and after rotation by means of imaging software.
An average shear stress of 50 N/m2 was determined for polished Ti6Al4V surfaces. To calculate the adhesion force, the cross-sectional cell area has to be measured by the xz-scan of the LSM.
Our results are reproducible and comparable to the data found in literature. The advantage of our new approach is that the same cells can be observed before and after rotation as well as different rotational speeds can be applied to the same cell population. Further investigations e.g. using different surfaces are carried out.
Biofilm development is a major factor in the pathogenesis of implant-related infections. However, there are only a low number of studies that analyses the ability of clinical isolates of bacteria to develop biofilm in vitro. Here we study biofilm development in several strains of Staphylococcus aureus and Coagulase-negative Staphylococcus (CNS) consecutively isolated from retrieved orthopaedic implants from patients diagnosed of implant-related infections.
We have evaluated in vitro biofilm development using the crystal violet technique in microtiter plates. Biofilm development was confirmed by visual microscopy and Confocal Laser Scanning Microscopy. Staphylococcal strains were isolated from implant-related infections by sonication of retrieved prosthesis as previously published by our group, and identified using conventional methods.
Twenty-seven strains (15 S. aureus, nine S. epidermidis, and one each of S. hominis, S. lugdunensis and S. warneri) were included in the study. Four strains of S. aureus (26.7 %) and one strain of S. epidermidis (8.3 %) did not develop biofilm in the test, showing OD lectures almost identical to the negative control. No statistical differences were detected between the two groups. The microscopic examination confirms this finding. Among the biofilm-producing strains, an important difference of the amount of biofilm produced was detected. One strain (S. aureus) produced biofilm in greater amount than all other strains, detectable even by visual examination of the plate.
In conclusion, not all staphylococcal strains isolated from implant-related infections are able to develop biofilm in vitro. There must be other pathogenic factors that are important in the pathogenesis of implant-related infections and need to be studied in order to develop a better strategy for treat these infections.
Recently, high-flexion knee implants have been developed to provide for a large range of motion after total knee arthroplasty. Since knee forces increase with larger flexion angles, it is commonly assumed that high-flex-ion implants are subjected to large loads in the highflexion range (flexion > 120°). However, high-flexion studies often do not consider thigh-calf contact which occurs during high-flexion activities such as squatting and kneeling. We hypothesized that thigh-calf contact is substantial and has a reducing effect on the prosthetic knee loading during deep knee flexion.
The effect of thigh-calf contact on the loading of a knee implant was evaluated using a three-dimensional dynamic finite element knee model. The knee model consisted of a distal femur, a proximal tibia and fibula, a patella, high-flexion components of the PFC Sigma RP-F (Depuy, Warsaw, USA) and a quadriceps and patella tendon. Using this knee model, a squatting movement was simulated including thigh-calf contact characteristics of a typical subject which have been described in an earlier study.
Thigh-calf contact considerably reduced the implant loading during deep knee flexion. At maximal flexion (155°), the compressive knee force decreased from 4.9 to 2.9 times bodyweight. The maximal joint forces shifted from occurring at maximal flexion angle to the flexion angle at which thigh-calf contact initiated (±130°). The maximal polyethylene contact stress at the tibial post decreased from 49.3 to 28.1 MPa at maximal flexion.
This study confirms that thigh-calf contact reduces the knee loading during high-flexion. Both the joint forces and the polyethylene stresses reduced considerably when thigh-calf contact was included.
Periprosthetic osteolysis, caused in a chronic inflammatory adverse reaction to wear particles in the surrounding tissues, is one of the major reasons for revision arthroplasty so that articulating surfaces with low wear rates are required. Compared with conventional ultra high molecular weight polyethylene (UHMWPE), highly crosslinked polyethylene (HXLPE) shows a reduced wear rate in a hip simulator. The crosslinking process which is achieved by gamma or electronic radiation, followed by heat treatment either above the melting point (remelting) or below (annealing), reduces the mechanical properties of UHMWPE, particularly its fatigue strength. UHMWPE fatigue occurs more frequently in the knee than in the hip due to its higher contact stresses. This is why HXLPE is still controversially discussed for use in total knee prostheses. We have examined the wear behaviour of different HXLPEs [one cruciate-retaining (CR; sequential irradiation and annealing), one ultra-congruent (remelting), one CR (remelting)], compared with conventional UHMWPE in a knee simulator (Stallforth-Ungethuem). In the fixed bearing knee recommended from the manufacturer the wear rates [gravimetric (mg/year); volumetric (mm3/year)] were determined according to the ISO standard and the wear mechanism was analysed by means of a scanning electron microscope.
All insert showed signs of abrasion, scratching and wear polishing, but no traces of fatigue reactions. All HXLPEs produced lower (p< 0.05) wear rates (0.47–3.3 mg/year; 0.5–3.5 mm3/year) than the UHMWPE (8.1–9.1 mg/year; 8.6–9.7 mm3/year), the inserts of HXLPE manufactured by sequential irradiation and annealing showed the lowest wear rates (p< 0.05) overall.
Due to the reduced wear rates without any fatigue symptoms, we conclude that HXLPE is suitable for total knee prostheses and a monitored clinical investigation can be recommended. HXLPE manufactured by sequential irradiation and annealing seems to produce still lower wear rates than those manufactured by remelting, at least when used in total knee prostheses.
A multibody dynamics program (LifeMOD/KneeSIM, LifeModeler, Inc., San Clemente, CA) was used to simulate knee bending. A PFC Sigma® (DePuy, Warsaw, IN) rotating platform (RP) posterior cruciate retaining total knee was subjected to two cycles of knee bending up to 130 degrees of flexion. The RP model (Free RP) included experimentally determined torsional frictional behaviour for the insert-tray bearing as a function of axial load and rotational speed. The analysis was repeated with the exact same implant design, but with the insert locked (Fixed RP) to the tray to prevent internal-external (IE) rotation (a theoretical design). IE rotation and tangential traction (frictional) forces were calculated over the contact patches and averaged at the centres of pressure in the medial and lateral compartments.
Cross-wise tangential traction forces were greater for the Fixed RP than for the Free RP design in both medial and lateral compartments. The tangential traction forces arising from rolling and sliding may cause delamination of the polyethylene, especially if they act cross-wise to the main direction of motion of the contact patches, in accordance with the strain-softening effect proposed as a mechanism of wear for multi-directional motion. Even though the amount of cross-wise motion in existing total knee arthroplasty designs has been shown to be limited, the present study indicates that cross-wise traction forces are greater in a theoretical design which is restrained from rotation at the RP bearing. These theoretical results lend support to the notion that a rotating platform design may reduce wear by reducing cross-shear traction forces between the femoral component and the tibial insert.
After 2 years, the dichotomy persisted (p=0.027). In the bisphosphonate-treated patients, no dichotomies could be found. The distribution of the migration vector length appeared similar to the larger and less migrating subgroup among the controls.
In TKA the generation of polyethylene wear debris is mainly affected by the factors design of the articulating bearing, contact stresses, kinematics, implant material and surface finish [McEwen et al. 2005].
The objective of our study was to evaluate the in vitro wear behaviour of fixed bearing knee designs in comprehension to the contact mechanics and resultant kinematics for different degrees of congruency.
For gravimetric wear assessment the protocol described in ISO 14243-2 has been used, followed by a kinematic analysis of the single test stations.
The articulating contact and subsurface stresses have been investigated in a finite element analysis.
The wear rates between the knee design configurations differ substantially and statistically analysis demonstrates a significant difference (p< 0.01) between the test groups in correlation with congruency.
The FIRST knee prosthesis (Free Insert in Rotation Stabilized in Translation, Symbios SA) is a new ultra congruent, postero-stabilized total knee arthroplasty (TKA) with a mobile bearing expected to reduce significantly polyethylene wear, to improve the range of motion and the overall stability of the knee while ensuring a physiological ligament balance. We compared subjective and really objective results of this new TKA with two other widespread models of TKA.
A clinical prospective monocentric cohort study of 100 consecutive patients (47–88 yrs) undergoing a FIRST TKA for primary osteoarthritis is currently being done. Pre- and post-operative follow-ups (6 weeks, 4,5 months and 1 year) are done with well-recognized subjective evaluations (EQ-5D and WOMAC scores) and semi-objective questionnaires (KSS score and radiography evaluation) as well as with a really objective evaluation using gait parameters from 6 walking trials, performed at different speeds with an ambulatory in field gait analysis system (Physilog®, BioAGM CH). The outcomes after one year of follow-up of 32 FIRST TKA are compared to 29 NexGen® postero-stabilized TKA (Zimmer Inc) with a fixed bearing and to 26 NexGen® TKA with a mobile bearing using the same methods.
The gait cycle time of the FIRST TKA was statistically significantly shorter at normal speed of walk, as well as double-support periods, as compared to both standard models. The normal walking speed was significantly higher with faster swing speed and stride lengths for the new TKA. Significantly better coordination scores were observed at normal walking speed for the FIRST TKA as compared to the fixed-bearing TKAs.
The FIRST TKA showed statistically significantly better really objective outcomes in terms of gait after one year of follow-up and similar subjective and semi-objective evaluations compared to two widespread TKA designs.
Absorbable suture anchors have become more and more important in rotator cuff surgery due to their easy revisability. In osteoporotic bone however they are thought to be of minor primary stability. Purpose of the present study was to compare different absorbable and non-absorbable suture anchors in their pullout strength depending on bone density
The absorbable screw-anchor SPIRALOK5mm (DePuyMitek, Raynham, MA, USA), the titanium screw-anchor SUPER-REVO5mm and the tilting-anchor ULTRASORB (both ConmedLinvatec, Largo, FL, USA) were tested, each anchor representing a different material and design. On the basis of bone density measurement by CT-scans a healthy (mean-age. 42 years) and a osteopenic (mean-age: 74 years) group of cadaveric human humeri were formed. Each anchor was inserted in the greater tuberosity six times. They were inserted according to the manufacturers instructions with the supplied suture material. An incremental cyclic loading was performed, starting with 75N. Until failure the tensile load was increased by 25N after every 50 cycles. The ultimate failure loads, the anchor displacements and the modes of failure were recorded.
In the non-osteopenic bone group, the absorbable SPIRALOK achieved a significantly better pullout strength (mean: 274N) than the titanium screw-anchor SUPER-REVO (mean: 188N) and the tilting-anchor ULTRASORB (mean: 192N). In the osteopenic bone group no significant difference in the pullout strength was found. The failure mechanisms, such as anchor pullout, rupture at eyelet, suture breakage and breakage of eyelet, varied between the anchors. In the osteopenic group the number of anchor pullouts clearly increased.
The present study demonstrates that absorbable suture anchors do not have lower pullout strengths than metal anchors. Depending on their design they can even outmatch metal anchor systems. The results of our study suggest that the anchor design has a crucial influence on primary stability, whereas the anchor material is less important.
Graft choices for revision anterior cruciate ligament (ACL) reconstruction and complex ligament reconstructions of the knee are controversial. The aim of our study was to analyze the biomechanical effect of harvesting bone plugs from both the distal and proximal poles of the patella, to simulate a simultaneous harvesting of a Bone – Patellar Tendon – Bone and Quadriceps Tendon – Bone grafts, in a transverse stress environment.
Sixty Bovine Patellae were analysed. They were divided into 4 groups – based on the residual bone bridge (percentage of total length of patella) remaining after bone plug resection. 0 – 10%, 11 – 20%, 21 – 30% and > 30%. All patellae were tested in a modified 4 – point bending environment, to a maximum load of 10,000N, in a customized designed jig. This method simulates the axial bending stress on the patella during knee flexion. All dimensions of the patellae were recorded including Depth of patella at bone resection and wall thickness adjacent to plug resection site.
All patellae with a 0% bone bridge fractured (Ultimate Tensile Strength/UTS) at a mean Tensile Force of 5863N (Range 3140 – 8730N). There was a subgroup of incomplete fractures – extra-articular fractures – which fractured at 6542N (Range 5085 – 9180N). The remaining specimens failed to fracture. Comparing the UTS and the patellar dimensions, using Weibull’s Statistical Analysis we demonstrated that less than 60% bone plug resection carried a very low probability of fracture.
This study demonstrates the safe criteria for bone – tendon graft harvesting from both the proximal and distal poles of the patella. With regards to a normal human patella, a 40% bone – bridge is approximately a 20mm bone – bridge. We conclude that the simultaneous harvesting of Bone – Patellar Tendon – Bone and Quadriceps Tendon – bone grafts from a patella has no significant increase in the fracture risk of the patella.
Quadriceps femoris muscle (QFM) weakness is associated with the development of knee osteoarthritis (OA). Neuromusclar electrical stimulation (NMES) circumvents neural inhibition causing muscle contraction, however there is little reported data demonstrating its role in knee OA. Our aim was to evaluate the effectiveness of a NMES program in patients with knee OA.
Sixteen patients (10 women, 6 men) with severe knee OA were randomised into control (n=6) or intervention (n=10) groups. These were similar in terms of age (64.8 ± 11.0 vs. 64.6 ± 7.6; mean ± SD) and BMI (31.8 ± 6.11 vs.30.7 ± 2.9). NMES was applied using a garment-based stimulator for 20 min/day, 5 d/wk for 8 weeks. Isokinetic and isometric QFM strength were determined at baseline, and weeks 2, 5, and 8 using a dynomometer. Functional assessments involved a 25 metre timed walk test (TWT), timed stair-climb test (SCT), and timed chair-rise test (CRT) at baseline and week 8. Subjects recorded NMES session duration in a log book while the device also recorded total treatment time.
Function significantly improved in the NMES group as determined by the timed SCT (p< 0.01) and the timed CRT (p< 0.01) at week 8 compared to week 0. Isometric QFM strength was significantly higher in the NMES group at weeks 2, 5 and 8 than week 0. Compared to week 0, isokinetic hamstring strength increased significantly in the NMES group at week 2, week 5 and week 8 while isokinetic QFM strength increased at week 5 (p< 0.05) and week 8 (p< 0.01). Patient recorded compliance was 99.5% (range, 97.1%–100%) and overall usage recorded on the stimulator was 96.1% ± 13.2.
The use of a portable home-based NMES program produced significant QFM strength gain with associated improvement in function in patients with severe knee OA. Compliance was excellent overall.
One of the recently introduced anchors is the absorbable suture anchor BIOKNOTLESS-RC, a press-fit anchor whose special feature is the knotless reconstruction of the ruptured rotator cuff. We compared the new knotless anchor BIOKNOTLESS-RC with established anchors.
The absorbable pressfit anchor BIOKNOTLESS-RC (DePuyMitek, Raynham, MA, USA), the titanium screw anchor SUPER-REVO 5mm and the tilting anchor ULTRASORB (both ConmedLinvatec, Largo, FL, USA) were tested 12 times in the greater tuberosity of human cadaveric humeri (mean age: 74 years). They were inserted according to the manufacturers instructions with the supplied suture material. An incremental cyclic loading was performed, starting with 75N. Until failure the tensile load was increased by 25N after every 50 cycles. The ultimate failure loads, the anchor displacements and the modes of failure were recorded.
The anchor displacement of the BIOKNOTLESS-RC (15.3mm) after the first cycle with 75N was significantly higher than with the two others (SUPER-REVO 2.1mm, ULTRASORB: 2.7mm). The ultimate failure loads of the tested anchors were comparable: BIOKNOTLESS-RC 150N, SUPER-REVO 150N, ULTRASORB 151N (p> 0,05).
Rupture of the suture material at the eyelet occurred more frequently with the SUPER-REVO. BIOKNOTLESS-RC and ULTRASORB showed a tendency towards anchor pullout.
Our results do not confirm the higher pullout strength of metal anchors, which was found in other studies. Knotless anchors facilitate surgery by eliminating the technically challenging step of arthroscopic knot tying. The disadvantage of the BIOKNOTLESS-RC is its unsatisfactory primary stability. Its initial displacement of a mean of 15.3 mm is clinically significant and jeopardizes the rotator cuff repair.
Because of the high initial displacement and the possible gap formation between tendon and bone, the use of the BIOKNOTLESS-RC in a zone of minor tension, for instance as a second-row anchor in double row technique only is recommend.
Total shoulder arthroplasty is a well-established and widely accepted method of treatment for a variety of shoulder disorders, loosening of the glenoid prosthesis is the main complication in total shoulder arthroplasty, it is highly dependent on the quality of the glenoid cancellous bone. Very little is known about mechanical properties of this cancellous bone. The objectives of this study were to determine the mechanical properties (elastic modulus and strength) of glenoid cancellous bone in the axial, coronal and sagittal planes including regional variation using a uniaxial compression test. To our knowledge, this kind of study was not done before.
Eleven scapulas were obtained from six fresh-frozen, unembalmed human cadavers (mean age eighty-eight years). Eighty-two cubic cancellous bone specimens of 6×6×6mm3 were used for mechanical testing in the three planes. The test was a uniaxial compression along each direction, Elastic modulus and strength were determined from the stress-strain curve. Apparent density was also calculated.
The study showed significant differences in the mechanical properties with anatomic location and directions of loading. Young modulus and strength were found to be significantly higher at the posterior part of the glenoid with the weakest properties at the antero-inferior part. Cancellous bone was found to be anisotropic with higher mechanical properties in the latero-medial direction (perpendicular to the articular surface of the glenoid). The apparent density was on average equal to 0.29 g/cm3 with the higher values at the posterior and superior part of the glenoid. Good correlation between apparent density and elastic modulus was found only in the sagittal plane but not in the coronal and axial plane, the overall correlation was low (r2 = 0.22, p< 0.0001) which emphasizes the role of trabecular bone architecture in predicting mechanical properties.
The mechanical properties determined in this study provide input data for finite element method analyses and may help to assist in uncemented shoulder prosthesis design.
The objective of this study is to analyze changes in the force needed to raise the arm caused by using a single or a double-row configuration of cuff repair.
Cadaveric study performed using 5 fresh-frozen shoulders. Supraspinatus tear created in all specimens beginning 0.5 cm from biceps tendon. Repair of tear with single and double-row configuration of anchors placed 1cm apart each one. Sutures fixed to digital dynamometer. Continuous traction applied and registered to elevate humerus to 30° and 45°. Experiment repeated 3 times for each configuration and angle of elevation on each specimen. Paired Student t test was used to compare difference between single and double-row configuration at 30° and 45° of anterior elevation.
Significant differences between force needed to raise the arm to 30° with single-row (4,76 kg) configuration and double-row (6,94) (p< 0,001). Significant differences between force needed to raise the arm to 45° with single-row configuration (10,32 kg) and double-row (15,93) (p< 0,008). Significant differences when comparing mean increase of force needed to raise the arm from 30° to 45° between single and double-row configuration (p< 0,012).
The force needed to raise the arm to 30° and 45° is significantly higher for double than for single-row configuration. Quality of tendon margin should be taken into account when choosing between double and single-row configuration. If repair is done to a frayed and degenerated tendon, surgeon has to imbalance benefits of double-row repair with the fact that tendon suture will have to resist an increased force in active movement.
Suture anchors are widely used to secure tendons and ligaments to bone during both arthroscopic and open surgery. However, single stage insertion suture anchors, i.e. anchors that could be inserted without predrilling of the bone, are not currently available.
We aimed to record the impact needed for insertion of the new design single stage suture anchors, and to compare their pull out strength with another range of commercially available suture anchors.
The force required to insert the new design of suture anchors was investigated using an impact hammer capable of recording the number and force of each of the hits. The anchors were inserted in a consistent manner into animal (porcine) bone at sites analogous to common anchor sites used in clinical practice. Pull out strength was assessed using a digital force gauge after tying the suture to create a secure loop. Thereafter, force was applied steadily until either the anchor or the suture failed and compared with a popular range of commercially available suture anchors (Mitek).
Our initial investigations using prototype designs for small, medium and large anchors compared favourably with the Mini-mitek, GII, and Superanchor range of Mitek anchors. Essentially the most common point of failure for each of the suture anchor families was the suture itself with both suture anchor systems performing similarly. In addition, similar pull out strengths were demonstrated for both the Mitek and new design of suture anchors when loaded parallel, or at 90°, to the line of anchor insertion.
The new design single stage suture anchors have an equivalent pull out strength compared with a popular commercially available family of suture anchors, but in addition have the significant advantage of being suitable for single stage insertion in many clinical settings.
We report a long term experience on massive rotator cuff tears treated by the means of a nonresorbable transosseously fixed patch combined with a subacromial decompression
From December 1996 until August 2002, a total of 41 patients were treated with a synthetic interposition graft and subacromial decompression. All patients had a preoperative ultrasound evidence of a primary massive full-thickness tear that was thought to be irreparable by simple suture. All patients were evaluated pre- and postoperatively using the Constant and Murley score, DASH questionnaire, Simple Shoulder Test, VAS scale for pain, ultrasound and plain radiographs.
The patients consisted of 23 men and 18 women aged 51–80 years (mean 67 years). We had a lost of follow up of 6 patients. One patient had a total shoulder arthroplasty at 7.7 years and one patient had a redo with a new synthetic graft at 9.6 years. They were followed up for a mean of 7.2 years. Their mean preoperative Constant and Murley score improved from 25.7 preoperatively to 69.6. Similar improvements were seen with the DASH score (56.6 to 23.3), SST (1.2 to 7.9) and VAS scale (75.4 to 14.1)
Anatomically, the repair resulted in mean acromio-humeral interval of 6.6 mm. Ultrasound showed a further degeneration of the rotator cuff with tears posteriorly from the interposition graft. In 67.7% of all patients the graft was continuous present. Histology – obtained from one patient scheduled for a reversed shoulder arthroplasty- showed partial ingrowth of peri-tendinous tissue.
Despite ongoing degeneration of the cuff in nearly half our population, restoring a massive rotator cuff defect with a synthetic interposition graft and subacromial decompression can give significant and lasting pain relief with a significant improvement of ADL, range of motion and strength.
Role of ultrasonography in shoulder pathology: Consistency with clinical and operative findings K. W. Chan, G. G. McLeod Department of Trauma and Orthopaedic Surgery, Perth Royal Infirmary, Perth PH1 1NX, United Kingdom.
Shoulder disorders are common and main causes of shoulder pain with/without functional deficit include adhesive capsulitis (frozen shoulder), impingement syndrome and rotator cuff pathology. The sensitivity and specificity of ultrasonography have been reported as 80% and 100% respectively in the literature. We carried out a retrospective case note review of patients that underwent ultrasonography of shoulder, comparing the radiological findings with clinical diagnosis and operative findings. 58 patients, 36 male and 22 female attended the orthopaedic outpatient clinic with painful shoulder and underwent ultrasonography of shoulder during the period of study. Mean age of patients is 55 (range 28 to 78 years old). 33 patients had ultrasonography of right shoulder, 20 patients had ultrasonography of left shoulder while 5 patients had ultrasonography of both shoulders. 79% (50/63) of the ultrasonography findings were consistent with clinical diagnosis. 17 patients had normal findings on ultrasonography and were discharged fully. 25 patients with clinical and radiological diagnosis of biceps tendon tear, calcifying tendinosis and partial/full thickness rotator cuff tear were treated conservatively. 19% (4/21) of patients with diagnosis of calcifying tendinosis had decompression surgery. 38% (8/21) of patients with diagnosis of partial/full thickness rotator cuff tear had decompression surgery + rotator cuff repair. The degree of rotator cuff tear in operative findings for 6 out of 8 patients (75%) that underwent decompression surgery +/− rotator cuff repair were consistent with ultrasonography findings. 4 patients had inconclusive ultrasonography findings and had magnetic resonance imaging to further confirm the pathology. We conclude that ultrasonography should be used as the first line of investigation in aiding the clinical diagnosis and management of shoulder disorders as it is non-invasive and cost effective. The sensitivity of ultrasonography in detecting shoulder pathology is 75% from this study.
Monolayer expansion of human articular chondrocytes (HAC) is known to result in progressive dedifferentiation and loss of stable cartilage formation capacity in vivo. For optimal outcome of chondrocyte based repair strategies, HAC capable of ectopic cartilage formation may be required. Thus, the aim of this study was to establish appropriate quality control measures capable to predict the ectopic cartilage formation capacity of HAC from culture supernatants. This strategy would avoid the waste of cells for quality control purposes, in order to improve cell therapy and tissue-engineering approaches for the repair of joint surface lesions.
Standardized medium supernatants (n=5) of freshly isolated HAC and chondrocytes expanded for 2 (PD2) or 6 population doublings (PD6) were screened for 15 distinct interleukins, 8 MMPs and 11 miscellaneous soluble factors by a multiplexed immunoassay. Cartilage differentiation markers like COMP and YKL-40 were determined by ELISA. Corresponding HAC were subcutaneously transplanted into SCID-mice and their capacity to form stable ectopic cartilage was examined histologically 4 weeks later.
While freshly isolated chondrocytes generated stable ectopic cartilage positive for collagen type II, none of the PD6 transplants formed cartilaginous matrix. Loss of ectopic stable cartilage formation capacity between PD0 and PD6 correlated with a drop of MMP3 secretion to < 10% of initial levels, while changes for other investigated molecules were not predictive. Chondrocytes from donors with low MMP3 levels (< 10%) at PD2 failed to regenerate ectopic cartilage at PD2, indicating that MMP3 levels of cultured chondrocytes, independent of the number of cell doublings and the time in culture, predicted ectopic cartilage formation.
In conclusion, loss of stable ectopic cartilage formation capacity in the course of HAC dedifferentiation can be predicted by determination of relative MMP3 levels demonstrating that standardized culture supernatants can be used for quality control of chondrocytes dedicated for cell therapeutic approaches.
Mesenchymal stem cells (MSC) are promising for the treatment of articular cartilage defects; however, common protocols for in vitro chondrogenesis induce typical features of hypertrophic chondrocytes reminiscent of endochondral bone formation. This may implicate a risk for graft stability. We here analysed the early healing response in experimental full-thickness cartilage defects, asking whether and how MSC can differentiate to chondrocytes in an orthotopic environment.
Cartilage defects in knees of minipigs were covered with a collagen-type I/III membrane, and half of them received transplantation of expanded autologous MSC. Integration into surrounding cartilage tissue was poor to moderate after 1 and 3 weeks and no sign of cartilaginous matrix production as indicated by negative safranin-O staining was visible for both groups. At 8 weeks regenerative tissue was integrated into the surrounding tissue and a safranin-O positively stained neocartilage was detectable in 4 tissue regenerates out of 6 in the MSC group compared to 2 out of 6 in the MSC-free group. At 1 and 3 weeks after surgery only marginal Col2A1 and no AGC expression were detectable in both groups. At 8 weeks Col2A1 and AGC levels had significantly increased. Hypertrophic maker induction (Col10A1 and MMP13) was similar in both groups 8 weeks after surgery. Immunostaining for collagen type X, however, was restricted to the regenerative tissue close to the subchondral bone in both groups, while collagen type II staining was detected from below the superficial to the deep zone.
Our data provide molecular evidence for spontaneous differentiation of MSC in cartilage and the development of a collagen type II positive, collagen type X negative neocartilage. Whether by remodelling of defect filling tissue collagen type X positive areas will further diminish or even disappear from repair cartilage at later stages has to be evaluated in a longer follow-up study.
Physiotherapists have developed examination techniques known as ‘neural tension tests’ to assess the mechanosensitivity of the major nerve trunks. Changes in neural tension provoked by these tests may alter the nociceptive responses of nearby tissues.
The aim of our study was to evidence changes in mechanical nociceptive thresholds (MNTs) of upper trapezius muscle in different neurodynamic positions.
Cross-sectional study. Fifty asymptomatic volunteers were evaluated with algometer in four neurodynamic positions:
Contralateral side-lying position with knees at 90° of flexion, hips at 70° of flexion and spine in neutral; initial position with the homolateral knee in complete extension to add neural tension of sciatic nerve; initial position with the homolateral knee in complete flexion to add neural tension of femoral nerve; In supine position to add neural tension of median nerve using the Upper Limb Neurodynamic Test 1.
One physiotherapist (PT) measured MNTs unilaterally over TrPs1. Three consecutive measurements was evaluated in the four described positions, a second PT reported the data in kilograms (kg). A third PT was responsible for modifying subjects positions.
The findings revealed significant mean differences (SMD) in algometry measurements (P < 0.0001) between position 1 (mean 2.880 kg; SD 1.012 kg) and position 3 (mean 2.522 kg; SD 0.87 kg), SMD (P < 0.01) between position 1 and position 4 (mean 2.616 kg; SD 0.968 kg). No SMD between position 1 and 2 (mean 2.728 kg; SD 1.103 kg) (P < 0.08) and between positions 3 and 4 (P < 0.378).
We concluded that MNTs of upper trapezius muscle decrease with neural tension positions. MNTs decrease is similar with crural nerve and median nerve tension positions. So, neurodynamic positions are important procedures to be taken into account in clinical reasoning, both physical therapy diagnosis and treatment.
Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown aetiology. In RA, inflammation and pain are initial symptoms followed by bone and cartilage destruction. Proinflammatory cytokines play a significant role in the initiation and progress of inflammation and tissue destruction. Sensory neuropeptide substance P (SP) participates not only in nociception but also in pro-inflammatory processes by enhancing vasodilatation and recruitment of inflammatory cells. Ubiquitin proteasome system (UPS) activates a transcription factor, NF-κB which regulates the synthesis of proinflammatory mediators like cytokines; however its role in regulating pro inflammatory sensory neuropeptides is unknown. A number of proteasome inhibitors have been shown to down regulate the activity of NF-κB and hence reduce inflammation. In the present study, the effect of proteasome inhibitor (MG 132) on the severity of arthritis and pain was observed along with the expression of SP-positive nerve fibres in the ankle joint in a chronic inflammatory model of rat adjuvant arthritis.
Histology and mechanical pain tests showed a significant reduction in inflammation and pain in ankle joint by daily administration of proteasome inhibitor MG132 at the dose of 1mg/kg body weight compared to untreated groups. Radiographic analysis of ankle joints indicated a reduction in soft tissue swelling and joint destruction in the treatment group. A marked reduction in the NF-κB activity was observed by EMSA. Furthermore, proteasome inhibition resulted in the normalization of up regulated neuronal response occurred during inflammation by significantly reducing the expression of SP-positive fibres in the ankle joint as demonstrated by immunohistochemistry.
Our data provide the evidence that proteasome inhibitor MG132 can reduce severity of arthritis and reverse inflammatory pain behaviour by influencing the peripheral sensory nervous system. The drugs targeting UPS can be developed for treatment of chronic inflammatory joint disorders.
At last we show tables of normal values at healthy population. The influence of sex and side-dominant are shown as a percentile distribution.
Various studies have demonstrated that menisci heal in the vascular region but do not heal in the avascular area. Experimental studies of the promotion of meniscal healing in the avascular area have involved the application of fibrin clot, fibrin glue to the injured area, as well as the construction of an access chanel to the vascular regiòn, all of them with poor results. The multilineage potential of adult stem cells has been characterized extensively. The adipose tissue has been described as a useful source of adult stem cells. We try to show that the use of stem cells from the adipose tissue may promete meniscal healing in the avascular area.
Twelve New Zealand white rabbits with a mean weight of 3 kg were used. The medial meniscus of both knees was aproached, and was performed a longitudinal tear in the avascular area in the anterior horn with a mean length of 0.5 cm. All the tears were sutured with one vertical stitch of nonabsorbable suture. In each rabbit a solution with 1 00 000–1 000 000 stem cells from the fat was introduced in one of the knees, and the other one was used as a control. The rabbits were killed at 12 weeks, and a macro-microscopic study of the meniscus was done, and also a inmunohistochemistry study for the stem cells.
The incidence of healing was better in those menisci with the stem cells solution. Three total and three partial healing was obtained in the stem cells group and none in the control group. The inmunohistochemistry showed that the stem cells were in the repair zone.
We think that stem cells will be very useful in the treatment of the lesion in the avascular area of the meniscus.
Osteoarthritis of the trapeziometacarpal joint can be treated by different surgical procedures. These are known to lead to complications, complex regional pain syndrome (CRPS) type I being one of them. We investigated prospectively our clinical results after total joint arthroplasty under vitamin C prophylaxis.
Patients with trapeziometacarpal joint arthritis stage II or III (according to Dell) underwent joint arthroplasty. Visual analogue scale (VAS) scores for pain, activities of daily living (ADL), satisfaction and first web opening were taken pre- and postoperatively. Vitamin C 500 mg daily was started two days prior to surgery during 50 days as prophylaxis for CRPS. Postoperative treatment consisted of a bandage with collar and cuff for 5 days. Follow-up was at 2 and 6 weeks, 6 months and 12 months (with check radiographs).
We performed 34 arthroplasties in 29 patients (23 females and 6 males) with a mean follow-up of 39 months. Mean age was 61 years. The degree of osteoarthritis according to Dell was stage II in 13 cases, stage III 20 times and in one case there was a traumatic trapeziometacarpal dislocation. Operation was performed in day care under general or regional anesthesia. We implanted a hydroxy-apatite coated, semi-constrained prosthesis, type Roseland (total trapeziometacarpal joint prosthesis; Depuy International Ltd, Leeds, England). First web opening increased with 18 degrees and there was a significant improvement for pain, ADL and satisfaction as well (p = 0.000). There were no signs of loosening of the prosthesis, no infections and no cases of CRPS.
In this study the postoperative treatment was completely functional. The semi-constrained design of the Roseland prosthesis doesn’t require immobilisation. Torrededia reported 5 patients with CRPS after 38 operations with this same implant (13%). The positive trend in preventing CRPS gives us enough arguments to further investigate this in the form of a RCT.
The purpose of this study was to investigate the effects of extra corporeal shock waves (ESW) therapy on the metabolism of healthy and osteoarthritic human chondrocytes, and particularly on the expression of IL-10, TNF-α and β1 integrin.
Human adult articular cartilage was obtained from 9 patients (6 male and 3 females), with primary knee osteoarthritis (OA), undergoing total joint replacement and from 3 young healthy donors (HD) (2 males, 1 female) with joint traumatic fracture. After isolation, chondrocytes underwent ESW treatment (Electromagnetic Generator System, Minilith SL1, Storz Medical) at different parameters of impulses, energy levels and energy fluxes. After that, chondrocytes were cultured in 24-well plate in DMEM supplemented with 10% FCS for 48 hours and then β1 integrin surface expression and intracellular IL-10 and TNF-α levels were evaluated by flow-cytometry.
At baseline, osteoarthritic chondrocytes expressed significantly lower levels of β1 integrin and higher levels and IL-10 and TNF-α levels. It has been recently reported that ESW may be useful to treat OA in dogs, and veterinarians have begun to use ESW also to treat OA in horses.
Following ESW application, while β1 integrin expression remain unchanged, a significant decrease of IL-10 and TNF-α intracellular levels was observed both in osteoarthritic and healthy chondrocytes. IL-10 levels decreased at any impulses and energy levels, while a significant reduction of TNF-α was mainly found at middle energies.
Our study confirmed that osteoarthritic chondrocytes express low β1 integrin and high TNF-α and IL-10 levels. Nonetheless, ESW treatment application down-regulate the intracellular levels of TNF-α and IL-10 by chondrocytes, suggesting that ESW might restore TNF-α and IL-10 production by osteoarthritic chondrocytes at normal levels thus potentially interfering with the pathologic mechanisms causing cartilage damage in OA and representing the theoretical rationale for using ESW as therapy of OA.
Meniscus injury is one of the causes of secondary osteoarthritis (OA). Cartilage oligomeric matrix protein (COMP) is a major component of the extracellular matrix of the musculoskeletal system. This study was undertaken to evaluate the changes occurring in meniscus from the knees of anterior cruciate ligament (ACL) transected rabbits during the early stages of OA development, especially regarding COMP changes.
Ten skeletally mature white New Zealand male rabbits underwent ACL transaction of the right knee joint. Left knee joints were used as controls. Animals were sacrificed at 4 and 12 weeks post-surgery. Meniscal tissues were processed for histology and immunohistochemistry.
The number of cells and positive cells were counted per high-power field (HPF). Anti-COMP antiserum was obtained according to Hauser et al. with minor modifications. Monoclonal Ki67 antibody was used to find out cells undergoing active division. TUNEL reaction was used for the study of apoptosis. Alcian blue staining was used to study glycosaminoglycans.
At 4 weeks post-ACL section 2/5 of the medial menisci presented with incomplete vertical posterior tears, while all lateral menisci were no altered. At 12 weeks post-ACL section 5/5 of the medial menisci and 2/5 of lateral menisci presented tears.
At 4 weeks postsurgery menisci showed: a weak increase of cells with a significant increase of cells undergoing active division; an increase in the number of apoptotic cells; glycosaminoglycans staining was increased and COMP staining was weakly increased. At 12 weeks postsurgery cells per HPF reverted to normal number; the number of cells undergoing active division decrease below normal; whereas the number of apoptotic cells was still elevated; glycosaminoglycans staining was more elevated than at 4 weeks postsurgery and COMP staining of extracellular matrix remain elevated.
Areas of large and abundant cell clusters were seen post-ACL around menisci tears.
We concluded that after ACL transaction, extracellular matrix changes and altered cell distribution occur early in the meniscus. Cellular division as well as apoptosis occur early too. Elevated concentrations of COMP after ACL transection might indicate meniscus changes early in osteoarthritis process.
The aim of this study was to investigate how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.
Fifty normal wrists in 25 subjects were assessed with a Polhemus Fastrak (TM) magnetic tracking system. The subjects, aged 19 to 57, placed their palms on a flat wooded stool. Sensors were attached over their 3rd metcarpal and distal radius. The sensors then recorded movement from ulna to radial deviation. The translational and rotational measurement accuracies were 1 mm and 1 degree respectively.
The mean range of movement was 45 degrees (SD 7). In ulna deviation the axis was in the region of the lunate. As the hand moved towards radial deviation, the axis moved distally. At the end of the movement the mean distal displacement was 21 mm (SD 15). In 32 wrists the distal displacement was accompanied by a mean displacement towards the ulna of 12 mm (SD 8). In 18 wrists the distal displacement was accompanied by a mean displacement towards the radius of 8 mm (SD 5).
The rotational axis position indicates how the wrist is moving during radial deviation. In early movement, when the axis is proximal, there is a high degree of sideways translation. In later movement, when the axis is distal, there is more rotational movement. In some cases the axis moved distally and toward the radius, whereas in other cases it moved distally and toward the ulna. This spectrum of movement may support the theory of 2 types of carpal movement proposed by Craigen and Stanley (J. Hand Surg, 20B, 165–170, 1995).
The treatment of the open tibial fractures is still an orthopaedic challenge and full of complications. In many cases the use of external fixation that has been known as a non-union machine is obligatory with a high incidence of pin track infection and other complications. The aim of this study was to compare the use of external fixation as a definite method of treatment of open tibial fractures with it’s subsequent conversion to internal fixation or casting.
During June 2004 to July 2006 in a randomized controlled trial 67 patients with types A and B of Arbeitsge-meinschaft fur Osteosynthesefragen (AO) open type III Gustilo tibial and fibular diaphyseal fractures were studied. Mean age of the patients was 25 years (18–40 years) and mean follow up time was 8 months.
After the external fixation of the fractures, the patients were divided into three groups by drawing from the random table of numbers. Group one consisted of 20 patients were selected for delayed conversion to internal fixation after 6–8 weeks (after three weeks of removal of external fixator).
Group two consisted of 25 patients in whom external fixation had continued in order to convert to Patellar Tendon Bearing (PTB) cast after developing union.
The remaining 22 patients were considered as group three in whom external fixation was continued until complete union.
There was a meaningful difference only in the union time (P=0.001) and superficial infection (P=0.018) between the first group and the other two groups.
So, in the treatment of the open tibial fractures there is priority for method of conversion of the external fixation to internal fixation compared to the other protocols of treatment.
Distal locking screw fixation, in intramedullary nail (IMN) fixation, remains the most technically demanding and problematic portion of the procedure being responsible for as much as one-half of the exposure of the surgeon‘s hands to radiation.
This biomechanical study was undertaken to compare the effectiveness of using one distal locking cross screw instead of two cross screws in femoral fractures fixed with IMN system.
A composite model made from a stainless steel IMN (12mm×1mm), was axially loaded to 2kN (3 times body weight) to reproduce the forces experienced during weight bearing, or until a maximum displacement of 1 mm was reached. The distal locking end of the intramedullary nail was attached to the centre of the cylinder, representing different parts of the distal femur, with a dedicated single or two rods (5mm diameter), made from stainless steel and titanium, to represent the distal locking cross screw.
In the 50mm×5mm cylinder (diaphyseal femur), the mean stability of fracture model using either single or two screws were similar. But in the 75mm×5mm and 100mm×3mm cylinders (metaphyseal and distal femur), the mean stability of the fracture model significantly decreased (50%) with single distal locking cross screw fixation when compared to two distal locking cross screws fixation. Similarly, stainless steel alloy provided more stability compared to titanium alloy cross screws in 75mm×5mm and 100mm×3mm cylinders. However there was no difference between the cross screws performance for 50mm×5mm when comparing both the alloys.
As shown in this experiment, femoral shaft (diaphyseal) fractures fixed with shorter IMN had the same stability for one or two distal locking cross screws. However fractures fixed with longer IMNs, to fix diaphyseo-metaphyseal junction fractures and extreme distal femoral fractures, single distal locking cross screw fixation provide poorer fracture stability compared to two distal locking cross screws fixation.
Infrapatellar Contracture Syndrome describes a postoperative complication characterised by a vertical migration of the patella due to Patella Tendon (PT) shortening and/or PT adhesion (PTA) formation. We investigated how removal of the central one-third of the PT influences both PT length (LP) and in vitro knee kinematics in 18 sheep divided into 3, 6, 12 and 24 week groups. At time of sacrifice the pelvis-lower extremities complexes were left in a supine position until rigor mortis set in. Limbs were CT-scanned (0.5mm) whilst frozen and LP measured (ProEngineer, PTC, MA). Specimens were fixed into a loading frame with 50N applied to the rectus femoris and knee kinematics obtained (Polhemus, VT). Bones and associated registration block portions of the receiver assemblies were CT-scanned (0.5mm), reconstructed, and imported into ProEngineer where coordinate systems were created in accordance with the Joint Coordinate System (JCS). Registration was accomplished by aligning models of the receiver assemblies with the reconstructed surfaces. Post-processing and statistical analysis (ANOVA) was performed using Matlab (MathWorks, MA) and data referenced to the contralateral controls.
No significant changes in LP were observed. The mean PT length ratio (LP/LC) in the 3 week group was 1.0028±0.004 (mean±SD). In the 6 week group this ratio had increased to 1.0282±0.0246, returning to 1.005±0.0035 at 12 weeks and back to 1.0159±0.0217 at 24 weeks. No PTA’s were observed. A significant proximal shift of the patella reflecting the increase in LP was observed which correlated well with a retardation of patellar flexion (r = 0.880, p< 0.001). A significant decrease in medial patellar tilt was also observed but was not coupled with changes in tibial rotation. Proximal and lateral tibial shifts were also detected.
The results of this study seem to suggest that the changes in knee kinematics and LP induced by removal of the central one-third of the PT do not recover 24 weeks post-operatively.
Although modern operative intervention for calcaneal fractures has improved the outcome in many patients, there still is no real consensus on treatment, operative technique, or postoperative management. Vira® is a system for reconstruction-arthrodesis of severe calcaneal fractures, consisting in m
The aim of our study was to elaborate a CPG to assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with severe calcaneal fractures.
The CPG was developed according to international methods of guideline development. To identify “best evidence” a structured search was performed. When no evidence was available, consensus between experts (physiotherapist and orthopaedic surgeons) was achieved to develop the guideline. To identify “best clinical experience” and “physiopathology reasoning” focus group of practicing physiotherapists was used. They reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.
CPG include three phases determined from the physiopathology and biomechanical reasoning of surgical system (weeks after the surgery: 2a–5a, 5a–14a, 14a–+/−24a). Unfortunately, evidence related to the treatment of severe calcaneal fracture was sparse and often of poor methodologic quality. The recommendations that were included: early onset (2a week after the surgery) with early mobility and loading, program of home exercises, manual therapy (articular and miofascial techniques), walking in swimming pool, continuous electromagnetic fields of 99Hz with an intensity of 99 Gaussian during 30 min/day; electrotherapy of the intrinsic muscles of the feet (80Hz; 8:12, 20 mi), a program of active exercises of the feet (dorsiflexion and plantarflexion, not supination and pronation) and resistive exercises of triceps surae muscle (7a week), criotherapy and anti-inflammatory positions.
Type 1 diabetes mellitus (DM) is associated with a decreased bone formation. Osteoblastic expression of parathyroid hormone-related protein(PTHrP) -an important modulator of osteoblast differentiation- decreases in age-related osteopenia. We here examined the putative role of PTHrP on the decreased osteoblastic function in DM.
We performed marrow ablation in the tibiae of diabetic mice after streptozotocin injection (glycemia > 300mg/dl). Some mice were treated with PTHrP(1–36) (100 ng/g/every other day, s.c.) or vehicle for 2 weeks. Both tibiae were then removed for histological evaluation or total RNA isolation. In vitro, MC3T3-E1 cells were grown in differentiation medium (a-MEM), with or without high glucose(HG) (25 mM) (or mannitol, as osmotic control), supplemented (or not) with PTHrP(1–36) (100 nM). In some experiments, anti-PTHrP N-terminal antibody C13 (1:100) or PTHrP(7–34) (1 μM) were added to normal-glucose medium. RANKL secretion was measured in the cell-conditioned medium by ELISA. Gene expression was analyzed by real-time PCR.
DM induced a 10–15% weight loss and a decrease (20–40%;p< 0.05) in the gene expression of the following osteoblastic factors in the regenerating tibia for 6 days: PTHrP, the PTH/PTHrP type1 receptor (PTH1R), osteocalcin, VEGF and its receptors 1 and 2; and in the OPG/RANKL ratio, related to an increased PPAR-γ mRNA expression. Compared to control mice, the regenerating tibia of DM mice showed a 5-fold increase in adipocyte number, and a decreased osteoblast number and osteoid surface. In MC3T3-E1 cells, HG decreased (20–40%) the OPG/RANKL ratio and the gene expression of both PTHrP/PTH1R and VEGF systems. PTHrP(1–36) reversed these HG-related effects in vivo and in vitro. Similar inhibitory effects were induced by a neutralizing PTHrP antibody or the antagonist PTHrP(7–34) in these cells in normal glucose.
In conclusion, a deficit in PTHrP production by osteoblasts seems to be at least in part responsible for the DM-related decreased bone formation in mice.
We investigated the feasibility of using porous titanium particles (TiP) to reconstruct femoral bone defects in revision hip replacement surgery in stead of using morzelised bone grafts. Questions regarding handling, initial stability and titanium particle release were addressed.
Seven composite femurs (Sawbones) were reamed and filled, stepwise, with 32 grams of large (Ø 3.15 – 4 mm) and 9 grams of smaller (Ø 2.8 – 3.15 mm) pure, 85% porous TiP. Subsequently an Exeter stem was cemented into the graft layer. All reconstructions were loaded axially (0–3000 N) for 300,000 loading cycles at 2 Hz. Subsidence of the stem was measured with radio stereometric analysis (RSA) and possible titanium particle release was measured using the laser diffraction technique.
The TiP were impacted into a > 3 mm (SD 1.43 mm) thick, highly entangled, graft layer. An average cement mantle of > 2 mm (SD 0.86 mm) was measured and little cement penetration was observed. The average subsidence of only 0.45 mm (SD 0.04 mm) was measured after 300 000 loading cycles. Most titanium particles were found directly after impaction. Most of these particles (87%) were smaller than 10 μm and could therefore be potentially harmful since they can induce osteolysis.
We can conclude that:
A graft layer of impacted TiP can be constructed, The graft layer is stable enough to initially support a cemented Exeter stem, Titanium particles are released during impaction.
These data warrant further animal tests to assess the biological response to these released impaction particles. Also, animal tests should clarify possible particle release upon loading and its effects.
Experimental and clinical studies have documented that meniscal allografts show capsular ingrowth in meniscectomized knees. However it remains to be established whether meniscal allograft transplantation can prevent degenerative changes after total meniscectomy. In this study, functional changes in articular cartilage after meniscus transplantation in rabbits were evaluated quantitatively.
Thirty rabbits were divided into five groups. Group A and Group C were subjected to meniscectomy. Group B and Group D underwent meniscal transplantation immediately after meniscectomy. Group E had delayed transplantation 6 weeks after meniscectomy. Six nonoperated knees served as controls. Using image analysis with QwinPro software ffunctional changes of articular cartilage were examined 6 weeks (Groups A, B) and 1 year (Groups C, D, E, controls) after surgery by measuring the lactate dehydrogenase (LDH) activity in chondrocytes as a measure of their vitality and the proteoglycan content of the extracellular matrix as a measure of its quality.
All experimental groups demonstrated a significant decrease in proteoglycan content of the cartilage as compared with the control group. At 6 weeks and 1 year follow-up, no significant differences were found between the postmeniscectomy group and immediate transplant group. The delayed transplant group showed a significantly decreased proteoglycan content as compared with the postmeniscectomy group. Compared to the control group, no significant differences in cellular LDH activity were found in the postmeniscectomy group and immediate transplant group at 6 weeks and 1 year. However, delayed transplantation caused diminished vitality of chondrocytes. No significant differences were found between the postmeniscectomy group and immediate transplant group at 6 weeks and 1 year. The delayed transplant group showed a significant decrease in LDH activity as compared with the postmeniscectomy group.
It can be concluded that immediate meniscal transplantation in rabbits did not significantly reduce degenerative changes of articular cartilage whereas delayed transplantation leads to even more degenerative changes than meniscectomy.
Chondrosarcomas are hyaline cartilage-forming tumours which can be classified according to malignancy through histological grading. Grade I chondrosarcomas rarely metastasize whereas in grade III chondrosarcoma metastasis is observed in 71% of cases. There is, so far, no clear molecular marker allowing an objective classification of chondrosarcoma. The aim of this project was to identify such marker genes through the comparison of gene expression of chondrosarcoma and normal hyaline cartilage and through the correlation of expression profiles to histological grading.
The mRNA of 19 chondrosarcomas with different histological grades and of eight normal cartilage samples was analysed. Gene expression profiles were assessed on a customised cDNA array including 230 cartilage- and stem cell-relevant genes. Data were analysed by hierarchical clustering and significance analysis of microarrays. Results were confirmed by real-time RT-PCR.
Gene expression profiles clearly discriminated between normal and neoplastic cartilage. Between them, 73 differentially expressed genes were identified. The genes higher expressed in cartilage included several genes encoding matrix proteins. Among the genes higher expressed in chondrosarcoma, molecules involved in PTH and BMP signalling were found. Genes differentially expressed between tumours of different grade were identified. Among others, galectin 1 was significantly higher expressed in highly malignant tumours compared to grade I tumours. This correlation could be confirmed at protein level by immunohistological analysis.
The comparative analysis of normal cartilage and chondrosarcoma gene expression showed that there are important molecular differences between the matrix of normal and neoplastic cartilage. Our results furthermore confirm that genes implicated in the regulation of the growth plate were expressed in chondrosarcoma. Remarkably, we identified galectin 1 as a marker correlating to malignancy on the level of gene and protein expression. More extended studies on this functionally polyvalent molecule would be necessary to establish it as a marker for malignancy in chondrosarcoma.
Patients were evaluated preoperatively using ODI, SF36, VAS, plain x-ray, MRI scanning & discography. Questionnaires were evaluated at the first and second years.
Kinematics characteristics of the spine and pelvis are one measure proposed to assess lumbar dysfunction. To extent our knowledge about this matter we described the relationship between the orientation of the sacrum, in the sagittal plane, at upright position and the differential lumbar spine and pelvis range of flexion at the toe touch position in free-pain subjects.
Position and motion measurements were recorded by an electrogoniometer. Individuals (n=39), were divided into two groups according to whether they have either pelvis (pelvis -group, n=18) or lumbar spine (spine-group, n=21) dominant movements during flexion. The mean age was 23,67±4,94 years (range18 to 33 years) in the pelvis-group, and 22,55 ± 2,70 years (range 19 to 27 years) in the spine –group. The range of pelvis flexion was significantly greater in the pelvis group than in the spine group, the range of lumbar spine flexion was significantly greater in the spine group than in the pelvis group (α≤.001); however, no differences were found in the range of back flexion (combined lumbar spine and pelvis motion) between the two groups. In the pelvis group the sacrum was significantly more horizontal than in the spine group (α≤.001). In the pelvis-group very strong correlation between sacrum orientation and the maximum range of pelvis flexion was found (r =0, 61). In the Spine group, sacrum orientation showed a negative strong correlation with the maximum range of spine flexion (r= − 0, 71). These results suggest the influence of the individual morphology on the lumbo-pelvic patterns of movements.
Adjacent segment degeneration with new, symptomatic radiculopathy occurs after ACDF in 2–3% of patients per year on cumulative basis. An estimated 15% of patients ultimately require a secondary procedure at an adjacent level.
An alternative to fusion is total disc arthroplasty (TDA). The key advantage of this promising technology is restoration and maintenance of normal physiological motion rather than elimination of motion.
We describe 4 patients with a serious complication observed following implantation of the Bryan disc prosthesis in our cohort of 48 patients.
Patient #1: 43 M, with neck pain &
left brachalgia, with left C6 dermatome signs, with MRI findings of C5/6 disc prolapse with left C6 root impingement, undergoing C5/6 Bryan TDA in April 2004, with treatment recommendation of C3/4 and C6/7 Bryan TDA in January 2006. Patient #2: 47 M, with worsening gait over 2 years with right brachalgia, with findings of progressive cervical myelopathy with right C5 radiculopathy, with MRI findings of severe C5/6 disc degeneration with spinal cord compression, undergoing C5/6 Bryan TDA in January 2003, with MRI FU findings after 16/12 with new left C6/7 disc prolapse and left C6 radiculopathy, with treatment recommendation of C6/7 Bryan TDA, on waiting list. Patient #3: 45 F, 6 years of neck pain with right brachialgia, with right C5 dermatome signs, with MRI findings of C5/6 central disc herniation with cord compression, undergoing C5/6 Bryan TDA in December 2000, with FU MRI showing after 5 years and 7/12 (67/12) new C6/7 canal narrowing with right C6 radiculopathy, and treatment recommendation of C6/7 Bryan TDA. Patient #4: 38 M, worsening gait over 5 years and exam findings of progressive cervical myelopathy, with MRI findings of severe C5/6 disc degeneration with spinal cord compression, undergoing C5/6 Bryan TDA in August 2003, with FU MRI showing after 3 years new C4/5 disc prolapse with C5 radiculopathy, followed by treatment recommendation of C4/5 Bryan TDA.
Despite the MRI images preoperatively, it is difficult to exclude the natural progression of degeneration as a reason for ASD.
Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.
Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.
Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.
We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.
In vitro testing of spinal motion segments provides valuable information about the effects of surgical procedures on the biomechanics of the spine. Few studies, however have investigated the effect of varying laboratory testing environments on the outcome of these tests. This study aims to identify differences in mechanical properties induced by testing in one of three testing environments, and trends due to repeated testing over time.
27 sheep lumbar motion segments were tested in either,
air at 18°C while wrapped with gauze soaked in Phosphate Buffered Saline (PBS), a PBS bath at 37°C, or at 37°C and 100% humidity.
Specimens were cycled through +/−8Nm in axial rotation, lateral bending, and flexion/extension. Tests were repeated every hour for 6 hours. Torque and angle were recorded and each bending mode was repeated for 4 cycles, the last 3 of which were used in calculations. Stiffness (5–7Nm), neutral zone (NZ), NZ stiffness, Range of Motion (ROM) energy under the loading curve and hysteresis area were calculated and evaluated with ANOVA.
Post hoc comparisons found differences in stiffness, hysteresis area and energy of bending between room temperature and both heated conditions during flexion/extension. Differences were also noted between the room temperature and PBS bath conditions for stiffness and hysteresis area during lateral bending. One explanation of the results could be the thermo-sensitive properties of spinal ligaments and intervertebral fibrocartilages.
Repeated testing was a factor that affected the outcome of NZ, NZ stiffness, ROM and energy under the loading curve in all modes of torsion. If not accounted for during repeated tests this could lead to confounding results. Many of the traditionally reported variables (NZ, ROM) showed changes with repeated testing while hysteresis area remained relatively steady during repeated tests while identifying differences between testing groups. This variable may be useful in evaluating the condition of a motion segment with less time related effects.
Purpose of study was to determine the value of the upper edge of the pectoralis major (UPM) insertion as landmark to determine proper height and version of hemiarthroplasties implanted for proximal humeral fractures.
UPM insertion was referenced with metallic device in 20 cadaveric humerus. Computed Tomography study was performed in all specimens. Total humeral length and distance between the UPM insertion and the tangent to humeral head was recorded. CT scan slice showing UPM superimposition in humeral head was drawn to determine prosthesis retroversion. Qualitative variables are presented in absolute and percentage values. Quantitative variables are presented with mean values and standard deviation.
Mean total humeral length 32,13 cm. Mean distance from the UPM to the tangent to the humeral head 5,64. Mean distance from UPM insertion to the tangent to the humeral head represents the 17,55 % of total humeral length. Mean distance of UPM insertion to the posterior fin of the prosthesis of 1,06 cm. Angle between UPM insertion and posterior fin of the prosthesis 24,65°.
Mean distance from the UPM insertion to the top of the humeral head of 5, 6 cm with a 95% confidence interval. Placement of the prosthesis in the proper retroversion can be achieved by placing the posterior fin 1,06 cm posterior to the UPM or by placing the posterior fin at 24,65° with respect to the upper insertion line. UPM constitutes a reliable reference to reproduce anatomy in hemiarthroplasties for proximal humeral fractures.
Physiological studies have revealed that the central nervous system controls groups of muscle fibers in a very efficient manner. Within a single skeletal muscle, the central nervous system independently controls individual muscle segments to produce a particular motor outcome. Mechanomyographic studies on the deltoid muscle have revealed that the deltoid muscle, commonly described as having three anatomical segments, is composed of at least seven functional muscle segments, which all have the potential to be at an important level independently coordinated by the central nervous system.[
Forty-four deltoids of 22 embalmed adult cadavers, were analyzed. The axillary nerve was carefully dissected together with his anterior and posterior branch upon invasion into the muscle. According to the pattern of fiber distribution and their fascial embalmment, we then carefully splitted the deltoid muscle into different portions each being innervated by a major branch of the axillary nerve. The position and volume of each segment in relation to the whole muscle was derived.
In 3 cases the axillary nerve branched out in 8 major divisions. In 22 out of 44 cases (50%), the axillary nerve branched out in 7 principal parts. A branching out pattern of 6 major divisions occurred in 14 out of 44 cases. Finally we found a division in 5 major branches in 5 of the specimens. In general, both posterior and anterior peripheral segments seemed to have the largest volume. In nearly all (93%) cases, the central segments were smaller in weight and volume compared to the more peripheral segments.
Based on the innervation pattern of the deltoid muscle a segmentation in 5 up to 8 major segments seem to be found. This confirms from anatomical point of view earlier reports of functional differentiation within the deltoid muscle.
Dimensions of the 60 male human lumbar vertebrae were quantified on their digitalised lateral images, and related to them across the five vertebral levels (range of 20–40 years). Vertebra dimensions’ were defined and referred to the upper endplate. Linear dimensions (mm) were: the length of the whole vertebra and of the spinous process; the anterior/posterior body heights, and the upper/lower endplate lengths. For each of the measurements L3/L1, L3/l2, L3/L4, L3/L5 ratios were calculated. The inclination angle (°) of the lower-end-plate was further calculated.
Significant differences were shown by a randomized complete blocks design, post-hoc test (Student-Newman-Keuls), (α< .05). Anterior bodies’ heights ratios progressively decreased from L1 to L5 level, which means a relative increase of the anterior bodies’ heights. Posterior bodies’ heights ratios progressively increased from L1 to L5 level, which means a relative decrease of the posterior bodies’ heights. Lower-endplates inclination angle significantly and progressively increased from L1 to L5 vertebral level. For L1 and L2 (𝛉< 0°), it means that vertebrae are ventrally wedged, whereas L3, L4, L5 vertebrae are dorsally wedged (𝛉< 0°). It could be suggested that individual vertebra morphology contributes to shape the anterior convexity of the lumbar curvature along with the intervertebral discs. Spinous process and vertebral lengths ratios significantly decreased from L1 to L2, and significantly increased from L4 to L5, but no differences between L1vs. L5 neither for L2 vs. L4. It shows that lengths of the spinous process and vertebrae define two segments with same trends at the lumbar spine, the upper L1 and L2 segment; and the lower L4 and L5, which join together at L3 vertebra. This design allows to drawn the concavity of the lower back while standing upright and its convexity while flexing forward.
The shoulder girdle is an extremely mobile joint. Rotator cuff tears alter the existing equilibrium between bony structures and muscles. The “subacromial impingement syndrome” resulting from this unbalance leads to an extension of the rotator cuff lesion.
Many authors have postulated a “mechanism of compensation”, but its existence still requires evidence. According to this model, the longitudinal muscles of the shoulder and the undamaged muscles of the rotator cuff would be able to functionally compensate, supersede the function of rotator cuff, and reduce symptoms.
The aim of this study was to evaluate muscular activation of the medium fibers of deltoid, the superior fibers of pectoralis major, the latissimus dorsi and the infraspinatus by a superficial electromyographic study (EMG) and the analysis of kinematics in patients with a massive rotator cuff tear.
We evaluated 30 subjects: 15 had pauci-symptomatic massive rotator cuff tear (modest pain and preserved movement), and 15 were healthy controls.
Paired t-test showed significant different activations (p< 0.05) of these 4 muscles between the pathological joint and the healthy one in the same patient.
The unpaired t-test, after comparing the mean EMG values of the 4 muscles, produced a significant difference (p< 0.05) between the experimental group and control group.
This study showed that a mechanism of muscular compensation is activated in patients suffering from rotator cuff tear, involving the deltoid and the infra-spinatus muscle, as already presented in literature, but also demonstrated the activation of 2 other muscles: the latissimus dorsi and the pectoralis major. It is, therefore, probable that, in these patients, these muscles, which would not normally pull the head of the humerus downwards, adapt in order to compensate for the pathological situation. We believe that these data are valuable in the surgical and rehabilitation planning in patients with a massive rotator cuff tear.
The concept of non-anatomic reversed arthroplasty is becoming increasingly popular. The design medializes and stabilizes the center of rotation, and lowers the humerus relative to the acromion, and lengthens the deltoid muscle up to 18%. Such a surgically created global distraction of muscles is likely to affect nervous structures. When nerves are stretched up to 5–10%, axonal transport and nerve conduction starts to be impaired. At 8% of elongation, venous blood flow starts to diminish and at 15% all circulation in and out of the nerve is obstructed. [
In a formalin-embalmed female cadaver specimen, the brachial plexus en peripheral upper limb nerves were carefully dissected and injected with an iodine containing contrast medium. At the same time 1.2 mm-diameter leaded markers were implanted at topographically crucial via points for later enhanced recognition on CT reconstructions. After the first session of CT scanning a plastic replica of the Delta reversed shoulder prosthesis® was surgically placed followed by re-injection of the plexus with the same solution. The preoperative and the postoperative specimen were studied using a helical CT scan with a 0,5 mm slice increment. The Mimics® (Materialise NV, Belgium) software package was used for visualization and segmentation of CT images and 3D rendering of the brachial plexus and peripheral nerves.
After surgery, there was an average increase in nerve strain below physiologically relevant amplitudes. In a few local segments of the brachial plexus an increase in nerve strain exceeding 5–10 % was calculated. The largest increase in strain (up to 19%) was observed in a segment of the medial cord. These results suggest there might be a clinically relevant increase in nerve strain following reversed shoulder arthroplasty.
Hyaline cartilage is a support tissue with a poor capacity to self repair. In the last years, tissue engineering and cell therapy have focused its efforts in the development of scaffolds that may support the differentiation and the implantation of mesnechymal stem cells (MSC) in the site of lesions performed in femoral cartilage. Among synthetic materials used for the construction of these scaffolds, poly(L-lactic acid) (PLLA) is a suitable option, since some studies have offered promising results. The use of PLLA, nevertheles has an important handicap, as cell seeding easily results in a non uniform distribution and a poor density of cells, wich have been proposed as key steps for the differentiation of MSCs to chondrocytes. In our work we have cultured sheep MSCs, and proved its potentiallity by differentiation to chondrocytes in micromass culture. PLLA scaffolds 1 mm thick and 6 mm in diameter were characterized by determining their porosity and their mechanical properties, and subsequently were used to assay the seeding of MSCs. We measured efficiency and retention by quantification of DNA, and density and distribution by light microscopy of paraffin sections. Our results describe a simple technique of cell seeding by aspirating cells with a syringe that achieves a uniform distribution and a high density of cells. Finally 3D seeded MSCs were cultured with condrogenic medium containing TGF-β3 for 21 days and results analyzed by massons trichrome staining in paraffin embedded sections.
Ex vivo cell-growing technique might be a solution for treatment of bone diseases leading to the local bone defects. We assessed the effect of ex vivo-cultured cells in ectopic bone induction in animals with normally functioning connective tissue cells.
After differentiation osteoprogenitor cells were transferred into beta-tricalcium phosphate scaffolds using either centrifugation or simple diffusion. Six types of implants (beta-tricalcium phosphate matrixes) were implanted into subcutaneous pouches. In the first group saline-immersed implants were used; in the second group the ex vivo cells were transferred into the implant by diffusion and in the third group by centrifuging; in the 4th, 5th and 6th group the implants were processed as in first three groups, respectively, but 12.5 microgram of rhBMP2 was added to the each implant. After 21 days the implants were removed and dissected systematically. Histomorphometry analysis was performed following the principles of stereology.
• Supported by Estonian Government SF 0180030s07
Calcification and ossification have been described in artery wall in pathologic conditions and aging. We previously described the use of cryopreserved arterial allografts as membranes for guiding bone regeneration. We hypothesize that artery is as good as synthetic membranes (e-PTFE, gold-standard in guided bone regeneration) due to the osteogenic potential of cells from its medial layer.
A comparative study was made creating 10 mm mid-diaphyseal radial defects in 15 New Zeland rabbits (30 forearms): 10 defects were covered with an e-PTFE membrane and 10 defects with no membrane (control group). Studies: X-rays, CT, MR, morpho-densitometric analysis, electronic and optical microscopy.
To demonstrate the cellular arterial stock, cryopre-served and fresh rabbit thoracic aorta specimens were studied. Medial layer was isolated and cultured as explants in normal medium. Cells were harvested and added to a 3-D scaffold based on plasmatic albumin in osteogenic medium. Immunocitochemical study was made. Radial defects surrounded by cryopreserved arterial membranes showed total regeneration in nine of 10 defects versus seven of 10 defects in e-PTFE group (no statistically significant differences were detected between them). No tissue layer was found between bone and artery while a connective tissue layer was observed between e-PTFE and bone. Neither radiological nor histological healing were detected in the control group.
Cells cultured had smooth muscle features as they showed immunofluorescence with anti-smooth muscle alpha-actin, anti-calponin and anti-vimentin antibodies. When cells were added to a 3-D matrix, they showed chondro and osteogenic differentiation, as they stained positive for types II and X collagen, alkaline phosphatase and von Kossa.
Although no statistically significant differences between artery and e-PTFE groups were detected, histological and cellular findings suggest a superiority of cryopreserved arterial allografts when compared with synthetic membranes of e-PTFE, with a contribution of the cellular stock of the medial layer in the healing process.
The most common indication for knee arthrodesis is pain and instability in an unreconstructable knee following an infected knee arthroplasty. In this study, we compare the use of the Mayday arthrodesis nail (Ortho-dynamics, Christchurch, UK) versus external fixation, Orthofix (Berkshire UK) and Stryker Hoffman II (County Cork, Ireland).
All patients in this study underwent arthrodesis between 1995 and 2006 at Conquest Hospital, Hastings. In group A, 11 patients underwent arthrodesis with a Mayday nail. In all cases, the indications were infected total knee replacements (TKR). Three of these patients previously had failed attempts at arthrodesis with external fixation devices. In group B, seven patients underwent arthrodesis using external fixation. In six patients, the indication was infected TKRs. Results were reviewed retrospectively, with union assessed both clinically and radiologically.
The mean inpatient stay for the Mayday nail group was 23 days (range 8 – 45 days) compared with 76 days (range 34 – 122) for the external fixation group (p< 0.01, CI 95). Ten patients in group A went on to confirmed primary arthrodesis. One patient underwent revision arthrodesis with a Mayday nail and subsequently united. In group B only two patients achieved union. The rate of union was significantly greater in the Mayday nail group than the external fixation group (91% vs 29%, p< 0.01). Of those patients that achieved union, there was no difference in the time to fusion between groups.
Our study supported the existing literature and found that the Mayday nail appeared more effective than monoaxial external fixators for arthrodesis in the management of infected total knee replacements.
We aimed to collate guidelines for preoperative marking in orthopaedic surgery, identify areas of convergence and difference and relate them to previous work on guideline effectiveness.
We performed a systematic search of Medline and Google using ‘correct site’, ‘wrong site’, ‘marking’, ‘surgery’, ‘orthopaedics’ and ‘guidelines’. Orthopaedic societies and bodies, personal knowledge and unindexed conference abstracts were also used.
We found nine guidelines from ten institutions in seven different countries; UK National Patient Safety Agency/Royal College of Surgeons of England, Australian College of Surgeons, JCAHO (USA), Canadian Orthopaedic Association, Veterans Health Association (USA), Copenhagen Hospital Corporation, German Coalition for Patient Safety, American Academy of Orthopaedic Surgeons and the New Zealand Orthopaedic Association.
We identified four ‘core-steps’ common to the majority of guidelines. Firstly, using indelible pen. Secondly, the operating surgeon should mark the patient. Thirdly, the patient should be involved in confirming side/site. Finally, a ‘time-out’ before starting the procedure. Only one of the ‘core steps’ is carried out in theatre. The others are carried out before theatre emphasising the importance of accurately identifying and marking early in the patient’s journey.
Common sense suggests guidelines should be simple, user friendly and quick to complete. Making guidelines compatible with existing values and not deviating from existing routines are recognised to increase their use. Guidelines issued by practitioners’ own professional bodies are likely to have more impact than those from outside the profession. However increasing the number of items a guideline contains does not necessarily make it better or safer.
The four core steps we identified are the basis for any marking guideline. It is reasonable to assume that incorporating the guidance into clinical orthopaedic practice will further improve safety. Future work should focus on establishing the relative impact of each guideline aspect.
Amniotic band syndrome (ABS) is a congenital disorder characterized by limb constrictions. The disorder lacks precise definition, and its exact pathogenesis is unknown. Though theories have been advanced to explain the condition’s origin, none have been scientifically validated. The “exogenous” theory, popularized by Torpin, is the most widely accepted. It suggests that early amniotic rupture leads to formation of amniotic strands, which by means of progressive compression induce formation of extremity bands. In this disorder, histological examination of the excised bands demonstrates them to be composed of fibrous tissue. Multiple clinical and experimental data reveal this theory has only low plausibility. Our purpose is to assess whether annular external compression of a fetal rabbit limb will produce a band of subcutaneous fibrous tissue characteristic of amniotic band syndrome.
We operated on one limb of 10 different rabbit fetuses, each at 21 days of gestation. The extremity was ligated with a nylon suture at the infracondylar level. At 30 days gestation, each fetus was delivered by caesarean section. Limbs were analyzed histologically using different techniques. Histological analysis did not show subcutaneous fibrous tissue in the mechanically constricted zone. The distal segment showed dilatation of lymphatic vessels and edema of soft tissue.
Annular external compression of a fetal rabbit limb does not induce development of new fibrous tissue; therefore this experimental study does not support the theory of a mechanical exogenous pathogenesis in amniotic band syndrome.
In many fields, such as orthopedics and rehabilitation, measurement of segment orientation or three-dimensional (3D) joint rotation is highly required. However, even if laboratory systems (e.g., optical-based tracker) are enough accurate for human movement measurement, they have some limitations (e.g., cost, complexity, capture volume) that exclude their uses in routine practice.
Recently, our group proposed an original system fusing a low level magnetic tracker (Minuteman®, Polhemus, USA) and 3D gyroscopes (Physilog®, BioAGM, CH) to measure segments orientation. These complementary devices were selected with the aim to provide real time orientation in clinical environment and without restriction on the acquisition duration. The objective of the present study was to assess the performances of this new system in routine clinical applications.
For this evaluation, five healthy young men were enrolled and the orientation of their left thigh was considered. They were asked to perform two times a long scenario (14 min) which included various postures (standing, sitting and lying) and activities (e.g., walking and stairs climbing). These activities were realized both, in the vicinity and far from the magnetic source. Additionally, different metallic objects were inserted and moved in the capture volume to simulate assisted clinical applications. An optical motion capture system (VICON®, UK) was used as reference.
In the absence of magnetic distortion and independently of the activity, we obtained a RMS orientation error of 1.2°. Generally, during distortion periods we obtained a slow growing orientation error of about 0.1°/s whatever the activity.
In conclusion, the proposed system provided an accurate and real-time measurement of orientation in a large capture volume over a long duration. Furthermore the system performances were tested in an environment including representative distortions of routine clinical uses. In combination with a functional calibration, this system was very promising for routine measurements of 3D joint rotations.
Bone growth was compared in six types of (beta-tricalcium phosphate) implants implanted in subcutaneous pouches or close to femoral head of male Wistar rats:
implants immersed in 0.9% sodium chloride solution (control implants), implants with the progenitor cells from femoral canal, implants immersed in inductive BMP-2 solution, implants with the progenitor cells from femoral canal + BMP-2 solution, implants immersed in inductive BMP-2 solution and implanted closed to the femoral head, implants immersed in inductive BMP-2 solution and implanted closed to the femoral head while leaving the femoral canal opened for better access of the femoral canal cells.
Implants were removed 21 days after operation and dissected following principles of stereology. Presence of bone or cartilage or connective tissue was evaluated by hematoxylin eosin histochemistry.
Results: Bone formation was only found in the implants where BMP-2 was introduced. However, no distinctive differences were found between the implants where cells and BMP-2 were introduced and between the implants where just BMP-2 was used. Percentages of the bone tissue out of all the implant were as follows: 0.0% in group 1, 1.2% in group 2, 32.4% in group 3, 42.4% in group 4, 44.4% in group 5 and, 54.9% in group 6. Differences in amount of bone tissue were statistically significant between groups 3 and 2, groups 3 and 1 and also between groups 1 and 2 (p=0.0013, p=0.0004 and p=0.0525 respectively). In the other cases, the differences between BMP-2 affected implants and implants without BMP-2 were even greater.
We concluded that presence of osteoconductive matrix and introduction of an osteoinductive agent (e.g. BMP-2) are the main components of designing of bone tissue and introduction of exogenous bone cells is not as important as the first two in subcutaneous pouches or close to the hip joint.
Hip and knee wear simulators have been used by implant manufacturers and researchers for many years as a performance predictor and comparator for hip and knee implants. The clinical accuracy of these simulators in predicting wear depends heavily on the type of simulator as well as the methodology used. The joint lubricant used in the simulators is one crucial aspect that has been well studied in hip simulators. This study will compare the wear performance of a modern total knee replacement system using two commonly used simulator lubricants at various dilutions (Alpha Calf Serum and Bovine Calf Serum, Hyclone Labs). The Triathlon knee implant system (Stryker Orthopaedics) was used along with a six station knee wear simulator from MTS Systems to determine the effect of lubricant type and dilution.
Wear rates were found to be dependent on the type and dilution of the lubricant. At 0g/L protein concentration (100% water) wear rates were 4.8mm3/million cycles (mc). With the introduction of Bovine serum, wear rates increase to a peak of 24mm3/mc at 5g/L of concentration. Increased concentration of Bovine serum resulted in a decrease of wear rates. Wear rates for Alpha serum peaked at 28mm3/mc at 20g/L concentration with decreased wear rates at higher concentrations.
Knee implant wear performance is often characterized by wear simulation. As has been previously shown for hip simulations, this study shows the importance of choosing the correct lubricant type and dilution to correctly simulate wear performance. While this study cannot correlate any of the lubricants to the synovial fluid present in vivo, this study shows that 20g/L of Alpha serum produces the highest wear rates and should be used to determine worst case wear rates in the wear performance characterization of knee implants.
Bone marrow edema syndrome (BMES) is a common cause of severe bone and joint pain. Intra-articular migrating of bone marrow edema syndrome (BMES) is a very unusual pattern of disease which has been previously described in only a few cases and may raise the suspicion of an aggressive disease.
We reviewed 8 patients (4 female, 4 male) with unilateral BMES located in the knee. The patients were aged 39–56 years (mean 50.2). In all the patients bone marrow edema (BME) found in the primary magnetic resonance imaging (MR imaging) shifted within the same joint, i.e. from the medial to the lateral femoral condyle or to the neighboring bone. Conservative therapy including limited weight-bearing for a period of three weeks was provided for seven patients after initial detection of BMES and one patient underwent surgical core decompression twice.
The final MR investigation performed on average 8 months after baseline (range, 7–11 months) showed full resolution of BMES in 6 patients. One patient had small residual edematous bone areas. No quadrant was newly affected. Improvement of the MR imaging pattern was correlated with the clinical outcome in all patients. The severity of effort-induced pain (VAS) was reduced from 7.5 (2.0–10.0) at baseline to 5.9 (2.4–7.9) after 3 months and to 0.6 (0–0.9) after the final examination. Pain at rest (VAS) diminished from 3.9 (1.5–7.8) to 2.8 (1.4–6.0) after 3 months and to 0 at the final follow-up. All patients became asymptomatic after a mean of 9 months (6–11).
Intra-articular migrating BMES is a condition seen very rarely. The disease is self-limited so that conservative therapy can be recommended.
Traumatic and vascular theories have been proposed as the cause of the SO, lack of blood in some critical areas, such as subchondral bone of femoral condyles or tibial plateaus, has been considered the underlying condition of this pathology.
ESWT can be suggested as an effective conservative treatment for SO of the knee.
Patients were treated with a cycle of three ESWT performed with 2000 pulses of 0,28 mJ/mm2 with Wolf Piezoson 300 with 6,5 MHz ultrasounds for three times in a month.
Clinical evaluation was performed at first and at third month after treatment and a MRI evaluation was performed at fourth month after treatment.
ESWT might have the potential to avoid the need for surgical treatment.
An uncomplicated, quantitative method of determining density from X-rays would be of extreme value to clinicians. In this study we perform a thorough assessment of applying a step wedge to grey level calibration method to X-rays obtained using Computed Radiography (CR).
An Aluminium step wedge of ten, 5mm-thick steps was X-rayed with a Fuji CR system together with a knee phantom (3M) at various energy and Fuji processing settings. Automatic detection of the steps by means of the Hough transform was used to assess optimum CR settings. Background variation due to the anode Heel effect was evaluated by acquiring an “empty field” X-ray at different energy settings and with copper filtering. The effects of beam hardening were considered with a custom-made phantom which was also used to assess correcting for soft tissue and bone thickness.
X-rays taken at higher energy settings and with wider windowing imaged the widest number of steps (nine) and gave the best accuracy in modelling the step thickness to grey level relationship. Fitting a straight line to the log of the net grey levels gives an excellent model of the data (R2 = 0.99). X-rays of copper sheeting show that automatic histogram analysis is performed by the Fuji CR system, which can have unpredictable effects on aluminium thickness to grey level relationship. Background variation in the anode-cathode direction due to the Heel effect was corrected with a 1D exponential model (R2 = 0.99), allowing position-independent measurements to be obtained. Correcting for bone thickness, soft tissue and beam hardening further improves measurement quality.
Use of step wedge calibration to provide quantitative information on plain X-rays without altering their clinical quality is possible using digital radiography. However, a thorough assessment of the entire X-ray process is necessary to achieve accurate and comparable information.
Whereas thermography has already been used as an assessment of disease activity in some kinds of inflammatory arthritis, it is a new method for objektive pain evaluation in patients with joint prosthesis. To our knowledge, no study has tested the correlation between increase of temperature and anterior knee pain with total knee prosthesis yet.
Thirteen patients were included in this study who suffered from anterior knee pain of the retinaculum patellae with total knee prosthesis. The patients were asked to walk 3 km before entering a room which was cooled down to 20 degrees Celsius. A black 1 cm times 4.5 cm square stripe was attached on the diameter of the patella and the patients rested for 20 minutes to cool down before thermographic fotos were taken from 90 degrees, 45 degrees, frontal medial and lateral. The evaluation of temperature difference of each side was performed by marking a 1cm times 2cm square field rectangular around the black stripe and comparing it with a reference point of the same size 3 cm distal of the field. The patients were compared with thirteen others, not suffering from anterior knee pain. Statistical analysis was performed using a t- test and a p value < 0.05 was considered to be significant.
The temperature differences between the rectangular field and the reference point increased significantly on the medial (p= 0.00037) or lateral (p= 0.000002) pain side of the knee. The thirteen knees with knee pain had significantly higher temperature differences between medial and lateral temperature differences, than the knees without knee pain.
We demonstrate a significant correlation between anterior knee pain and an increase of superficial skin temperature around the retinaculum patellae. To our knowledge, this is the first report of an objective assessment of pain of the retinaculum patellae with total knee prosthesis.
Anterior knee instability associated with rupture of ACL is a disabling clinical problem, especially in the athletic individual. The gracilis and semitendinosus tendon (T4) represent an alternative autograft donor material for reconstruction of the ACL.
The aim of our study was to elaborate a CPG to assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with ACL reconstruction with T4.
The CPG was developed according to international methods of guideline development. To identify “best evidence” a structured search was performed. When no evidence was available, consensus between experts (physiotherapist and orthopaedic surgeons) was achieved to develop the guideline. To identify “best clinical experience” and “physiopathology reasoning” focus group of practicing physiotherapists was used. They reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.
CPG include three phases determined from the evidence, physiopathology reasoning and the biological process of autograft (weeks after the surgery: 2a–6a, 6a–10a and 10a–16a). The recommendations included: In postoperative weeks (2a–6a) physiotherapy focused on early range of motion of the knee; manual therapy (passive range of motion (PROM) 0–120° and miofascial techniques), pulsed ultrasound of low intensity with a power of 0.3w/cm2 (1MHz) during 10min/day in tibial tunnel, early active hamstring beginning with static weight bearing co-contractions (closed-kinetic-chain) and adductors, partial weight bearing with crutches, exercises in the swimming pool and cryotherapy to pain control (30 mi/4 hours). In weeks 6 to 10, full weight bearing, manual therapy (PROM 0–140° and miofascial techniques), hamstring strengthening progress complexity and repetitions of co-contractions, electrotherapy hamstring and quadriceps co-contractions. Starting at week 10, progress to more dynamic activities/movements, proprioceptive work, open-kinetic-chain, stationary bike and Theraband squats. In week 12, progress jogging program and plyometric type activities. The patients performed sports-specific exercises by about 3½ months postoperative.
Bone marrow edema (BME) is frequently observed on MR images in patients presenting with severe joint pain and may be present in numerous bone and joint diseases. BME may be subdivided into ischemic (bone marrow edema syndrome, BMES), mechanical and reactive BME. Although bone marrow edema of the knee is a common phenomenon, physical tests to diagnose this condition have not been investigated thus far. We hypothesized that a mallet test would be useful as a diagnostic aid as well as a screening tool.
70 patients (36 female, 34 male) were investigated in this blinded controlled study. Group 1 consisted of patients with painful BME in the knee and group 2 of patients with a painful knee without BME. Pain provoked by a reflex mallet was assessed for each quadrant on a visual analog scale (VAS).
The VAS score was 3.7 (±2.1 cm) for quadrants affected by BME (group 1), 1.59 (±1.44) in non-affected quadrants of the knee affected by BME (group 1) and, 0.85 (±0.85) in painful knees without BME (group 2). Pain on the tapping test was significantly correlated with the presence of BME in the affected knee (p< 0.0001) as well as the affected quadrant (p< 0.0001 for the medial femoral condyle and the medial femoral plateau).
The probable mode of action is that high intramedullary pressure in the BME affected bone (normal values are less than 30 mmHg) is additionally raised for a short period of time by the impact of the hammer on the bone surface, causing intense local pain. The test is economical, easy to perform in a doctor’s office, and not time-consuming but the final and evidentiary dignosis of BME can only be made by MRI.
The tapping test is a good screening instrument to diagnose BME in the knee.
The aim of this study was to investigate the molecular features of progressive severities of cartilage damage, within the phenotype of Anteromedial Osteoarthritis of the Knee (AMOA).
Ten medial tibial plateau specimens were collected from patients undergoing unicompartmental knee replacements. The cartilage within the area of macroscopic damage was divided into equal thirds: T1(most damaged), to T3 (least damaged). The area of macroscopically undamaged cartilage was taken as a 4th sample, N. The specimens were prepared for histological (Safranin-O and H& E staining) and immunohistochemical analysis (Type I and II Collagen). Immunoassays were undertaken for Collagens I and II and GAG content. Real time PCR compared gene expression between areas T and N.
There was a decrease in OARSI grade across the four areas, with progressively less fibrillation between areas T1, T2 and T3. Area N had an OARSI grade of 0 (normal).
The GAG immunoassay showed decreased levels with increasing severity of cartilage damage (ANOVA P< 0.0001). There was no significant difference in the Collagen II content or gene expression between areas. The Collagen I immunohistochemistry showed increased staining within chondrocyte territorial areas in the undamaged region (N) and immunoassays showed that the Collagen I content of this macroscopically and histologically normal cartilage, was significantly higher than the damaged areas (ANOVA P< 0.0001). Furthermore, real time PCR showed that there was a significant increase in Collagen I expression in the macroscopically normal areas (p=0.04).
In AMOA there are distinct areas, demonstrating progressive cartilage loss. We conclude that in this phenotype the Collagen I increase, in areas of macroscopically and histologically normal cartilage, may represent very early changes of the cartilage matrix within the osteoarthritic disease process. This may be able to be used as an assay of early disease and as a therapeutic target for disease modification or treatment.
Over the last 10 years ACI (Autologous Chondrocyte Implantation) has become an important surgical technique for treating large cartilage defects. The original method has been improved by using cell seeded scaffolds for implantation. The aim of our prospective study was to evaluate the efficiency of a matrix based ACI (MACI) with a collagen type I scaffold for repairing large cartilage defects of the knee. We present the clinical and radiological results of 22 pts. one year after collagen scaffold based ACI.
Out of 39 pts. treated with ACI for cartilage defects of the knee 22 had reached the one year follow up. We documented preoperatively and postoperatively (3, 6 and 12 months) the clinical situation with the IKDC Knee Examination Form. MRI scans were evaluated at all time points.
41% of the pts. were female, 59% male. The average age was 33 yrs. (min:15; max:49), the average BMI 25,4 (min:19; max:36). One third of the cartilage defects were localized retropatellar, the remaining on the medial or lateral femoral condyle. The average defect size was 5.7 cm2. In about 75% of the cases an additional surgical procedure was performed (ACL-reconstruction, lateral release, meniscal surgery). One major complication (a deep wound infection) occured. The IKDC score improved over time during follow up significantly. Patients with retropatellar defects have a poorer outcome compared to femoral defects. The MRI showed an improvement of the implanted scaffold over time as well.
The present study confirms the benefits of MACI in young patients with large cartilage defects of the knee. The matrix based ACI is a surgically less demanding technique then the traditional ACI. We expect a good long term outcome from MACI comparable to that of traditional ACI.
Animal experimental studies indicate that pulsed low-intensity ultrasound might enhance cartilage repair in early stages of osteoarthritis (OA) and to improve healing of osteochondral defects. The purpose of this in vitro study was to determine systematically whether and to what extent pulsed low-intensity ultrasound
influences the synthesis and release of PGs, modulates chondrocyte viability within human osteoarthritic cartilage explants, and is affected by the degree of OA alterations.
Full-thickness cartilage explants of the lateral compartment of the proximal tibia were taken from OA patients undergoing knee replacement surgery. Explants with mild or moderate OA alterations were cultured in a CO2-incubator at 37°C, 5% CO2 and 95% relative humidity. After 2 days, explants were subjected to ultrasound applied in a pulsed-wave form (1: 4) on the following 3 days. The ultrasound application apparatus was specifically designed and constructed to function within an explant culture system under sterile conditions. The effect of the ultrasound parameters intensity (2, 30, 120, 250 mW/cm2), duration (20, 3 × 30 minutes/day) and frequency (0.5, 1.2, 4.7 MHz) on PG synthesis and release were measured. PG synthesis was determined by the incorporation of 35SO4 during the final 22 h of the experiments whereas the content of PGs were quantitated with the DMMB-assay. The viability of chondrocytes was assessed microscopically using fluorescein diacetate and propidium iodide. Results were compared to untreated explants from the same joint. Each experimental condition was repeated five times using explants always obtained frrom 6 different patients (N=6).
Neither the degree of OA alterations of explants, nor the various ultrasound parameters tested displayed any significant effect on the synthesis and release of PGs as well as on the viability of explants.
This work was supported by the Deutsche Arthrose-Hilfe e.V.
Human cells: CD13+ (94–99%), CD44+ (87–99), CD49d (14–70%), CD90+ (92–99%), CD105+ (90–97%), CD 117-BD+ (2–22%). Sheep cells presented CD13+ (32–70%), CD34-, CD36, CD44+ (90–96%), CD49d (40–80%), CD54+ (50–80%), CD90+ (90–97%), CD105+ (10–25%). CD117-BD+ (48–76%). Rabbits cells: CD13+ (14–78%), CD44+ (10–80%), CD49d (2–9%), CD90+ (27–92%), CD105+ (2–24%), CD 117-BD+ (15–57%). Human cells number/mL did not show significant differences between patients, or between P0 0 (14 culture days) (average mean: 525000 ± 298956) and P5 (525000), nevertheless the average mean decreased from P5 to P6 (130.000) until P8 (111 culture days) (85.000). Rabbits cells number/mL did not show significant differences between P0 (673000 ± 379697) and P1 (596000 ± 488740) and decreased in P2 (299500 ± 159161) without any significant change in P8. Ovine cells number/mL average mean in P0 was 1.370.600 (± 802758), this decreased in P1 (420000 ± 95197) however, showed no significant changes in P8 (291875 ± 86394).
Recent epidemiological studies have demonstrated that more than half of postmenopausal women with osteoporosis (PWOP) treated with an antiresorptive drug plus calcium (Ca) and vitamin D, have serum levels of 25(OH)D3< 30ng/ml. Chronic low levels of vitamin D can contribute to the inefficiency of main antiresorptive treatment. A possible explanation for this phenomenon is the non-compliance with the daily supplementation of Ca and vitamin D. A fixed combination of Alendronate Once Weekly (OW) 70mg plus 2800 UI of cholecalciferol (AL+D) made its appearance in the market two years ago as a solution to this problem.
The current study was designed to assess the efficacy of AL+D versus the old scheme of Alendronate 70 OW plus daily Ca 500mg + 400 UI of vitamin D (AL+S) on serum levels of 25(OH)D3. 100 randomly assigned PWOP treated already for 1 to 5 years with AL+S have changed their treatment to AL+D for one year. Serum levels of 25(OH)D3 (Biomedica.co.at/vitamind) has been measured before and after 12 months and also their BMD (Hologic Delphi), PTH, TSH, serum chemistry and hematology has been recorded for safety reasons. At the end of the study only 83 PWOP (MA=59,9±6,6 yrs) appeared for comparison.
Our results are as follow:
The mean plasma level of 25(OH)D3 under AL+S treatment and before taking AL+D is 24,3±8,4 ng/mL and The plasma levels of 25(OH)D3 after 12 months of treatment with AL+D are 33,3±9 ng/mL. The paired t-test has been used to compare the levels of 25(OH)D3 between treatment groups. There is a highly important statistical difference (t=−8.989, df=82, p<
0,0001) between treatment groups.
From the above data it can be concluded that fixed combination of AL+D can improve the 25(OH)D3 status over 12 months versus AL+S probably because it assures a better compliance of vitamin D.
Osteoporosis is one of the most common diseases in modern aging society. Receptor activator of nuclear factor-κB ligand (RANKL) plus macrophage colony stimulating factor (M-CSF)-mediated osteoclastogenesis has been recently implicated in the pathogenesis of this disease. Among other causes, the anticoagulant drug heparin is a notable inducer of secondary osteoporosis, although the molecular pathway underlying this process, particularly in human model, has not been clarified yet. Recently, we reported the differentiation of two subtypes of osteoclasts starting from human peripheral blood CD14-positive monocytes (Monocytes), respectively fusion regulatory protein-1 (FRP-1/CD98)-mediated osteoclasts and RANKL+M-CSF-mediated osteoclasts. We, therefore, investigated in details effects of heparin on differentiation and activation using a simple system of human osteoclastogenesis.
When Monocytes were cultured with osteoclastogenesis-relating factors and a high dose of heparin, heparin suppressed osteoclastogenesis in both pathways. However, a proper quantity of heparin enhanced tartrate-resistant acid phosphatase-positive multinucleated giant cell formation. There were significant differences in fusion indices between control osteoclasts and osteoclasts stimulated by moderate concentrations of heparin in two systems (P< 0.05). As a result of osteoclastic activity, FRP-1-mediated osteoclasts treated with a proper quantity of heparin formed larger pits on Ca plates. Moreover, lacunae on dentin surfaces induced by FRP-1-mediated osteoclasts were enhanced with moderate concentration of heparin. In contrast, heparin did not increase pit-formation area on Ca plates and on dentin surfaces by RANKL+M-CSF-mediated osteoclasts. Evaluating the relation between the concentration of heparin and the osteolytic areas on Ca plates, Pearson’s correlation coefficient of the FRP-1 and the RANKL+M-CSF were −0.973 (P< 0.05) and −0.695 (P=0.19), respectively.
In present study, although moderate doses of heparin stimulated differentiation in both systems, in osteoclastic activity, heparin promoted only to the FRP-1 system, not to RANKL+M-CSF system. Our results suggested FRP-1-induced osteoclastogenesis mainly contributes to development of heparin osteoporosis and also that the onset mechanism after long-term administration of heparin may be affected by the characteristic bone resorption ability of FRP-1osteoclasts.
Extensor tondon lacerations are much more common than flexor tendon injuries. The outcome of this lesions depends on mamy factors including severity of initial trauma, coexisting lesions, of the hand, site of the laceration, experience of the surgeon, and post operative rehabilitation. The aim of this prospective study was to review our results of primary extensor tendon repair with regard to the zone of injury.
During a period of 28 months, 32 patients with open extensor tendon laccerations were repaired by modified kessler technique using 4-0 nonabsorbable suture. After tendon repair, immobilization with a volar splint was applied for 4-weeks and physiotherapy was carried out. Patients were followed–up for a mean of 12 months. we used the 5 extensor tendon zones and results were assesed using Miller’s rating system. Patents with closed tendon ruptures or concomitant hand fracture were excluded from the study.
Seventy two extensor tendons were repaired. The mean age of patients was 24.6 years (17–46 y). Excellent and good resalts were obtained as the follows: in zone 5(88/4%), zone 3 (84%), zone 2(55.5%), zone 4(42.7%), zone 1(40%). Results were poor in zone 4(42.8%), zone 1(40%), zone 2(22.2%), zone 3(4%), and zone 5(3.9%). No in fection was seen.
We found a strong correlation between the site of the repair and outcome. More excellent and good results were obtained when the repair was performed distal to the extensor retinaculum (Zone 3), and above the wrist (Zone 5). Unsatisfactory results were seen when the tendon repair was done at or near DIP joint (zone 1), in the region of complex extensor mechanism (zone 2) or beneth the extensor retinaculum (zone 4). We cocluded the anatomic location of tendon repair has an important effect in outcome.
The most frequent pathogenic organism in arthroplasty infections is Staphylococcus. The immune response impairment is a frequent finding in elderly people. Objective: to investigate the response of some cytokines and the effect of age in an experimental model of osteomyelitis.
In view of possible clinical applications of mesenchymal stromal cells (MSCs), interesting results in repairing the Achilles tendon have been achieved in rabbit models since 1997. Histological and immunochemical studies have demonstrated the quality of repair. A basic problem in tissue repair is the way to administer stem cells. Several questions remain:
have the cells to be differentiated or not? Could cells be administered without using scaffolds?
Attempting to cure, as a clinical model, horses with a pathological core lesion in the superficial digital flexor tendon (SDFT), MSCs were recovered from autologous bone marrow, expanded ex vivo, suspended in autologous serum and re-injected directly into the core lesion.
All 11 horses implanted with autologous MSCs exhibited no adverse reaction due to the implantation of the cells, either locally or systemically. After rehabilitation therapy nine MSC-treated animals recovered from their clinical conditions, had an excellent ultrasound image of tendons after a period ranging from 3 to 6 months, and returned to racing with good or even optimal results in the previous category of competition in 9 to 12 months without any re-injuring event. All of them are still active more than 2 years from diagnosis. One of the 2 remaining horses received less than 1×106 of MSCs, and its tendon did not heal relapsing after rehabilitation, the other was lost to follow-up. In contrast, most of horses from the control group showed tendon ultrasound images that revealed fibrosis during the healing process, and all of them were re-injured after a median time of 7 months.
The ability of tissue microenvironments to induce cell differentiation could render unnecessary a partial or total ex vivo differentiation and direct infusion of undifferentiated MSCs could represent a safe therapeutic approach to tendon repair.
The problem of prophylaxis and treatment of infected complications after total joint replacement is relevant today, especially in case of revision procedures. The important factor in successful preventive maintenance and treatment of purulent complications is reduction of so-called «dead space» of the operated joint. Aim of this study is to analyze the Taurolin-Gel 4% application for “dead” space filling in patients with high risk of wound infections after total hip replacement.
Follow-up results of 178 operations with Taurolin-Gel 4% application have been studied. Patients were observed from 2 to 12 years (average 6 years). All patients were divided on 4 groups. First group consisted of 46 patients with early postoperative infected complications; second group (38 patients) was with first step of two-step revision in chronic infection. Third group included 35 patients on second stage of two-stage revision and fourth group consisted of 59 patients with medical history of infected problems in affected joint. In all four groups the infection recurrences after Taurolin implantation were noted in 6 patients (3,4 %).
Taurolin-Gel 4%, inserted into joint cavity, is not only a good local antibacterial agent, but it also fills up “dead” spaces in the affected joint and displaces haematoma. Deleting a haematoma, which is the favourable environment for bacterial functioning, risk of infections complication in the postoperative period reduces. Besides, Taurolin-Gel decreases postoperative blood loss for approximately 30 %, causing mechanical haemostasis. In difference from filling of a joint cavity with the moved muscular tissue, Taurolin Gel 4 % using are much easier technically, reduces time of revision intervention and traumatic of operation.
Animal models have shown that artificially induced temporomandibular joint (TMJ) disc displacement or perforation affect histology and biochemistry of joint cartilage, leading to osteoarthritic changes. However, it is still unclear whether TMJ disc cartilage fails simply due to wear or is degraded by a biological response to mechanical loading.
In order to gain insight into TMJ cartilage mechanobiology, a system reproducing the dynamic TMJ compression effects on live tissues was developed. Bovine nasal septum (BNS) cartilage was chosen as a convenient tissue model. However, little information is available in the literature on its material properties. Aim of this study was to determine BNS material properties using a viscoelastic model and verify its suitability as model for TMJ disc cartilage.
Cartilage samples were harvested from the central part of BNSs of young, healthy animals. Stress-relaxation tests in unconfined compression were performed on cylindrical plugs samples, obtained by means of biopsy punches. A 10% strain (strain rate 0.01 mm/s) was applied and held for 30 minutes.
Stress was estimated from the compressive force data and the initial cross-sectional area. Experimental data were fit to a mathematical model in MATLAB. Experimental results show a highly viscoelastic behavior of the BNS, with a maximum average stress of 0.73 ± 0.14 MPa and relaxed stress of 0.21 ± 0.03 MPa. The numerical model shows good correspondence to the experimental data (R2=0.96). The average values for the instantaneous and relaxed elastic moduli are E0= 7.72 MPa and ER= 2.30 MPa, in the same order of magnitude as the TMJ disc.
We conclude that bovine nasal septum can be modeled as viscoelastic tissue and can be used as a first approximation to study mechanobiology of the TMJ disc.
Bone marrow edema (BME) is a rare cause of pain in the foot.
We reviewed 19 patients with unilateral bone marrow edema of ischemic, stress or osteoarthritic origin located in the hindfoot treated with the vasoactive prostacyclin analogue iloprost. The patients’ mean age was 61,5 years (25–76) and the duration of symptoms lasted 19 weeks before the therapy started. Bone marrow edema was located 9x in the talus, 3x in the calcaneus, 3x in the navicular bone and 2x in the cuboid. 11 cases were estimated to have a primary ischemic origin, the other 8 ones to be secondary to an activated osteoarthritis or to mechanic stress. Our therapy consisted of a series of five infusions with 20 μg (50 μg in the first six patients) of iloprost given over 6 hours on 5 consecutive days each. Mazur’s foot score was used to assess function before and 3 months after therapy.
During this time, the score improved from a mean of 54,9 (range 23–73) before to 87,8 points (47–100) 3 months after therapy, with the best results in ischemic lesions with an improvement from 56,2 to 93,9 points and inferior results in patients with osteoarthritic edema as well as edema due to stress with a change in the score from 53 to 79,3 points. Magnetic resonance imaging showed complete recovery of the bone marrow edema within 3 months in 12 patients, 3x partial regression and no change in 4 cases with bone marrow edema due to activated osteoarthritis.
We conclude that the parenteral application of the vasoactive drug iloprost might be a viable method in the treatment of bone marrow edema of different origins but especially in ischemic ones. In edema secondary to osteoarthrosis or stress, therapy effect with iloprost is of a symptomatic character depending on the grade of the basic disease.
For surgical treatment of hallux rigidus many different procedures have been described. Resection arthroplasty (‘Keller procedure’) is a surgical procedure mostly used for older patients suffering from severe osteoarthritis of the first metatarsophalangeal joint. As a modification of this procedure, resection arthroplasty is combined with cheilectomy and interposition of the dorsal capsule and extensor hallucis brevis tendon, which are then sutured to the flexor hallucis brevis tendon on the plantar side of the joint (capsular interposition arthroplasty, IA).
Capsular interposition arthroplasty was performed on 22 feet of 14 patients (six male, eight female) suffering from osteoarthritis of the 1st MTP-joint were included in this study (group 1). These results were compared to the outcome of 30 feet of 22 patients (12 male, 10 female) treated with resection arthroplasty (group 2). The indication for resection arthroplasty were the same as for IA. The mean age was 55.3 years (37.6 to 71.2) in group 1 and 57.8 (43.5 to 75.6) in group 2. The age distribution of our patients at surgery did not differ significantly between both groups (p=0.633). The mean follow-up period was 15.1 month, range 6 to 27 months and did not differ between both groups (group 1: 16.5 month, group 2: 14.1 month; p=0.143).
The mean follow-up period was 15 months. No statistically significant difference was found between both groups concerning patient’s satisfaction, clinical outcome and increase in range of motion of the first metatarsophalangeal joint. At follow-up, patients who had undergone interposition arthroplasty did not show statistically significant better AOFAS forefoot-scores compared to the Keller procedure group. A high rate of osteonecrosis of the first metatarsal head was found in both groups. These radiological findings did not correlate with the clinical outcome at follow-up.
There is no benefit in clinical or radiological outcome for capsular interposition arthroplasty compared to the Keller procedure.
Pain free function of the thumb carpometacarpal (CMC) joint is essential for manual work. Osteoarthrithis of the thumb saddle joint is very common. Among different conservative and operative treatment options (ergotherapy, intraarticular infiltration, ligament reconstruction, resectionarthroplasty, arthrodesis, spacer), the implantation of a prosthesis is an alternative. This prospective study reports short time results of the uncemented hydroxilapatite coated Ivory prosthesis. The mean follow up time of the 21 patients was 12.1 months (range 6 to 18 months) and the mean age 57.2 years. The patients suffered from osteoarthritis of the thumb saddle joint stage II–III according to Eaton Littler. We evaluated the Disabilities of the Arm, Shoulder and Hand Score (DASH), pain with the visual analogue scale (VAS), clinical (abduction, flexion, strength) and radiological outcome.
The clinical results showed excellent pain relief with an improvement of the VAS from 7.3 preoperative to 0.8 postoperative (p< 0.05) and a decline of the DASH score from 42.9 to 6.05 points (p< 0.5). We measured an abduction with a mean of 47.5° and a flexion with a mean of 43.2°. The power of the fist grip was in mean 31.3 kg, of the key grip 6.4 kg. Radiological there were no signs of implant loosening. As complications occurred one posttraumatic trapezium fracture with luxation and one tendovaginits De Quervain.
The advantage of a total replacement of the CMC I joint, compared to the standard resection arthroplasty, is faster rehabilitation and preservation of the length of the thumb and so better strength. Our results are encouraging, but we have to wait for long time results mainly concerning implant loosening. In the case of the trapezium fracture with luxation we could remove the prosthesis and performed a resectionarthroplasty.
An unstable CMC I joint causes pain and dysfunction. Chronic subluxation can lead to cartilage damage and furthermore to rhizarthrosis. This study should evaluate the results of the Eaton Littler ligament reconstruction, in which a slip of the Flexor carpi radialis tendon (FCR) weaved through the basis of the first metacarpal and around the tendon of the Abductor pollicis longus and back to the FCR. Aftertreatment consists in 4 weeks cast, 4 weeks thermoplastic splint and physiotherapy, full opposition is allowed after 8 weeks.
We performed 10 operations in 8 patients with a mean age of 35.9 years (6 female, 2 male). In 8 times the diagnosis was a rhizarthrosis Eaton Littler stadium I and in 2 times a posttraumatic instability. The mean follow up time was 15.4 months. We evaluated subjective satisfaction with the Disabilities of the Arm, Shoulder and Hand Score (DASH), pain with the visual analogue scale (VAS) and the patients were asked, if they would undergo the operation again. Furthermore the range of motion (ROM) was examined, the strengths (key and pin grip) were measured and radiographs were made.
All patients would undergo the operation again. The mean DASH score was 17.4 points, the mean VAS in rest 0 and under stress 1.29. The mean pin grip strength was 3.98 kg and the mean key grip strength 7.14kg. The ROM was excellent with a mean anteposition of 39.5°, a mean abduction of 49.3°. The mean thumb opposition was Kapandji 9.9. Radiological there was no progression of the Eaton Littler stadium. As complications occurred 1 keloid and 1 hypaesthesia.
Our experiences with the Eaton Littler procedure for stabilisation of the hypermobile thumb saddle joint were positive. Long time results will show, if the procedure can prevent cartilage damage and progression of rhizarthrosis.
Despite developing refinements of chemotherapy regimens for osteosarcoma, multi-drug resistant cases are frequently seen and patients with metastatic or recurrent disease continue to have a very poor prognosis. Recently, the expression of the longevity gene Sirt1 was found to be relatively higher expressed in tumors compared with the normal tissues. Association of high level of Sirt1 expression with the development of multi-drug resistance in tumor cells has also been indicated. Thus, it is interesting to study the therapeutic potential of regulating Sirt1 activity for the treatment of osteosarcoma.
In the present study, we evaluated the effects of two Sirt1 activators, resveratrol and isonicotinamide, on growth and apoptosis in four human osteosarcoma cell lines, HOS, Saos-2, U-2 OS and MG-63. We found that Sirt1 protein was expressed in all osteosarcoma cell lines. Instead of promoting cell survival, both resveratrol and isonicotinamide decreased cell growth and induced cell apoptosis in a dose-dependent fashion. Furthermore, the pro-apoptotic effect of resveratrol could be enhanced by L-asparaginase-induced nutrition restriction of cultured osteosarcoma cells.
Our results demonstrated that Sirt1 activators elicited pro-apoptotic effects in osteosarcomas. Thus, Sirt1 could be a potential target in the treatment of osteosarcoma. However, due to the non-specificity of the Sirt1 activators used further studies, such as knock-down of Sirt1 by siRNA, are needed to confirm the effect of Sirt1 activation on malignant cells.
Birmingham Hip resurfacings have been a popular mode of treatment for younger and more active patients with arthritis of the hip. However the use of hybrid hip arthroplasty system with a Birmingham hip resurfacing cup and modular head with a variety of cemented/uncemented stems is less well described in the literature.
We analysed radiographic and clinical outcomes of 99 consecutive hybrid hip arthroplasties performed by a single surgeon between 2000 and 2006.
A total of 93 patients (52 females and 41 males) with an average age of 69.9 (47 to 88) and average BMI of 28.8 (18.7 to 140.9) had arthroplasties with a mean follow up of 4.1 Yrs (1 to 6.3 years). 57 right and 42 left hip arthroplasties were performed of which 6 patients had bilateral consecutive hybrid hip arthroplasties.
93 were performed for osteoarthritis, 4 for RA, 5 patients for revision of failed hip resurfacing arthroplasties with #NOF and 1 revision for failed THR.
No patients had dislocations and one patient had revision of a resurfacing cup secondary to hip pain due to excessive cup anteversion, no loosening of components were identified at the most recent follow-up and all patients were mobilising well with no complaints of pain.
Hip Resurfacing procedures are gaining popularity in the younger individuals with arthrosis of the hip. Some patients who are fairly independent and active fall short of satisfying the criteria for a hip resurfacing and we preferred the option of the Birmingham hip resurfacing cup with a large modular head and a compliment of stems. This metal-on-metal option with large heads would ideally increase stability and reduce wear patterns with the prospect of increasing longevity of total hip arthroplasties.
In several countries fine needle aspiration (FNA) biopsy of soft tissue tumours is regarded as a standard procedure. However, various problems using FNA compared to core needle biopsy have been reported. Less cell amount, blood and other non tumour tissue aspirated and cells torn out of their environment lead to problems in histological diagnose. The aim of this study was to measure the number of cells harvested by two new needle systems (THYROSAMPLER®) in comparison with the conventional fine needle system (C-FNA). The innovation of the new system is aeration after aspiration by a valve, so that undesired aspiration of blood, debris, and cells from outside the tumour during withdrawal of the needle is minimized.
In a blinded setting, 45 punctures from fresh pig thyroid glands were made and analysed – 15 for each needle (C-FNA, single-needle with air valve T-ONE and multi needle system with air valve T-THREE). The aspirated cell material was evacuated into 10ml cell-culture liquid and calculated according to the manufacturer’s recommendations for the CASY cell counter (CASY® technology, Reutlingen).
With each system, 15 punctures each were aspirated and the cells counted. With the T-ONE System the amount of vital cells was 688%, the amount of total cells 521% higher then using the C-FNA system. With the T-THREE System the amount of vital cells was 901%, the amount of total cells 798% higher then using the C-FNA system.
The mean difference between C-FNA and T-ONE was significant regarding total number of cells (p=0.030) as well as number of vital cells (p=0.032).
The needle systems with the air-valve led to a significantly higher cell amount in needle aspiration biopsy. According to the requirement of cytological diagnosis of soft tissue sarcomas more cell volume could be harvested, which is a well-defined benefit.
New concepts in plate fixation have led to an evolution in plate design for olecranon fractures. The purpose of this study was
to compare the stiffness and strength of a contoured Locking Compression Plate (LCP) with a conventional plating method (one-third tubular plate) in a cadaveric comminuted olecranon fracture model with standardized osteotomy, and to evaluate the LCP fixation method in a prospectively included group of patients with complex olecranon fractures using validated outcome scores.
In the biomechanical study, five matched pairs of cadaveric elbows were randomly assigned for fixation by either LCP or a conventional plating method. Specimens were mounted to a custom-made testing bench and subjected to cyclic loading until failure occurred while measuring gapping at the osteotomy site. In the clinical study, twenty-one patients treated with LCP for complex olecranon fractures had a mean follow up of 20 months (3–39 months) and functional and patient rated outcome were evaluated.
In the biomechanical study, there was no significant difference in fixation stiffness and strength between one third tubular plating and LCP (p > 0.05). In the clinical study, the mean time to union of the fracture was 6 months (2–28 months). According to the Mayo Elbow Performance Index (MEPI) most patients had a good or excellent outcome. No patients reported difficulty with activities of daily living. Physical capacity showed minimal loss of stability and strength. Six patients had their hardware removed.
Technical ease of application and advantageous features of the LCP -such as unicortical screw fixation and improved holding power in osteopenic bone- make it a good alternative implant for comminuted olecranon fractures.
Although IL-6 mRNA expression in rat is restricted to the first day post-fracture, the inflammatory phase, the protein has been observed later in the healing process, indicating additional roles. The importance of IL-6 was demonstrated by delayed healing in knockout mice through diminished osteoclast numbers, formation thereof being stimulated by IL-6. The aim of our study was to investigate with which cells this cytokine is associated and when during fracture healing.
A closed fracture of the lower right limb was created in rats. The tibia was obtained from six animals at each of 1, 3, 7, 14 and 28 days post-fracture, decalcified and prepared for standard immunohistochemistry with an IL-6-specific polyclonal antibody. The number and types of cells positively stained for IL-6 along the whole length of the periosteal callus on one surface and in the fracture was evaluated.
Mostly inflammatory cells were initially stained, becoming virtually absent by day 7 when this phase has normally ended. Within the immediate vicinity of the fracture where endochondrial ossification occurred, staining of chondrocytes was significant (69%) by day 7 when this cell was laying down cartilaginous tissue that was also calcified. Distally to the fracture where direct bone formation occurred through intra-membranous ossification by osteoblasts, staining of these cells was observed, peaking at day 14 (56%). As this bone started to take on the appearance of cortex and surviving embedded osteoblasts differentiated to osteocytes, the latter cells were stained, suggesting a role in remodelling. At the fracture as bone replaced the cartilaginous tissue and union occurred, staining of chondrocytes decreased, whereas local osteoblasts were positive.
IL-6 appears to play a role throughout fracture healing, in endochondrial and intra-membranous ossification. The level of staining of each cell type reflected the degree of their activity with respect to production of related tissue.
Pain relief in hip arthroplasty plays an important role in the intra/post operative stages in order to achieve an almost pain free post operative recovery period to mobilise the patient as early and safely as possible and avoid undesirable post surgical complications.
A consecutive series of 99 total hip arthroplasties in 93 patients performed by a single surgeon between December 1996 and January 2006 were assessed for signs of clinical or radiological loosening.
Intra-operative local anaesthetic mixture (Ropivacaine-Ketorolac (30mg) -Adrenaline or RKA mixture) was infiltrated into the joint capsule and surrounding tissue around the acetabular component, and into the different muscle layers in the thigh around the femoral component. A total of 150–200 mls of this mixture was injected and a further 50 mls (with 30mg ketorolac) injected through a catheter left in-situ before discharge 12 to 24 hours later. Radiographic analysis was carried out using the Hodgkinson criteria to predict acetabular component loosening and the Gruen method to determine femoral component loosening.
Of the 99 hybrid hips, 57 were right and 42 were left hip arthroplasties and 6 patients had bilateral consecutive hips done. 5 were performed for revision of fractured necks of femur in Birmingham hip resurfacings and one total hip arthroplasty revised to a hybrid and the remaining 92 were primary hybrid hip arthroplasties. The arthroplasties were performed for Osteoarthritis (89), Rheumatoid arthritis (4), and others (6). At mean follow up of 4.2 years, no aseptic loosening was noted radiologically or clinically, no components have been revised for failure or loosening and no components have dislocated.
The use of high dose local infiltration NSAIDs in the intraoperative and early post operative phase does not seem to affect prosthetic fixation at-least during short to mid term follow up of total hip joint arthroplasties.
Osteoporosis can be caused by many miscellaneous factors. These factors include medical, lifestyle and socioeconomic variables, the latest being not well studied and defined in international bibliography. From these there are the factors regarding the working environment (house or office) and the living environment (urban or countryside). Our hypothesis is based on the fact that women living in an urban environment or working in an office environment should have lower Bone Mineral Density (BMD) and thus, greater fracture possibility because of their lower level of physical activity, greater alcohol/coffee consumption and increased smoking frequency compared to women living in the countryside or women housekeeping.
In order to find whether this hypothesis is true, a population based observational retrospective study has been performed. The fracture rate of 4616 post-menopausal osteoporotic women (PMOW) (mean age=64,1±9,3 years) from 160 centers all over Greece has been compared with the two aforementioned possible risk factors. Descriptive statistics like the mean±SD and frequencies were used to present the data. In order to assess for relationships between categorical variables the chi-square (χ2) test was performed. Statistical analysis was conducted using the software SAS, version 9.1 and statistical significance was established as 5%.
The results are as follow:
16,2% of these PMOW had a history of fracture and for 80,3% of them was a hip fracture. 84,1% of PMOW lived in urban environment and had lower fracture rate than women living in the countryside (p<
0,05). 47,2% of the PMOW worked at home and had lower fracture rate than women working for more than 20 years in an office environment (p<
0,0001).
It can be concluded that more fracture-susceptible PMOW are those working in an office environment and also living in the countryside. It can be assumed that the first is related with lower BMD and the second with the more ‘fall-prone’ nature of the country environment.
Previous studies suggested the lack of capture wall of acetabular Ultra High Molecular Weight Polyethylene (UHMWPE) liner can significantly increase the risk of hip joint dislocation. To date, the dislocation studies have been focused on the femoral neck impingement models. The purpose of this study was to identify a new Dislocating Force (DF) generated by rim directed joint force alone and investigate the factors to affect the magnitudes of the DF. The 3 D Finite Element Analysis (FEA) models were constructed by (30) 10 mm thick UHMWPE liners with six inner bearing diameters ranging from 22 mm to 44 mm and five capture wall heights in each bearing size from 0 mm to 2 mm. A load of 2 446 N was applied through the corresponding CoCr femoral head to the rim of the liner. The DF was recorded as a function of capture wall height and head diameter. The results were verified by the physical tests of two 28 mm head bearing liners with 0 and 1.5 mm capture wall heights respectively.
The results showed that the highest DF was 1 269N in 0 mm capture wall and 22 mm head. The lowest DF was 171 N in 2 mm capture wall and 44 mm head. The DF decreased as the capture wall and head size increased. When capture wall increased from 0 mm to 1 mm, the DF was reduced more than 50%. Two experimental data points were consistent with the trend of DF curve found in the FEA.
We concluded that the new intrinsic dislocating force DF can be induced by the rim directed joint loading force alone and can reach as high as 51% of the femoral loading force. A capture wall height above 1mm can effectively reduce DF to less than 25% of the joint force. In addition, the larger head diameter also resulted in less DF generation.
Demand for ceramic bearings is increasing rapidly because of excellent clinical results. Alumina offers advantages such as chemical resistance, excellent bio-inertness and tribology. However, alumina has limited strength, therefore the applications are restricted to certain designs. Zirconia materials have been used clinically for ten years, they reveal problems due to poor hydrothermal stability. Thus, there is a strong need for new bearing material that combine strength and stability.
The new ceramic named Alumina Matrix Composite (AMC) uses the following principle of transformation toughening: Firstly, the dispersing of small particles of Y-TZP Zirconia in the alumina matrix and secondly the reinforcement by introduction of an anisotropic crystal like whiskers. This process dissipates the crack energy that is associated with an increase of strength. The examination of the tribological situation of AMC, especially under challenging conditions of hydrothermal ageing and under severe micro separation, shows the aptitude of this material in wear applications.
Alumina Matrix Composite offers a better mechanical resistance than alumina while maintaining the structural stability and equivalent tribological qualities. This is a material that has been very thoroughly evaluated and tested as a permanent implant material for the last 9 years. The results of this evaluation and testing process have been included in the manufacturer’s Master File at the Food and Drug Administration and approved.
The substantial improvement in mechanical properties and the excellent wear behaviour, even under severe microseparation conditions, make this material a promising new addition to the orthopaedic surgical community and a possible solution to the longevity problems seen with many total joint systems in young and active patients. No complications have been reported yet at six-year follow-up, with more than 310,000 components (heads and inserts) implanted. Additionally, due to the enhanced mechanical behaviour, new applications in orthopaedics are possible.
Success of a total hip replacement is commonly assessed by the Haris Hip Score (HHS), which provides information on pain reduction and regained mobility. Radiographic images provide information relative to the stability of the prosthesis.
We use the intraoperatively manufactured prosthesis since 1989; the initially performed THR were done with uncoated prostheses. After introduction of the hydroxyapatite coating our prosthesis stems were coated.
We retrospectively evaluated the clinical and radiographic outcome of 3 patient cohorts who received intra-operatively custom made stem prosthesis.
Group 1: Uncoated stem prosthesis fixated with tro-chanteric osteotomy. Group 2: Uncoated stem cementless implant Group 3: Cementless hydroxyapatite coated stem prosthesis
Clinical assessment and radiographic assessment is performed using pre-operatively and at each follow-up visit.
Baseline data are the pre-operative HHS and first radiography postoperatively. These data are compared with the data of the latest follow-up visit.
RX’s are scored according to the ARA score.
Records were analysed for 83 patients in group 1, with a mean follow-up period of 93 months. In group 2, 35 patients were followed for 105 months and 54 patients from group 3 were followed for 41 months.
In the 3 groups the HHS at follow-up was > 75, this means an improvement of minimum 25 points for group 1 and 2 (baseline HHS for group 2 was not available)
The mean ARA scores at follow-up were 1.6; 1.7 and 5.3 for respectively group 1; 2 and 3.
Clinical outcome is comparable in the three studied cohorts.
The ARA score is indicating poor outcome for the uncoated prosthesis, regardless of the type of fixation, while the coated prosthesis group has a good to excellent ARA score.
These findings tend to confirm the superiority of the hydroxyapatite coated prosthesis.
The results showed that in all rim supported conditions, the maximum principal stress were in compressive patterns, a preferred pattern to reduce the potential polyethylene liner fracture. In rim unsupported conditions, the stresses was in tensile on the internal bearing surface when polyethylene liner thickness was bellow 5 mm, or was bellow 9 mm if the average maximum principal stress cross the rim was considered.
We conclude that the metal rim support changes the stress pattern in the rim region of UHMWPE liner to compressive for all liner thicknesses. The stress pattern turns to tensile, or there will be a higher potential for rim fracture, if UHMWPE liner is unsupported and the polyethylene rim thickness is less than 9 mm.
Although components used this study did not include the locking details which add higher stress concentrations, the trend of stress patterns should follow the results found in this study.
Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a very rarely seen disease with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Although isolated BMES is generally considered to be a self-limiting disease, progression to irreversible avascular necrosis of the femoral head has occasionally been observed. The conservative standard treatment of BMES consists of analgesic or anti-inflammatory medication combined with reduced weight bearing and physiotherapy. Better results regarding pain reduction are achieved by surgical intervention, with core decompression being the current standard technique for the management of BMES.
The patients were aged between 31 and 43 years (mean 37.5 years). All patients presented with pain on effort, with gait disturbance and pain at rest starting in the third trimester of pregnancy at a mean gestational age of 28 weeks (25 to 32 weeks). Symptoms rapidly progressed over a 2-week period. We treated 4 postpartal women (6 hips) presenting femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. MRI was used to investigate the outcome of BMES.
Symptoms regressed rapidly during and after therapy. After 4 weeks all patients were asymptomatic with no limitations in ambulation. In the MRI assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck of one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (14–43 months).
The vasoactive drug iloprost has good analgesic potency in the treatment of postpartal women suffering from BMES and accelerates the natural course of the disease.
Femoral head roughening is a clinically observed phenomenon that is suspected to cause increased wear of acetabular inserts. Two approaches have been taken to reduce hip bearing wear. Improved femoral head materials may decrease the impact of roughening and reduce the effect of abrasion. Additionally, improved polyethylene materials may be utilized to reduce wear against smooth or roughened femoral heads. This study looks at these two approaches in the form of a toughened alumina femoral head (Biolox Delta) and a sequentially crosslinked and annealed polyethylene (X3). A wear study was performed with new and artificially scratched ceramic femoral heads (28mm Biolox Delta) as compared to new and artificially scratched Cobalt Chromium femoral heads. These femoral heads were articulated against both conventional (N2\Vac) and highly crosslinked (X3) polyethylene acetabular cups. Artificial scratching utilized a Rockwell C indentor loaded at 30N to scratch a multidirectional scratch pattern on the articulating surface of the femoral head to simulate in vivo roughening.
Delta femoral heads exhibited superior resistance to scratching. Peak to valley roughness for CoCr heads was 7.1um while Delta heads only roughened to 0.4um. Head material under standard conditions (no scratch) had no effect on PE wear (p=0.31 and p=0.53). Under abrasive conditions, the Delta femoral head exhibited a clear advantage over CoCr heads (65–97% reduction in wear rate; p< 0.007). X3 polyethylene also showed a clear advantage over conventional PE against either CoCr or Delta heads and under both conditions (all p < 0.012).
This study clearly demonstrates that X3 polyethylene has a clear wear advantage over conventional polyethylene despite head material or abrasive conditions. Secondary to the polyethylene choice, the use of a ceramic femoral head leads to superior performance under abrasive conditions.
We report the follow-up of a cohort of 86 patients who underwent total hip replacement (THR) with custom-made stem prosthesis. Fixation mode, cemented (group 1) or uncemented (group 2) is based on the bone quality. Aspects of physical health and changes in mental health are documented using 3 patient-administered questionnaires, pre-operatively and 6 weeks, 3, 6 and 12 months post-operatively.
Harris Hip Score (HHS), Hip disability and osteoarthritis outcome score (HOOS) and SF-36, multi-purpose, short-form health survey were used.
Globally HHS increases significantly (p< 0.01). In group 1 up to 3 months post-operatively and in group 2 up to 1 year. (p < 0.05). In group 2 HHS is significantly higher 6 months and 1 year postoperatively (p< 0.05). No significant differences in HOOS subscores between subjects of group 1 and 2 for subsequent time points were found. The scores related to Pain and Symptoms increased significantly 6 weeks after THR (p< 0.01). Sports and recreation scores increased significantly up to 3 months after THR (p< 0.01). Activities of daily living, and Quality of Life (QoL) improved up to 6 months after surgery (p< 0.01).
No significant difference between the 2 groups in QoL was observed. The physical component summary increased up to 3 months after surgery (p< 0.01). The mental component summary did not change significantly after THR.
The difference noted in HHS between group 1 and 2 may be due to the selection of the fixation technique which is often directly related to the patient’s age. The results of the HOOS score confirm the findings of the HHS. Not all patients responded to the questions relative to recreation and sport of the HOOS score. QoL is an important indicator for success as perceived by the patient. In this study a rapid improvement of QoL is observed (3 months) and there is little change at 6 and 12 months.
In total hip replacement (THR), the initial fixation of the femoral stem has a critical influence on its long term stability. Objective intra-operative assessment of primary stability is a challenge, surgeons having to rely mainly on their clinical experience. Excessive press-fitting of the stem can cause intra-operative fractures in up to 30% of revision cases. In a previous study we demonstrated the feasibility and validity of a vibrational technique for the assessment of the femur-stem fixation in vitro.
In this in vivo study the vibration analysis was applied for the per-operative assessment of stem fixation in 30 THR patients who obtained an intra-operatively manufactured, hydroxyapatite coated, cementless prosthesis.
The surgeon inserted the stem through repetitive controlled hammer blows. After each blow, the frequency response function (FRF) of the stem-bone structure was measured directly on the prosthesis neck in the range 0–10 kHz. The hammering was stopped when the FRF graph did not change anymore. Extra blows would not improve the stability but would increase the fracture risk.
In 26 out of 30 cases (86.7%), the correlation coefficient between the last two FRFs was above 0.99 when the insertion was stopped. In four cases, when the surgeon decided to stop the insertion because of suspected bone fragility, the final correlation coefficient attained lower values.
During the insertion of a cementless prosthesis, the changes of boundary conditions and implant stability between subsequent stages are reflected by the FRF evolution. The higher resonance frequencies are more sensitive to the stability change. The correlation between successive FRFs can be used as a criterion for the detection of the insertion endpoint. Moreover, the FRF analysis can be used to detect dangerous situations during surgery like stem blockage and fracture risk. This study should be completed and validated by a post-operative follow-up of the patients.
The use of monoblock tapered stems has shown very good results in hip revision surgery, particularly in case of severe proximal femur bone deficiency.
However a too valgus neck, a short offset, may result in a high risk of dislocation. In addiction monoblock stems make the control of limb length difficult, and potentially increase the risk of subsidence or intraoperative fracture. Different types of modular tapered stems with distal fixation have been developed to allow a more user-friendly restoration of limb-lenght discrepancy and an indipendent proximal control of offset and anti-retroversion.
We assessed 64 hip revisions performed on 63 patients (mean age 62 years). Indication for treatment was: aseptic loosening (42 cases) septic loosening (18 cases) and periprosthetic fracture (4 cases). According to Paprosky classification, femoral defects were staged as type I (2 cases), type II (20 cases), type IIIA (25 cases) and type IIIB (13 cases); periprosthetic fractures were all type B2 according to the Vancouver classification. In all cases we used a Restoration® Modular (Striker, Orthopaedics) cone-conical uncemented stem implanted by a lateral approach, with a trans-femoral osteotomy in 19 cases. A preventive cerclage cable was used in 10 patients in case of very thin cortex. We used the minimum size stem in most of the cases.
Mean follow-up was 20 months (range 6–36). Short-term complications included hip dislocation (1 case), recurrent infection (1 case), stem subsidence > 5 mm (1 case). Mean Harris Hip Score improved from 43 to 81.9 (t test p< 0.0005), while limb lenght discrepancy improved in 97% of cases with symmetry in 76%.
The use of modular revision stems is an effective alternative in hip revision surgery that ensures good primary stability, while modularity enables the implant to be tailored to the patient, allowing restoration of the limb length and correct muscular balancing.
Previous studies have shown improved outcome following surgery for spinal cord compression due to metastatic disease. Further papers have shown that many patients with metastatic disease are not referred for orthopaedic opinion. The aims of this paper are to study the survival and morbidity of patients with spinal metastatic disease who receive radiotherapy.
Do patients develop instability and progressive neurological compromise?
Do patients require surgery or are the majority adequately treated by oncologists?
Review of patients receiving radiotherapy for pain relief or cord compression as a result of metastatic disease. Patients were scored with regards to Tomita and Tokuhashi, survival and for deterioration in neurology or spinal instability.
94 patients reviewed. All patients were followed up for a minimum of 1 year or until deceased.
Majority of patients had a primary diagnosis of lung, prostate or breast carcinoma.
Mean Tomita score of 6, Tokuhashi score 7, and mean survival following radiotherapy of 8 months.
11:94 patients referred for surgical opinion.
Four patients developed progressive neurology on follow-up.
One patient developed spinal instability. The remainder of the patients did not deteriorate in neurology and did not develop spinal instability.
All patients with normal neurology at time of radiotherapy did not develop spinal cord compression or cauda equina at a later date.
This study suggests that the vast majority of patients with spinal metastatic disease do not progress to spinal instability or cord compression, and that prophylactic surgery would not be of benefit.
The referral rate to spinal surgeons remains low as few patients under the care of the oncologists develop spinal complications.
Dynamic stabilisation system for the spine relies on titanium screw purchase within the pedicle. Decision on osteointegration is important especially when the patient becomes symptomatic following initial good outcome. From our cohort of 420 Dynesys patients, over all incidence of screw loosening was 17%. Only 35% were symptomatic.
Seven observers composed of two expert orthopaedic spine consultant surgeons and one spine expert consultant radiologist and four Specialist Registrars in orthopaedics and radiology.
Data gathered were distributed and presented in tables in the form of descriptive statistics. The evaluation of interobserver agreement was performed by obtaining a Kappa (K) index. For continuous variables comparison, the t test was employed, with a significance level of 0.05.
We are planning to evaluate a 3D computer reconstruction model based on 2 X-ray views at 45 degree angle to each other which might be sensitive to detect screw loosening.
Lumbar spinal surgery may be associated with considerable pain in the early postoperative period. This often leads to a delay in patient mobilisation and a consequent increase in the risk of developing perioperative complications. Several studies have demonstrated the efficacy of intrathecal opioids for analgesia following spinal surgery.
We present our experience of using intrathecal diamorphine for analgesia following lumbar spinal surgery. Data were collected on all patients undergoing surgery who received intrathecal diamorphine and stored on a database (Microsoft Access).
Mobility score dropped in 34% patients whilst domestic circumstances’ score dropped only in 34%. ODI averaged 18% (range 0–53%). Mean HAD for anxiety and depression was normal for 86% and 93% of patients respectively. VAS for pain averaged 1.3 (range 0–9) and that for distress was 1.8 (range 0–9).
Overall it was calculated that HIAS had saved a total of 940 in-patient days.
Soon, UK surgeons will need to undergo regular revalidation and relicensing. As a part of this process they will need to collect accurate outcomes data. However, a lack of standardisation has led to numerous generic and disease specific outcome tools being available with increasing complexity in their administration and interpretation. In research and university settings these tools are easily administered, but in a busy general spinal practice with limited human and time resources, it may not be possible to use them reliably and consistently. Web-based systems remove some of these problems, but data-input can be time consuming.
This study evaluates the utility of a subjective Patient Satisfaction Evaluation Questionnaire (PSE) by comparing it to well-known outcome tools, the Oswestry disability Index (ODI) and the Low Back Outcome Score (LBOS).
The PSE (modified Odom’s Criteria) evaluates pain, the willingness to undergo surgery again in similar circumstances, the likelihood of recommending the operation undergone to a friend or family member and satisfaction with the process of care. Pain relief is ranked as “complete”, “good but not complete”, “little” or “no pain relief/pain worse than before surgery”. The responses are scored with three points allocated to complete relief of pain, down to none for no relief. The other questions score one for a positive and zero for a negative response. The maximum score is six. Four, five or six points count as success as long as the pain component is two or three. Nought to three, counts as failure, as does a score of four when pain is rated as “poor”.
The ODI, LBOS and PSE are not directly numerically comparable, but the results of them all can be grouped into “Success” and “Failure” which gives a basis for comparison of the tools.
150 consecutive patients who underwent lumbar spine surgery completed the three questionnaires independently of the treating surgeon. The scores were subjected to regression analysis (R square) and a Pearson’s correlation. Feedback was sought from the patients regarding the “user friendliness” of the questionnaires.
Results showed a good correlation between the ODI and LBOS with a Pearson’s value and R Square (RSQ) value of 0.86 and 0.75 respectively. The PSE compared to the ODI showed a Pearson’s value of 0.86 and RSQ of 0.74. The LBOS and PSE comparison had a Pearson’s value of 0.78 and RSQ of 0.61. The results show that the PSE in the form used correlates well with results from the ODI and LBOS. However, the patient feedback data indicated that the PSE was the most user friendly of the three tools.
The PSE was found to be a useful and user friendly tool, correlating well with recognised outcome measures, being easy to administer, document and interpret. If surgeons with limited resources cannot reliably use a more rigorous outcome tool, using the PSE should provide enough data to meet the standards that are likely to be required for revalidation and relicensing.
Main outcome measurements: The clinical and radiological evidence of disease progression, need for minimally invasive and invasive treatments as well as return to previous level of sport.
Nine patients (33%) in Group B were treated by physiotherapy alone while 13 (48%) had minimally-invasive treatment in addition to physiotherapy. Five patients (18.5%) required surgery. Two patients required revision surgery. All patients returned to their normal level of sporting activity.
The Prosthetic Disc Nucleus (PDN) is an implant designed to replace the nucleus of the lumbar disc in early stage symptomatic disc degeneration. The PDN originally was a paired device. Due to technical difficulties encountered by surgeons these were converted to a single implant (PDN Solo range). Mechanical testing suggested the new device would function as well as the original paired device. However, the implant was introduced into clinical practice, outside of the US, without any clinical evaluation.
Four more unrevised patients were identified as clinical failures. The total failure rate was therefore 51.4%. In patients with a successful outcome there was a 33 point improvement in the mean LBOS score.
In all cases of failure the PDN jacket became disrupted with concomitant fragmentation of the hydrogel core
The clinical results of transarticular fixation are satisfactory in terms of clinical outcome with few complications. However there are concerns that these patients develop subaxial kyphosis. It is important to highlight that none of these patients in our series had supplementary wiring techniques with TAS The purpose of this study is to analyse postoperative Xrays of patients who have undergone transarticular atlantoaxial fixation and look at the following parameters;
What percentage of patients develop subaxial kyphosis? Are the ADI and PADI maintained postoperatively? Is there a late failure rate of TAS despite the absence of supplementary wiring techniques?
We analysed the following parmeters:
Pre and Postoperative ADI and PADI. C0/C1, C1/C2, C1/C7, C2/C7 angles C2/C3 slip and C2/C3 osteoarthritis Any breakage or pullout of screws. Postoperative basilar invagination.
It is important to highlight that all these 15 patients had bony fusion at the C1/C2 joints and these findings have been analysed and published in the clinical counterpart of this study (Fusion rates 97% in 36/37 patients).
There was only 1 patient with C2/C3 slip on flexion/extension views. 2 patients developed subaxial kyphosis with evidence of significant disc degeneration on preoperative imaging.
There are some interesting conclusions from these 15 xrays.
Only 2 out of 13 patients have developed a subaxial kyphosis. The 2 patients that have developed subaxial kyphois had subaxial disc degeneration at the level of the kyphois There was only 1 patient with a C2/C3 spondylolisthesis on flexion/extension. The ADI and SAC were maintained at the craniocervical junction. There is no late failure rate despite the absence of a modified gallie fusion
16 patients had MRA, confirming the SAVF in all cases and correct site in 12.
DSA failed to demonstrate the abnormality in one patient.
Overall there was a mean improvement in pain VAS scores of 1.9 (p=0.0875).
SF36 scores showed minimal improvement in both physical and mental parameters and there was minimal improvement in subjective outcome in 55% of patients.
However it was observed that a small subgroup of patients (30%) aged less than 40 with low volume positive discography and single level disease mean pain VAS scores improved by 3.78 from 7.52 to 3.74. 72% of these patients reported a subjective improvement in symptoms and SF36 scores improved significantly compared to the overall group.
Further analysis also revealed that the use of pain diagrams when interpreted according to the principles of Mann et al was the predictive value.
35 patients were required for the study. They were randomized to have DBM and autograft on one side of the posterior approach and autograft alone on other side of the same approach. Patients were followed up with interval radiographs for total of 24mons. To date 32 patients have been recruited and with an average follow up a15.3 months. The mineralization of fusion mass lateral to the instrumentation on each side was graded as Absent, Mild (< 50%), Moderate (> 50%) or Complete fusion (100%). The assessment was made by independent orthopaedic consultant and a musculoskeletal radiologist who were blinded to graft assignment.
There were 36 patients, 18 patients in each group, average age 66, average follow up 8 months. There was no commercial support or funding of any sort. Outcome measures were the Oswestry Disability Index (ODI), visual analogue for pain (VAS), and self perceived walking distance in yards. N.I.C.E. guidance IPG 165 was given to all interspinous distraction device patients.
This was a clinically significant and statistically significant difference P=0.002 in favour of simple decompression. The VAS was 7.88 improving to 3.05 in the decompression group, whereas the interspinous distraction group the change was from 7.3 to 4. Complications were 3 spinous process fractures and one late migration of implant in the distraction group. There were 2 incidental durotomies and one epidural bleed greater than a litre in the decompression group. Six of the interspinous distraction devices already demonstrate lucent zones around the implant at post op follow up the significance of which is not clear.
Surgery was done with the patient in the kneeling, seated prone position which leaves the abdomen free and avoids venous kinking in the legs.
Outcome measures used were post operative mortality, Post operative improvement in Frankel score, level of pain perception, level of mobility and ability to perform activities of daily living.
95% of patients presented with back pain, with or without neurological compromise.
All patients were imaged with MRI or CT. 90 (86%) patients had microbiological and/or histological confirmation of TB. The majority of patients (52%) had two vertebral levels affected. The Thorocolumbar junction was the area most commonly affected. 4% of patients had paravertebral abscesses with no bony involvement seen on imaging. 29 patients (26%) had associated psoas abscess.
Combination chemotherapy, according to NICE guidelines, was the main modality of treatment. 67 (61%) patients were managed with combination chemotherapy alone. Surgery was performed for certain indications: deteriorating neurology, instability and post tubercular kyphosis. 42(39%) of patients required surgery.
Because of the high incidence of spinal TB in East London and in order to standardise treatment of these patients we set up dedicated multidisciplinary spinal TB clinic and are managed jointly by respiratory and orthopaedic teams.
The mean duration of instrumented surgery was 4 hours 19mins. The infection rates for operation duration < 5 h versus operation duration > 5 h (3/96 Vs 6/51) were not statistically significant (p = 0.065)
Of the 147 instrumented spinal operations, 8 of 117 operations performed in a laminar air flow system and 1 of 30 performed without laminar air flow were infected (p = 0.69)
Infection rates for those patients transfused < 2 units (4/85) were not significantly different to those in patients transfused > 2 units (5/62), p = 0.49.
SSI in spinal surgery was heavily influenced by instrumentation, but was not reduced by laminar airflow. Duration of operation and number of units of blood transfused were not significant factors.
Caudal epidural steroid injections are widely employed although there is little hard evidence to confirm their efficacy. This empirical treatment still remains a matter of personal choice and experience.
A standard mixture of 80 mgs of triamcinalone plus 7 mls of 1% lignocaine plus 5 mls of 0.9% saline used for all patients. All patients reviewed at 3 months interval in a dedicated epidural follow up clinic. The epidural database included age, BMI, duration of symptoms, smoking, employment status and source of referral, any pending litigation, i.e., work or accident related, MRI results, diagnosis and complications. VAS scores documented both axial and limb pain for actual and comparative analysis. ODI and HADS were recorded prior to treatment and at three months follow up. Overall patient satisfaction was recorded on a scale of 0–10 and complications noted.
58 % were females, 24% smoked and 4.1% had ongoing litigation due to their pain. The mean age was 56yrs with BMI ranging from 17 to 50 (mean=28). 7 (1%) patients required subsequent surgical intervention due to disc herniation. BMI did not affect the outcome. Mean VAS for axial pain reduced from 5.859 to 2.59 at three months. Mean VAS for limb pain similarily reduced from 6.23 to 2.53. Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months. Mean HADS also improved from 17 to 7. Following treatment, overall Patient satisfaction ranged from 0–10 with mean of 5.4.
Long term follow-up is underway. Subgroups predicting poor outcome are identified. Positive primary care feedback encourages further recruitment.
In our unit we do not have blood cross matched for anterior surgery alone.
This is a preliminary retrospective report on a novel technique for achieving fusion at the lumbo-sacral disc. Current methods of complete discectomy and instrumented fusion involve either a posterior approach and the insertion of cages or an anterior approach. Both methods involve quite extensive dissections with potential stabilising muscle stripping. They also require significant post operative analgesia, inpatient stay and post operative recovery. There are attendant risks of nerve injury, blood loss and thrombosis.
A novel method of approach from the sacrum via a ‘safe zone’, described by Yuan et al., is presented. The technique along with the anatomical considerations is described. The operation basically consists of a posterior sacrococcygeal incision and an x-ray guided approach to the anterior surface of the S1/S2 junction with blunt obturators. The L5/S1 disc is then accessed by drilling through the sacrum. The disc is then removed from within with shaped tools leaving the bulk of the annulus. The void created is filled with bone graft and the L5 vertebra fixed to the sacrum via a bolt. The initial results of the first 20 patients are presented. 21 patients have been operated upon but one has been lost to follow up due to a psychological disorder. That patients details have been excluded.
The patients underwent surgery between 4/7/06 and 8/10/07. All operative procedures were completed without complication, the operative time improving from 60 minutes to a ‘standard’ 45 minutes. There were no post operative complications. Two patients underwent additional procedures. One was an L4/5 Wallis ligament the other an inter-transverse non instrumented fusion. Several patients required a further pain control procedure, 3 caudal epidurals, 2 facet blocks and 2 coccyx injections. One patient required an L4/5 PLIF 12 months after the first procedure and two patients required posterior stabilisation at the same level. One after 4 months the other at 18 months.
The indications for surgery are the same as for a standard fusion procedure. In this group there were 12 degenerative discs with mechanical LBP, 3 spondylolistheses, 2 previous failed posterior fusions and 3 post discectomy patients. Discography was used for confirmation of the pain source in 15 cases. The duration of symptoms ranged between 2–15 years with a mean of 6.25. There were 12 male and 8 female patients. The age ranged between 34–70 with a mean of 47. The female mean being 48 and the male 46.
The Oswestry disability index showed a mean of 47 pre-operation and 23 post-operation. 13 out of 20 have been discharged with symptoms resolved or easily bearable. The hospital stay varied between 1 night and 4 nights with a mean of 3.3.
This novel approach to the lumbar spine gives rapid and safe access to the lumbar disc space despite the unusual approach for spinal surgeons. Once the initial incision is made the procedure is carried out under x-ray control using techniques which are very familiar to Orthopaedic surgeons. The lack of intra-operative problems and post-operative complications testify to a safe procedure.
The question mark remains on the rate of fusion. Two patients and potentially a third required a secondary posterior instrumented fusion. One was due to demonstrable loosening of the bolt and the other two continued pain possibly due to inadequate stabilisation. In my view, despite the European teaching, posterior instrumentation is desirable. This can be achieved via a percutaneous technique.
Late referral for definitive treatment may result in increased and perhaps avoidable medical morbidity, social and psychological drift, including early mortality.
Patient pool obtained from theatre records, radiology and coding departments. Post-spinal operative infections and patients under 65 years old excluded. Initial presentation, admitting speciality, initial investigations and differential diagnosis, time to diagnosis, date and day of referral, mode of definitive treatment, pathologic entities, complications and outcomes were noted. Patient outcomes were measured as duration of treatment, length of hospital stay, complications, ambulatory status, complications, discharge destination and death. Outcomes were correlated with delayed diagnosis and referral.
Age ranged from 65–91 with mean of 71. 62% referral from Physician colleagues. Fever with malaise associated with chronic LBP was the commonest presenting complaint. 34 patients had discitis and 12 had epidural abscess. Time to diagnosis ranged from 2–17 days with mean of 8 days. Mean referral time to spinal team was 9 days with 39% referrals on Friday. Duration of hospital ranged from two weeks to three months. 46% required surgical decompression with four cases of related mortality during acute hospital stay.
The incidence of haematogenous spinal infection in the elderly has increased over the years in our series, contrary to popular belief.
A high index of suspicion in elderly patients with PUO promotes early diagnosis and optimises outcome.
In all age groups curves were more frequent and had greater average Cobb angles in female patients except in the 30–39 year olds–where the males equalled females in frequency and had the greatest Cobb angles.
Preoperative segmental Cobb angle averaging 34 º at last follow up. Compensatory coronal cranial and caudal curves corrected by 50%. The angle of segmental kyphosis averaged 39º (range, 20º to 80º) before surgery and 21 º (range, 11º to 40º) at last follow up. This represents a 43% of improvement of the segmental kyphosis, and a 64% of improvement of the segmental scoliosis at last followup.
One case with initial kyphosis of 80 º continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.
In progressive congenital kyphoisis, early diagnosis and aggressive surgical treatment are mandatory for a successful result. Early treatment minimizes the risks of surgery. Anatomical and physiological pitfalls in the treatment of congenital kyphosis are discussed. Anterior instrumented fusion of congenital kyphosis provides sagital and coronal correction in very young children with low risk of complications.
The predominant presenting symptom was pain. Pathological fracture occurred in 7 patients. The operative treatment consisted of curettage (21), excision (51) and resection (9) with supplemented bone grafting (13). Adjuvant chemo (=61) and radiotherapy (=131) was also used in selective cases. Thirty patients were alive with no evidence of disease at a mean 5 year follow-up. Six were alive with persistent primary disease and/or local recurrence and/or metastases at the time of review. Eighty four patients died with persistent primary disease, 30 patients died of metastatic disease, 9 due to local recurrence and 17 of unrelated causes.
Screws that perforated the lateral cortex were the easiest, and those that were wholly within the pedicle were the most difficult to identify correctly. The use of plain radiographs to detect thoracic pedicle screws placed through the critical medial cortex is unreliable. AP + lateral views provides higher accuracy in determining the screw position, while, the major contribution comes from AP views. Surgeon experience, in the use of tactile skills and anatomical knowledge continue to be vitally important in the safe placement of thoracic pedicle screws.
Cervical spine disorders represent a good proportion of the daily practice of many neurosurgeons. The rapidly increasing knowledge base on spinal conditions and the progressive complexity of surgical interventions appear to be generating a renewed interest in this evolving subspecialty among neurosurgical trainees. In order to assess the current level of spinal surgery training and conveyed competence in dealing with spinal disorders, a self assessment questionnaire was devised and distributed to the neurosurgical trainees attending the EANS (European Association of Neurosurgical Society) training courses. 126 questionnaires were returned with a return rate of 32%. The majority of trainees responding to the questionnaire were in their final (6th) year of training or had completed their training (60,3% of total) representing 25 European nations. A separate analysis of the data pertaining to cervical spine disorders revealed 80% of the trainees completing their training in University hospitals with cervical spine injuries predominantly managed by neurosurgeons (75%). In their practical skill assessment, 78% of the senior trainees were competent in the treatment of cervical disc herniation and cervical spinal stenosis in their anterior microsurgical techniques. In emergency management of cervical spinal trauma, 45% of the senior trainees were competent in being able to perform procedures without direct supervision. Regarding skills in anterior and posterior cervical stabilisation techniques, 33% and 15% respectively were competent in performing as well as dealing with complications & difficulties that may arise. Spinal surgery training in European residency programs has clear strength in the traditional areas of microsurgical decompression for spinal stenosis and disc herniation. Deficits are revealed in the management of spinal trauma and spinal conditions requiring the use of implants, with the exception of anterior cervical stabilisation. In order to achieve a high level of competency, EANS trainees advocate the development of a post-residency spine sub-specialty training program.
Despite reported differences in patient presentation the abnormal scan rate was comparable (ESP 91%, orthopaedics 92%).
The tertiary referral rate was also comparable (ESP 47%, orthopaedics 37%).
Of the patients referred to the tertiary referral centres the percentage listed for operative intervention was 68% and 72% respectively for ESP and orthopaedic surgeons. In terms of the number of patients investigated by MRI scan 32% and 26% of patients from the ESP and Orthopaedic centres respectively were listed for surgery.
In this study we aimed to retrospectively assess the local experience by reviewing patients, treated over the last 10 years, in whom scoliosis has been established, by means of MR imaging, to be associated with a cord syrinx.
The syrinx was treated surgically in 10 patients, with 80% of these achieving either deformity arrest, or no longer requiring surgical deformity correction. In the 2 patients from the same subset who did undergo deformity correction there was no neurological sequelae. Of the conservatively managed syrinxes, deformity correction with intraoperative cord monitoring was nevertheless undertaken in 31%, all without neurological sequelae. In just 4 patients (of 69%) who did not proceed to deformity correction, surgery was precluded by the inherent risks in the presence of an untreated syrinx.
We describe a case of a three year old girl with Caudal Regression Syndrome (CRS) at the ninth thoracic vertebral level with termination of the spinal cord at the unusually high level of the third thoracic vertebra. We describe this rare condition and discuss the challenging management in an extremely rare case where there is termination of the spinal cord at a high thoracic level.
CRS is a severe congenital neural and skeletal deficiency that is characterized by absence of the entire sacrum and of variable amounts of the lumbar and occasionally thoracic spine with associated neural elements. This is accompanied by a number of congenital visceral abnormalities.
Controversy belies the optimal orthopaedic management of the spinal anomaly and the associated lower extremity deformities in this condition. Affected children have multiple musculoskeletal abnormalities, including foot deformities, knee and hip flexion contractures, dis-located hips, spino-pelvic instability, and scoliosis.
We believe the care of these complex patients should be highly individualized.
Patients with types I and II lumbosacral agenesis have an excellent chance of becoming community ambulators and early interventions should be taken to correct the associated orthopaedic deformities. Treatment of types III and IV lumbosacral agenesis is controversial. In these severe forms of agenesis periodic examinations of the spine for scoliosis should be performed and the patient must be monitored for spinopelvic instability as indicated by a worsening posture. The management of these and other orthopaedic deformities is controversial but we do advocate the surgical correction of fixed deformities of the lower extremities which interfere with sitting or with the wearing of braces or shoes thereby avoiding amputation and maintaining body image.
Decompression of the lumbar spine for spinal stenosis is the most commonly performed spinal surgical procedure in patients over 60 years old. The aims of surgery are to relieve compression of the spinal nerves and retain integrity of the structural elements of the spinal column and its function as a supportive structure.
In trying to avoid excessive removal of the posterior supportive structures of the spinal column without compromising full and safe decompression of the spinal nerves, techniques are being developed to reduce bone removal but also allow access to the spinal canal. One such micro-decompression involves a hemi-lami-nectomy and lateral recess decompression on the more symptomatic side followed by undercutting the spinous process and facet joints and decompressing the opposite side from within the canal aided by the use the operating microscope, a high speed burr and a metal guard to protect the dura and nerves.
Although previous reports exist, as yet, there is no long-term evidence that the theoretical benefits of this “micro-decompression” translate into real clinical improvement in outcome with a reduction in the incidence of post-operative instability in comparison with the bilateral “fir-tree” type of decompression.
We have reviewed our first 100 consecutive patients who have had a spinal micro-decompression carried out by a single spinal surgeon over a period of 5 years. Patients with central or lateral recess stenosis with unilateral or bilateral symptoms were considered for this procedure with 58 female and 42 male patients included in the follow-up series. Mean age was 65 years. Patients were assessed by a combination of clinical review and self-assessment questionnaires. After a follow-up period of up to 5 years (mean 3 years) we have seen symptomatic late instability develop in 4 patients requiring a further surgical procedure in 2 of these. Symptoms typically developed 2 years after the original operation following an initial improvement in radicular symptoms and back pain. This compares favourably with published results for wide decompression where re-operation rates of 18% are reported. We have analysed the cases of delayed instability in more detail to evaluate whether the late deterioration could have been predicted. This has allowed us to clarify the specific indications and contra-indications to the micro-decompression procedure.
Lumbar micro-decompression has proved to be safe with few complications. It would appear that this technique has advantages over wide decompression without compromising safety but it will be important to continue with longer term follow-up of these cases.
We describe the clinical results of a new technique of direct pars repair stabilised with a construct that consists of a pair of pedicle screws connected with a modular link that passes beneath the spinous process. Tightening the link to the screws compresses the bone grafted pars defect providing rigid intrasegmental fixation.
14 patients aged between 10 and 17 years were included in this study. 7 were males and 7 females. Each of the patients had high activity levels and suffered from significant back pain without radicular symptoms or signs. All patients had undergone at least 12 months of activity modification, a trial of bracing and physical therapy before surgical options were discussed. None of the patients had spondylolisthesis. Definitive pseudo-arthrosis and fracture were confirmed via computerize tomography (CT). Magnetic resonance imaging was performed in every patient to assess the adjacent disc spaces which demonstrated normal signal intensity. The pars defect was at L5 in all 14 patients.
A midline incision was used for surgery. The pars intercularis defect was exposed and filled with autolo-gous iliac crest bone graft prior to screw insertion. After screw insertion, a link was contoured to fit, and placed just caudal to the spinous process, deep to the interspinous ligament of the affected level, and attached to each pedicle screw. There was early mobilization post-operatively without a brace.
The average inpatient stay was 3 days. Post-operative complications included 1 superficial wound haematoma. Follow-up was at 6 weeks, 6 months and at 1 year. At the latest follow-up, visual analogue scores ranged between 0 and 4 for all patients, indicating excellent overall pain control. Functional assessments for all patients via the modified Oswestry scores were 0% to 13%, indicating a good overall functional result. All patients had radiographs at follow-up which showed fusion rates of 80% in those patients followed up for 1 year.
This new technique for direct pars repair demonstrates high fusion rates in addition provides the possible benefits of maintaining adjacent level motion. Clinically this group had good-to excellent functional outcomes as indicated by visual analogue scales and the Oswestry Disability Index.
Seventy-two percent of patients (47/65) were graded Frankel D pre-operatively and 65% (42/65) remained so after surgery. SF36 data were obtained for 17 patients. Pre-operatively, patients with ISCT had significantly lower SF36 physical domain scores when compared with normative data from age-matched population controls (p=0.0096). There was no difference between post-operative scores and those of normal controls. Matched pairs analysis on the patients with complete SF36 data sets (n=12) demonstrated a significant improvement in physical function post-operatively. Eleven of these 12 did not show an improvement in their Frankel grade, remaining Grade D pre- and post-operatively.
The objective of this study was to assess the clinical outcome and efficacy of the X-Stop™ interspinous implant.
67 patients (36 male, 31 female) with mean age of 62.4 years (range 50–94 years) and radiologically proven lumbar stenosis, underwent X-Stop™ implantation during the period of June 2004 to June 2007. Patients were assessed pre-operatively and post-operatively at 3, 6 and 12 months using the Back and Sciatica Questionnaire, the Oswestry Disability and the SF12 questionnaire. Patient’s satisfaction was assessed in each visit. Minimum follow up 2 years in 45 patients and 1 year in 22 patients.
70% had significant improvement in the walking distance following the operation.
With the Back and Sciatica Questionnaire the average preoperative VAS of back and leg pain was 7.1 and 6.7 and improved to 2.5 and 2.6 postoperatively.
86% patient had improvement in their ODI score by 14% and more with average pre and postoperative score 44% (range18%–84%) and 15.8% (range 0%–61%) respectively.
With the SF12 questionnaire 68% patients had significant improvement in physical score and 77% in the mental score. Complications included five superficial wound infections and one wound haematoma. One patient required revision surgery.
This new surgical technique for the treatment of lumbar spinal stenosis, is simple and effective with minimum complications.
Patient outcomes using the Scoliosis Research Society (SRS) questionnaire after thoracoscopic and posterior surgical techniques for thoracic idiopathic scoliosis were compared after > 2 years post-op. Additional comparisons were made with non-operated scoliosis and normal patients. Our objective was to determine if scoliosis surgery and surgical technique used to treat a cohort of patients with the same type of scoliosis deformity affects patient outcome. The SRS-24 questionnaire was prospectively administered to 4 groups of patients:
42 patients with thoracic idiopathic scoliosis who underwent thoracoscopic instrumented fusion surgery (thoracoscopic group); 42 patients with thoracic scoliosis who underwent posterior instrumented fusion surgery (posterior group); 97 patients with thoracic scoliosis who did not have surgery (scoliosis control group); 72 patients who did not have scoliosis (normal group).
The 2 surgical groups were comparable with regards to age at surgery, pre-op Cobbo and follow-up. SRS-24 domian scores were computed for all 4 groups and were compared on SPSSv13 software. Our results show the thoracoscopic group having a significantly smaller mean post-op Cobbo (17° vs 25.1°, respectively; p< .001), which was achieved using less fusion segments (7 vs 9.3 segments, respectively; p< .001). The mean Cobbo of the scoliosis control group was significantly larger than the post-op Cobbo of the thoracoscopic group (p< .001), and was comparable to the post-op Cobbo of the posterior group. Comparing the 2 surgical groups, the thoracoscopic group showed trends towards better scores in 4 of the SRS-24 domains compared to the posterior group, but this only reached statistical significance for the satisfaction domain (p< .05). When comparing the 4 groups, Pain scores of both surgical groups were similar to those who did not have surgery, and were worse than normal patients (p< .0001); Self-image scores after surgery were higher than those who did not have surgery(p< .05) and were comparable to normal patients; Function and Activity scores of the thoracoscopic group was significantly inferior to the scoliosis control group (p< .05). Our study demonstrates that > 2 years after surgery, both thoracoscopic & posterior surgery resulted in pain scores that were similar to patients with scoliosis that did not have surgery, and were worse than the normal group. However, both surgical techniques resulted in self-image scores that are comparable to normal individuals despite a difference in post-op Cobbo. When comparing the two surgical techniques, the SRS-24 showed no difference between the 2 surgical techniques, except for patient satisfaction which was better in the thoracoscopic group.
Group 4 = Very high suspicion of pathology (n=41) Group 3 = Moderate suspicion of pathology (n=21) Group 2 = Some suspicion of pathology (n=10) Group 1 = Pathology unlikely but scan indicated eg thoracic pain (n=4).
Group 4: 88% Group 3: 67% Group 2: 40% Group 1: 0%
Radiological Occurrence of segmental cervical kyphosis Loss of overall cervical alignment Clinical SF36, Neck disability index, Visual analogue neck and arm pain scores
Specific indications for use of cell saver in thoracolumbar spinal instrumented fusion not clearly determined.
No previously published literature from Britain to our knowledge.
To analyse the safety and benefits of using cell saver technique. To determine the cost-effectiveness of use of cell saver technique.
There was no randomisation; use of cell saver was at surgeon’s discretion. Cell saver group consisted of 25 patients and control group consisted of 26 cases. Patients with degenerative scoliosis and tumours excluded. Demographic data recorded. Clinical notes reviewed to include smoking status, BMI, pre-operative diagnosis, revision surgery, number of levels fused, use of iliac bone graft, pre and post operative haemoglobin, haematocrit and platelets, intra-operative blood loss, amount of blood salvaged, duration of surgery, nature and amount of allogenic blood transfused.
Iliac crest bone graft harvested in 20% of cell saver group and 40% in control group. Levels of fusion ranged from 1–7 [Mean=2.8] in the cell saver group and 1–4 [Mean=1.9] in the control group. Study group averaged 4 hrs of surgery, 15 mins longer than control group. Intra-op blood loss higher in cell saver group (mean=1245 mls vs 800 mls). Revision surgery did not affect the intra-op blood loss or duration of surgery. 20% in cell saver group and 26% in control group required blood transfusion. 8 units of red cells was transfused cell saver group as against 17 units of red cells plus 2 units of platelets transfused in the control group. Percentage drop in the post operative haematocrit was 19.1 in cell saver group compared to 36.3 in control group.
Use of cell saver significantly decreased the risk of post-operative need for blood transfusion. In this study, number of levels of fusion, duration greater than 4 hrs and a low pre-op Hb/Hct were significant parameters in predicting intra-operative blood loss. If blood loss is less than 700 mls, gains from cell saver is debatable.
Observation of sub-clinical neurological abnormalities has led to the proposal of a neuro-developmental etiologic model for AIS. Our research group have demonstrated longer latency in somatosensory–evoked potential (SSEP) and impaired balance control in AIS subjects. A previous pilot study compared the regional brain volume between right thoracic AIS subjects and normal controls. Significant regional brain differences were found relating to corpus callosum, premotor cortex, proprioceptive and visual centers. Most of these regions involved the brain unilaterally, indicating there might be abnormal asymmetrical development in the brain in right thoracic AIS. In this pilot study, we investigated whether similar changes are present in left thoracic AIS patients who differ from matched control subjects. Nine AIS female patients with atypical left thoracic AIS (mean age 14.8, mean Cobb angle 19°) and 11 matched controls as well as 20 right thoracic AIS (mean Cobb angle 33.8°) and 17 matched controls, underwent three-dimensional isotropic magnetization prepared rapid acquisition gradient echo (3D_MPRAGE) magnetic resonance (MR) imaging of the brain. Fully automatic morphometric analysis was used to analyse the MR images; it included brain-tissue classification into grey matter (GM), white matter (WM) and cerebrospinal fluid (CSF). and non-linear registration to a template brain. Tissue densities were compared between AIS subjects and controls. There was no significant difference between AIS subjects and normal controls when comparing absolute and relative (i.e. brain-size adjusted) volumes of grey and white matter. Using voxel-based morphometry, significant group differences (controls > left AIS) were found in the density of WM in the genu of the corpus callosum, the left internal capsule (anterior arm) and WM underlying the orbitofrontal cortex of the left hemisphere. The above differences were not observed in the right AIS group. This first controlled study of regional tissue density showed that corpus callosum, which is the major commissural fiber tract, was different in the atypical left thoracic scoliosis while significant regional brain changes have not yet been found in those with typical right thoracic scoliosis. Further investigation is warranted to see whether the above discrepancy is related to laterality of the scoliotic curves and infratentorial neuroanatomical abnormalities. A larger sample and a longitudinal study is required to establish whether the brain abnormalities are predictive of curve progression.
uni- or bilateral single level nerve root decompression Three month post-operative visual analogue scores (VAS, 10 = maximum pain, 0 = no pain) of less than 2 was required as an indicator that the pre-operative diagnosis had been correct (i.e. the surgery had significantly improved the patient’s pain).
The MRI report of these patients was then scrutinised to see if the decompressed nerve root had been reported as significantly compressed on the pre-operative scan.
However, in this sample a large minority of MRIs had no formal report. Of those that were reported, there was underreporting of potential surgical targets by radiologists. This implies that there could be a high incidence of false negative MRI reporting with potentially treatable conditions being unrecognised.
Previous studies of EMG recordings from lumbar para-spinal muscles have shown correlations between some EMG variables and low back pain. However there are discrepancies in the literature concerning the usefulness of some of these variables. It has been suggested that ordinary fatigue influences the reproducibility of these measurements, introducing a confounding factor.
In this study we have investigated changes in EMG variables, following a day of normal activity. Forty six subjects participated in this study. EMG recordings were performed at the beginning of their shift (time 1) and at 6 h 20 ±5 min afterwards (time 2) under isometric condition at 60% and 40% of their lean body mass (LBM). Variables studied were initial medial frequency (IMF), median frequency slope (MFS) and half width (HW).
At 60% LBM, IMF measurements at time 1 and time 2 were highly correlated (r2= 0.84, p> 0001) and this was the case for HW measurements (r2=0.84, p> 0001) and MF slope (r2=0.52, p=0> 001). Conducting paired sample t-test also showed no significant change in the IMF from time 1 (M=48.6, SD=8.9) to time 2 (M=49.2, SD=7.3), t(45)=−0.9, p=0.38, or in HW from time 1 (M=47.2, SD=15.5) to time 2 (M=45.9, SD=13.9), t(45)=1.7, p=0.29, or MF slope from time 1 (M=−0.2, SD=0.17) to time 2 (M=−0.24, SD=0.16), t(45)=1.67, p=0.10). The relations observed at 40% LBM almost mirrored those reported at 60 % LBM but with even less significant difference from time1 to time2.
We conclude that IMF, HW and MFS are highly reproducible EMG variables that are not affected by ordinary fatigue and may therefore be valuable in examining differences between subjects or over longer time periods. However they are not useful in assessing changes due to daily exertion.
28 were applied under local anaesthetic (LA), one with LA and sedation and 8 were applied under general anaesthetic (either for another trauma procedure or due to head injury). All halos applied were Bremer Halo Crown with Classic or Classic II vest (DePuy Spine, Warsaw, IN, USA).
Indications for application included fractures (n=21), tumours (n=6) or subluxations (n=10).
8 patients required pin repositioning. This was due to poor position (n=2), pain (n=5) and pin loosening (n=1, 3%). Pin site infection was diagnosed using an accepted definition2. This occurred in 5 patients. 3 settled with antibiotics, one with debridement and one with repositioning. Overall infection rate was 13.5%, which compares favourably with published rates of 20–22%. Pin site infection dropped significantly after introduction of a pin care regimen introduced and published by our limb reconstruction team
The halo vest was a cause of significant morbidity in terms of pressure ulceration (3 patients) pneumonia (3 ventilated ITU patients of whom 2 died) and pain in one patient.
Our pin site infection rate dropped significantly after use of our limb reconstruction teams pin care regimen. We now utilise this regimen in all halo patients with good effect. A prospective study is ongoing.
The ODI (Oswestry Disability Index) score was 27.4 (+/−13) preoperatively and 42.2 (+/−10.9) post operatively (p=0.004). The scores for SF-36 (Short Form-36) were 34.0 (+/−10.9) preoperatively and 29.7 (+/−6.3) post-operatively (physical component summary; p=0.3); 39.2 (+/−7.9) preoperative and 40.6 (+/− 14.9) postoperative (mental component summary; p=0.85).
There were 6 major complications (1- wound break-down, 3 – required extended respiratory support of which 1 required thoracotomy for lung re-expansion, 1- developed severe distal junctional kyphosis requiring revision, 1 – recurrent laryngeal palsy needing thoraco-plasty) and 3 minor (2- dural tears, 1-chyle leak).
The survival in the ‘curative’ group was 10/15 (67%) with a mean follow-up of 27.3 months; five patients died at a mean of 115 days (86–129 days) due to respiratory complications. All ten surviving patients reported that they were satisfied/very satisfied with surgery. The survival in the ‘palliative’ group was 192 days (48–360).
Education is now recognised as a crucial component of the management of non specific low back pain. Mostly education is carried out informally in one to one consultations with health professionals. This has draw backs as it is costly, time limited, labour intensive and biased towards the discipline, training and beliefs of the clinician. The Back Book is a realistic alternative but provides very generic neutral information mostly promoting the message that pain isn’t damage.
We would see the process as one of the facilitation of knowledge acquisition rather than a formal teaching process. The latter implies engagement and responsibility on the part of the learner, rather than a pedagogic exercise by clinician or therapist.
We propose a group based, community delivered, interdisciplinary education module in which 4 different specialists contribute to an afternoon information session aimed at informing patients about: the causes of back pain from a non disease perspective, the complexity of pain perception, the biopsychosocial model, evidence based treatment of pain and some principles of paced pain management. The focus is on dispelling myths (such as the need for MRI scanning, surgery etc.) and enabling sufferers to make improved decisions about their care.
Data from over 120 patient attendances will be presented. These indicate high acceptability and satisfaction with 92% rating the afternoon as good or excellent and only 11% claiming the session had not helped them make better decisions about future treatment.
This model is simple, relatively low cost and accessible to primary care, which is acceptable and seemingly helpful to sufferers. It appears to be a viable model for presenting information to back pain sufferers early in their illness. The aim of this is to help them make more informed decisions and to see the need to incorporate self management approaches early in their history. More data are needed to ascertain whether these are achievable goals.
We sought to determine the distribution of pain which significantly improves following decompression of lumbo-sacral nerve roots.
uni- or bilateral single level nerve root decompression Three month post-operative visual analogue pain scores of less than 2 (0 = no pain, 10 = worst pain).
For individual nerve roots the distribution of pain described on post-operative pain drawings was sub-tracted from that described on pre-operative pain drawings. This produced a composite pain drawing demonstrating the distribution of pain most reliably improved by decompressing a particular nerve root.
Pain as a consequence of lumbo-sacral nerve root compression does not appear to be restricted to classical dermatomal distributions. Lumbo-sacral nerve root compression may be a significant cause of back pain. In order to decide who is likely to benefit from lumbo-sacral nerve root decompression further characterisation of the pain distribution attributable to lumbosacral nerve root compression is required.
Osteoporotic vertebral fractures predispose to significant morbidity in the elderly and are strongly associated with an overall decline in health, functional status and social drift.
Current evidence supporting the use of kyphoplasty versus medical management alone in the management of these factures is limited and based on several small prospective cohort studies. These published case series report the use of several end points, variously including Visual analogue score (VAS), Vertebral height, kyphosis angle and Oswestry disability index (ODI).
We present prospectively collected data supporting the use of kyphoplasty in a U.K. based population tested by examining VAS, vertebral height, vertebral and kyphosis angles, ODI and hospital anxiety and depression score (HADS).
40 patients in our kyphoplasty group have undergone 70 kyphoplasty procedures. With a mean follow up of 6 months, the mean post-operative VAS score was 3.9 versus a pre op score of 8.5. This reduction was maintained at 6 weeks and 6 months with mean scores of 3.7 and 3.8 respectively.
Functional status ODI scoring improved from a pre-operative score of 53 to 48 post-operatively, to 42 at 6 weeks, and further, to 41 at 6 months. This result was reinforced by HADS scoring at the same time intervals recording 15.3, 12.0, 10.1 and 11.3 respectively.
Post-operative radiographs demonstrated a 24% mean increase in the vertebral angle with increases in the anterior, middle and posterior vertebral body heights of 26, 40 and 11 % respectively. Kyphosis angle has been improved by a mean angle of 2 degrees.
The Derby experience demonstrates that kyphoplasty can improve pain and functional status and may help correct deformity after osteoporotic vertebral compression fractures.
Our experience has encouraged further recruitment for kyphoplasty as the preferred management for those patients who fail to respond to initial non-operative management.
In a high-risk technically advanced speciality like spine surgery, detailed information about all aspects of possible complications could be frightening for the patients, and thereby increase anxiety and distress. Therefore, aim of this study was to
Analyze written evidence of the consenting procedure pertaining to (a) nature of operation (b) benefits intended as a result of the operation (c) risks specific to the particular type of operation (c) general risks of spine surgery and anaestheia. Patients’ experiences of information regarding the risk of such complications and how the information affects the patients.
The study had a non-randomized design and patients divided into TWO groups Group A and group B.
The patients in the group A received standard information and were consented in a routine way without being given written proforma with all complications. The patients in the group B were given the same information as patients in the control group, with written information about common and rare complications. Patients in both groups were assessed on an ‘impact of events scale’ and hospital anxiety and depression scale immediately before ad after the consent process and again after surgery when they were discharged from the hospital.
For comparison of the proportion of Yes and No answers in 2 groups, Fisher’s exact test was used, and for comparison of more than 2 groups, the Chi-square test was used. For graded answers and other ordinal scales, the Mann–Whitney U-test was used for comparison of 2 groups and the Kruskal–Wallis test for comparison of more than 2 groups. Spearman’s test was used when assessing the correlation between 2 variables measured on an ordinal scale.
67% of open subluxations occurred at L3/4. In closed subluxations the most frequent level involved was LI/2 (53% of cases). Open dislocations are located closest to the apex of the curve, with closed dislocations being more peripheral. The curve was noted to rotate towards the apex.
Clinical outcome was assessed by Zurich claudication questionnaire (ZCQ), visual analogue score (VAS), Oswestery disability index (ODI) and SF36 questionnaires preoperatively and at 2 years. ZCQ has three components- symptom severity, physical function and patient satisfaction. ZCQ is considered the most precise, reliable and condition specific questionnaire for lumbar canal stenosis.
Out of 57 patients, 2 died due to unrelated causes, 3 withdrew from study and 3 had the device removed within 2 years. Forty-five, 44, 42 and 48 completed ZCQ, ODI, SF-36 and VAS respectively at 24 months.
The mean ODI improved by 6.5 in single level and 10.8 in double level cases. The SF-36 showed improvement in physical function, role physical, bodily pain and vitality social domain.
Average hospital stay for the procedure was 1.6 days. One patient stayed for 10 days for investigation unrelated to the procedure. There were no major complications.
To identify radiological patterns of compression (POC) of the spinal cord To develop a surgical protocol based on POC and determine its efficacy. To identify parameters predicting outcome of surgery
Pattern I – predominant one/two level compression in normal/narrow canal Pattern II – anterior &
posterior compression at one/ two levels (pincer cord) Pattern III – Three or more levels of predominant anterior compression with a normal canal Pattern III(A) – Pattern III in a patient with multiple medical co-morbidities Pattern IV – Three/more levels of anterior compression in narrow canal +/− posterior compression (beaded cord) Pattern IV(A) – Pattern IV with one/two level severe compression amongst the multiple anterior compressions.
Mean follow-up was 3 yrs (2–8). ACDF was performed for patterns I, II & III and posterior decompression for pattern IV and III(A). For pattern IV(A), a two stage primary posterior decompression followed by targeted ACDF at the site of maximal compression was performed. The clinical outcome was measured by modified JOA (mJOA) score, Hirayabashi Recovery Rate (HRR) and functional outcome by modified Neck Disability Index (NDI).
Horse riding is a popular competitive sport and leisure pursuit worldwide. Previous research has highlighted the unpredictable and independent nature of horses and high injury risk inherent in travelling at speeds of up to 65kph, 3-metres above the ground on an animal weighing between 450–500kg. In Ireland, jockeys register with the Turf Club as either professional or amateur with the remaining riders participating as unregistered.
The aim of this study is to determine the national incidence of acute spinal cord injury (ASCI) and vertebral body injury (VBI) in horse riding in the Republic of Ireland, and to compare and contrast injury characteristics in registered and unregistered riders over an 11-year period (1995–2005).
Chart review and structured telephone interview was performed in all cases to determine mechanism of injury, discipline, protective equipment, immediate management and whether the rider considered the injury could be prevented. American Spinal Injuries Association (ASIA) impairment score was used to classify outcome. Data for injuries sustained in competitive racing, for both registered and unregistered riders, was correlated with Irish Turf Club race records to ensure accuracy.
Twenty two tumours were excised and 3 had curettage performed (1 child and 2 adults). There were 2 recurrences (one osteoid osteoma, one osteoblastoma), one from the excision group and one who had curettage, both in adults. These were successfully treated with re-excision. Mean follow-up was 8 years and all were alive at the time of final follow-up.
Shoulder Instability impacts on the ability of military personnel to fulfil their operational role and maintain sporting competence. Magnetic Resonance Imaging (MRI) and Arthrogram (MRA) are increasingly available as diagnostic adjuncts. We analysed MR reports from personnel undergoing stabilisation, correlating clinical diagnosis with operative findings and reviewed the literature in order to recommend improvements.
This was a retrospective, consecutive case note analysis of 106 personnel undergoing open anterior capsulolabral reconstruction (ACLR) by a single surgeon.
70 patients had MR (48 MRA, 22 MRI). Commonly reported pathology included Hill Sachs Lesions (41%), Soft tissue (59%) and bony Bankart lesions (16%), capsular laxity (20 %), supraspinatus lesion (20%), ACJ disease (13%) and SLAP tear (12%). The sensitivity of MR for identification of labral lesions was 82% with a specificity of 86%. For bony glenoid lesions, sensitivity was 63% and specificity 94%. Disparity between report and operative findings occurred mainly in standard MRI. Patients with lesions unrelated to instability achieved a pain free functioning shoulder following stabilisation. 100% of patients referred for ACLR with clinical evidence of instability without MR had positive pre-operative and operative correlation with instability. In 5 cases, the original equivocal MRI was repeated by MRA due to clinical suspicion of instability. In all cases the repeat MRA correlated with pre-operative and operative findings of instability. In 5 cases with equivocal clinical findings, MRA provided confirmation of instability. Delay in referral due to scanning and follow up ranged from 0–15 weeks.
The diagnosis of those instigating referral is accurate. Reporting of MR is open to variation and has cost implications. MRA performed by a radiologist with a musculoskeletal specialist interest is recommended on an individual basis only and routine use of non-arthrographic studies should be discontinued. This will improve the efficiency of the fast track pathway.
It is common practice in wrist arthroscopy to suspend the patient’s arm using Chinese finger traps and to distract the wrist joint by applying weight to the arm at the elbow. It is possible that this may cause significant pressure to be applied to the fingers, and potentially damage the digital nerves. We examined the pressure applied by finger traps and consider the risk this poses to the digital nerves.
Standard finger traps were suspended from a spring balance and the author’s fingers inserted along with a length of rubber tubing. The tubing was filled with saline and connected to a digital compartment pressure monitor. The hanging mass was gradually increased and the pressure in the rubber tubing noted. This pressure was taken as analogous to the pressure affecting the neurovascular bundle.
Pressure increases linearly with increasing mass. A pressure of 500mmHg has been suggested as necessary to cause nerve injury1. Using non-invasive technique it was not possible to accurately measure the absolute pressure acting on the digital nerves. However the increase in pressure was noted.
Using weight to distract the wrist during arthroscopy has potential to cause nerve injury. We suggest that pressure insufflation combined with Chinese finger traps with minimum weight traction provides a more than satisfactory view at wrist arthroscopy and can avoid potential digital nerve injury. However traction through finger traps for other purposes such as fracture reduction may be used with caution.
To review the changing pattern of orthopaedic injury encountered by deployed troops with special regard to the importance of hand trauma sustained in conflict and non- war fighting activities.
Literature review relating to recent military operations (1990–2007) encompassing 100 conflicts worldwide. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded by Oxford Centre for Evidence-based Medicine Levels of Evidence.
Two hundred and ten published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. These works were primarily level five evidence comprising reviews, correspondence, sub-unit experiences and individual nation database analyses.
The importance of extremity trauma is clear. The combination of changing ballistics and increasing survivability off the battlefield leads to a previously under emphasised increase in complex hand trauma.
Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Articles concerning military hand trauma management were mainly published prior to the conflicts of the last decade. Within these papers injury classification and treatment priorities are highlighted as core knowledge for trauma surgeons.
This paper provides a review of conflict related injury patterns with special regard to hand trauma. The key learning points from historical literature are highlighted. Proposals for improving management of these injuries from battlefield to home nation are discussed with regard to training opportunities and dialogue to ensure past lessons are not forgotten.
Chronic instability of the acromioclavicular joint is relatively common and normally occurs following a fall onto the point of the shoulder. Reconstruction of the joint (Weaver-Dunn procedure) is often required in service personnel, and numerous methods of fixation have been used, including vicryl tape, PDS loops and the use of a hook plate. Many of these operative methods require a second operation to remove the plates and/or screws, and are associated with a failure rate of up to 30%.
The ‘Surgilig’ was designed as a method of revision for failed Weaver-Dunn procedures. However this study evaluates its use in the primary operation.
We prospectively followed up the Modified Weaver Dunn procedures using surgilig. The post-operative x-rays were reviewed at six weeks, 3 months and then 6 months when the patients were discharged to assess the radiological success of the procedure.
We have performed this procedure in 11 patients. Of the eight patients that have reached the six month postoperative time so far, at which they would be discharged from clinic follow-up, none have had radiological failure of the fixation. One patient even had weight-bearing x-rays taken at 6 weeks, with no detrimental effect. Even though a small study, the initial results for primary fixation of acromioclavicular joint disruption with surgilig are extremely encouraging. The study suggests that surgilig should continue to be used in its current role. As patient numbers increase, a follow-up study should be conducted to evaluate these preliminary findings.
We retrospectively studied 67 patients who underwent proximal humeral replacement with the Bayley-Walker prosthesis, for tumour of the proximal humerus between 1997 and 2007. Of the 67 patients 10 were lost to follow up. Of the 41 surviving patients, function was assessed using the Musculoskeletal Tumour Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) questionnaire.
4 of the 41 patients received the new Bayley-Walker ‘captured’ proximal humeral replacement. The mean age was 46 years (7–87). The mean MSTS score at follow-up was 72.0 % and the mean TESS score was 77.2 %. The sub-group of 4 pts who received the new captured prosthesis had a mean MSTS score of 77.7 %. There was no mechanical failure of any prostheses in the follow up period.
Endoprosthetic replacement for tumour of the proximal humerus with the Bayley-Walker prosthesis, is a reliable operation yielding reasonable functional results and good long-term prosthesis survivorship. The performance of this prosthesis is expected to improve further with the new ‘captured’ prosthesis.
We report on a group of 20 metal-on-metal resurfaced hips (17 patients) presenting with a soft tissue mass associated with various symptoms. We describe these masses as pseudotumours.
All patients underwent plain radiography and fuller investigation with CT, MRI and ultrasound. Where samples were available, histology was performed. All patients in this series were female. Presentation was variable; the most common symptom was pain or discomfort in the hip region. Other symptoms included spontaneous dislocation, nerve palsy, an enlarging mass or a rash. The common histological features were extensive necrosis and lymphocytic infiltration. Fourteen of the 20 cases (70%) have so far required revision to a conventional hip replacement and their symptoms have either settled completely or improved substantially since the revision surgery. Two of the three bilateral cases have asymptomatic pseudotumours on the opposite side.
We estimate that about 1% of patients develop a pseudotumour in the first five postoperative years after a hip resurfacing. The cause of these pseudotumours is unknown and is probably multi-factorial, further work is required to define this; they may be manifestations of a metal sensitivity response. We are concerned that with time the incidence of these pseudotumours will increase.
Classification systems are used for communication, deciding/planning treatment options, predicting outcome and research purposes. The vast majority of subtrochanteric fractures are now treated with intramedullary nails, which questions the need for classification.
Our objective was to assess the intra- and inter-observer reliability of the Seinsheimer, AO and Russell-Taylor (RT) classification systems and assess a new simple system (KMG).
The KMG system was developed to alert the surgeon to potential hazards: Type 1 – subtrochanteric fracture (ST#) with intact trochanters. Type 2 ST# involving greater trochanter (entry point for nailing difficulty). Type 3 –ST# involving lesser trochanter (most unstable).
32 AP and lateral radiographs of subtrochanetric fractures were classified independently by 4 observers twice with a 6-week interval (2 Consultants and 2 Registrars). The observers were asked to rank the systems based on how descriptive they thought they were, whether they felt they influenced treatment plan and whether they would predict outcome.
The intra- and inter-observer variation was poor in all systems. KMG gave the best inter-observer reproducibility (Kappa 0.3 to 0.6) followed by AO and RT, and then Seinsheimer. The observers felt that Seinsheimer and KMG were the most descriptive and would influence the treatment plan, and Russell-Taylor would perform worst at predicting outcomes. All of the fractures in this series united
The classification systems analysed in this study have poor reproducibility and seem to be of little value in predicting outcome of intramedullary nailing. The KMG system may be of some use in alerting the surgeon to potential problems.
Resurfacing arthroplasty is advantageous over conventional total hip arthroplasty in that femoral bone stock is preserved. However, there has been controversy over the preservation of acetabular bone stock in resurfacing arthroplasty, with the concern that it may result in excess reaming compared with total hip replacement. This is of concern as the prosthesis is primarily advocated in the young patient, who is likely to face future revision surgery.
We prospectively identified a cohort of 68 patients with primary hip osteoarthritis undergoing conventional total hip arthroplasty. During surgery, the excised femoral head and neck diameter was measured, along with the diameter of the final acetabular reamer used to achieve a bed of bleeding cancellous bone. The measured neck diameter was then used to calculate the minimum possible resurfacing head and cup sizes, with corresponding final reamer sizes that could have been used in each patient without neck notching for both Birmingham Hip Resurfacing (BHR, Smith & Nephew, 3rd Generation) and Articular Surface replacement (ASR, De Puy, 4th Generation). Reaming diameter and volume was compared for all 3 groups.
Mean reaming diameters for the THR, ASR and BHR groups were 51, 52 and 56mm respectively. Mean reaming volumes were 39, 40 and 47cc. There was a statistically significant difference between the THR and BHR groups for both reamed diameter and volume (p< 0.001). There was also a significant difference between the ASR and BHR groups for both reamed diameter and volume (p< 0.001). This difference was more pronounced with larger neck diameters.
Our data shows that the BHR results in more ace-tabular bone loss compared to total hip replacement. An implant with a lower profile acetabular cup and a larger variety of sizes such as the ASR may allow better preservation of acetabular bone stock.
The management of displaced femoral neck fractures in independent, healthy patients remains controversial. Acetabular erosion is a time dependant phenomenon and our aim was to assess the long-term outcome of the Universal Head bipolar with an Exeter stem.
49 consecutive cemented bipolar hemiarthroplasties were performed in 49 patients between 1992 and 2000. Mean age was 71.6 (range 54–91). There were 13 male and 36 female. 23 patients were alive at final follow up. 17 patients were assessed in outpatients with clinical and radiographic assessment. 2 patients had a telephone questionnaire and 4 patients were lost to follow up or were unable to attend clinic. Kaplan-Meier Survivorship analysis was performed.
Median follow up was 7.1 years (range 5–13.3 years). 26 patients had died by the time of final follow up. 5/14 patients (36%) with an ASA score of 3 died within 30 days. There was one dislocation and one periprosthetic fracture. There were no deep infections. There were no revisions for aseptic loosening or acetabular erosion. 75.6% of surviving patients returned to their pre-injury mobility level at 1 year. 5 year cumulative survival was 60% (95% confidence interval 46–74%). There was a statistically significant reduction in cumulative survival for ASA grades 3 and 4 compared to 1 and 2 (p=0.004).
Cemented bipolar hemiarthroplasty for femoral neck fractures is a good alternative to Total Hip Arthroplasty for independent, healthy patients. There is no evidence of acetabular erosion. Careful patient selection is necessary as patients with high ASA scores have greater mortality rates regardless of surgical prosthesis.
Most hospitals have introduced digital radiography (PACS) systems. Accurate pre-operative templating prior to hip arthroplasty requires precise information on the magnification of the digital image. Without this information the benefits of expensive digital templating programs (Orthoview-£10000) cannot be realised.
To determine the magnification of a digital image involves the placement of a “calibration object” at the level of the hip joint. This is unpopular with patients and radiographers alike. We describe a method that requires a single measurement to be made from the greater trochanter to the digital film.
An AP pelvis x-ray was taken of 50 patients with hip replacements. The “predicted” magnification was calculated using the new method. As the size of the head of the prosthesis was known the “actual” magnification could be calculated also. There was no significant difference at 0.05, Wilcoxon T, 2-tail test.
Conventional radiography, which assumes a magnification of 20%, results in errors up to 11%. Templating may therefore predict an incorrectly sized prosthesis. Our method is as accurate as methods using a calibration object whilst being acceptable to patients and staff. Its use should lead to more accurate pre-operative templating prior to total hip arthroplasty
Following the invasion of Iraq in April 2003, Coalition forces have been conducting counter-insurgency operations in a bid to maintain security within the country. The improvised explosive device (IED) has become the weapon of choice of the terrorist and is the leading cause of death and injury amongst Coalition troops in the region.
From Jan 2006, data was collected on 100 consecutive casualties who were either injured or killed during hostile action. Mechanism of injury, new Injury Severity Score (NISS), ICD-9 diagnosis and anatomical pattern of wounding was recorded in a trauma registry.
During the study period, 53 casualties were injured by IEDs in 23 incidents (mean 2.3 casualties per incident). Twelve (22.6%) were killed or died of wounds. Mean NISS score of survivors was 5.4 (Range 1–50). There was no significant difference in NISS scores of survivors from fatal and non-fatal incidents. A mean 2.61 body regions were injured per casualty. Limb injuries were present in 45 (84.9%) of casualties, but primary blast injuries were seen in only 9 (14%). Twenty (48.7%) of survivors underwent surgery by British surgeons in the field hospital. Sixteen (39%) were deemed fit to return to duty after injury.
IEDs used in Iraq do not follow the traditional pattern of injuries seen with conventional high explosives. Primary blast injuries were uncommon despite all casualties being in close proximity to the explosion. When the IED is detonated, an Explosive Formed Projectile (EFP) is formed which results in catastrophic injuries to casualties caught in its path, but causes relatively minor injuries to personnel sited adjacent to its trajectory. Enhanced vehicle protection may prevent the EFP from entering the passenger compartments and thereby reduce fatalities.
Despite modern advances, amputation is still a commonly performed operation in war. It is often difficult to decide whether to amputate following high-energy trauma to the lower extremity. To help guide this assessment, scoring systems have been developed with amputation threshold values. These studies were all conducted on a civilian population, encompassing a wide range of ages and methods of injury. The evidence for their sensitivity and specificity is inconclusive. The purpose of this study was to assess the validity of Mangled Extremity Severity Score (MESS), the only verified score, in a population of military patients with ballistic mangled extremity injuries.
52 military patients with 58 limbs who had ballistic mangled extremity injuries were identified, 13 of whom required amputation. Using both the trauma audit and the hospital notes, demographics were assessed. Patients were retrospectively evaluated with the MESS system for lower extremity trauma.
The MESS would not help in the decision-making. However, we were able to develop an algorithm for management, in particular the need for early amputation.
The management of ballistic extremity injuries in military patients should be considered separate to that of civilians with high-energy trauma extremity injuries. The authors have developed an algorithm to provide guidelines for management.
British military forces remain heavily committed in both Iraq and Afghanistan. A recent workload analysis from Op HERRICK identified a high surgical workload, particularly orthopaedic, under the care of a sole consultant orthopaedic surgeon. There are no orthopaedic training posts in UK that consistently provide training in ballistic trauma. In order to prepare Military orthopaedic trainees for future deployment, a new orthopaedic registrar post, on Op HERRICK, was created.
Prospective analysis of trainee and trainer operative logbooks, between Jan 27th and March 24th 2008, was performed. Records were kept of orthopaedic and postgraduate teaching schedules, audit and research projects and all OCAP training assessments.
One hundred and fifty-seven cases and 272 procedures were performed during the study period. Sixty-two per cent of cases were orthopaedic. Fourteen major amputations were performed and 7 external fixators applied. Five fasciotomies, 9 skeletal traction pins were inserted and 7 skin grafting procedures were performed. Limb debridement was the most common procedure (n=59). Eleven per cent of cases were children and 50 per cent of cases were emergencies. Thirty-eight per cent of cases were performed out of hours (18.00–08.00 hrs). Mean operating hours per week was 35 hrs. Four Procedure Based Assessments were performed and 16 hours of postgraduate education was conducted during the deployment. Two major audits were initiated and five publications were prepared, one has already been accepted for publication.
Trainee exposure to high-energy transfer trauma is high when compared to that seen in the NHS. The numbers of certain index procedures, such as external fixation, is similar to those achieved by an average orthopaedic trainee in six years of higher surgical training. The opportunity for one-on-one training exceeds that available in the NHS and learning and academic opportunities are maximised due to the close working environment.
Extremity injuries on the battlefield are commonly secondary to high energy mechanisms. These cause significant injury to soft tissue and bone and are contaminated. Evacuation to medical care can be difficult in the operational environment and may delay the time to initial surgery. There is already substantial literature on the complications of such injuries but this is the first report from UK forces. Our aim was to assess the complications, but specifically infections, in relation to delay in surgery and also the method of fracture stabilisation.
Military patients who had ballistic mangled extremity injuries were identified from the database (courtesy of ADMEM). Using both the trauma audit and the hospital notes, demographics were assessed. The injuries sustained (including the fractured bones), time to theatre, associated injuries, method of stabilisation at Role 3, definitive fixation and complications were noted.
81 patients were identified with 95 limbs injured (68 lower limb, 27 upper limb). The most commonly fractured bones were the tibia, radius/ulna, femur and humerus. Primary stabilisation was either ExFix (53%) or plaster (44%). Of those stabilised by ExFix, the definitive stabilisation was mainly by either a nail (44%) or plate (17%). Those stabilised by plaster mainly stayed in plaster. 72% of patients developed at least one complication, the most common of which was superficial infections. Other complications were deep infections, delayed union, haematomas, neuropathic pain and flap failures. The main organisms involved were Acinetobacter, Bacillus and Pseudomonas. There was no association between delay to theatre and decision to amputate. There was an association between the use of plaster for definitive stabilisation and superficial infection and plates for definitive stabilisation and deep infections. There was no association between time delay to theatre and infections.
This provides the first report of complications from extremity injuries secondary to ballistic missile devices in UK forces. It allows for comparison with reports from other sources on similar injuries and helps to guide further management of patients. In particular it agrees with recent civilian data that initial surgery does not have to be carried out as soon as possible, which has implications for military planning.
Our aim was to review the short-term clinical results of a single-institution cohort undergoing opening wedge high tibial osteotomy (HTO).
We undertook a prospective clinical and radiographic review of our cohort of patients who had undergone opening wedge HTO for varus malalignment. The Cincinnati scoring system was used for objective assessment. Pre- and post-operative radiographs were evaluated and Blackburne-Peel (BP) and Insall-Salvati (IS) ratios recorded, as well as integrity of the lateral hinge.
We reviewed 55 knees (51 patients: 34 men and 17 women; mean age, 44.2years; range 34–58years) followed up for a minimum 12 months (range, 12–62months). All patients had relief of pain, but six met our criteria of failed treatment where either revision fixation was required or proceeded to total knee arthroplasty for persisting symptoms. Cincinnati scores were 94.5% excellent (52/55) and 5.5% good (3/55) at 1 year, whilst at last follow-up they were 87.2% excellent (48/55), 9.1% good (5/55) and 3.6% fair (2/55). There was a significant improvement in mean American Knee Society score at 1 year and maintained at last follow-up (p< 0.05). Radiographically the lateral hinge was noted to be breached in 9.1% (5/55), but no incidence of non-union was identified. There was no significant change in IS index, however BP index diminished by a mean 15.3% (range, 7.4–28.2%). Medial opening wedge tibial osteotomy results in patellar infera, but successful clinical and functional outcomes have been demonstrated. The fact ther e is inconsistency between the two indices assessing patellar height ratio we believe reflects the inherent variability in the techniques employed. Distalisation of the tibial tubercle will mean the IS ratio remains unaffected, whilst the BP index more accurately demonstrates the lowering of patella relative to the joint line. However there may be other factors which are not immediately appreciated, such as changes in the tibial inclination or antero-posterior translation.
British military forces are heavily committed in Iraq and Afghanistan. Operation HERRICK, currently supported by a Role 2(Enhanced) medical facility at Camp Bastion, is predicted to continue for the next 10 years.
There has been no large published series on surgical workload on Operation HERRICK. The aim of this study is to determine and plan future medical needs.
A retrospective analysis of operating theatre records between 10th October 2006 and 31st Oct 2007 was performed. Data was collated on a monthly basis, to assess seasonal variation, and included patient demographics, operation type and time of operation.
During the study period 968 cases required 1262 procedures. Thirty-four per cent were ISAF, 27% were Afghan soldiers, police or enemy forces and 39% were civilians, of which, 43% were children. Ninety-one per cent were secondary to battle injury and 50% were emergencies. The breakdown of procedures, by specialty, was 67% (841) were orthopaedic, 16% (199) general surgery, 8% (96) head and neck, 5% (55) burns surgery and a further 4% (50) were non-battle, non-emergency procedures. During the second half of the study period 655 cases were operated on compared to 313 in the preceding half (p< 0.05). Twenty-eight per cent of cases were performed between 6pm and 8am.
Surgical workload remains consistently high throughout the study period, however there was significant seasonal variation with casualty rates being greater in the summer months, this may have bearing on the decision to deploy additional surgeons and trainees in the future.
Our aim was to review the short-term clinical results of a single-institution cohort undergoing opening wedge high tibial osteotomy (HTO).
We undertook a prospective clinical and radiographic review of our cohort of patients who had undergone opening wedge HTO for varus malalignment. The Cincinnati scoring system was used for objective assessment. Pre- and post-operative radiographs were evaluated and Blackburne-Peel (BP) and Insall-Salvati (IS) ratios recorded, as well as integrity of the lateral hinge.
We reviewed 55 knees (51 patients: 34 men and 17 women; mean age, 44.2years; range 34–58years) followed up for a minimum 12 months (range, 12–62months). All patients had relief of pain, but six met our criteria of failed treatment where either revision fixation was required or proceeded to total knee arthroplasty for persisting symptoms. Cincinnati scores were 94.5% excellent (52/55) and 5.5% good (3/55) at 1 year, whilst at last follow-up they were 87.2% excellent (48/55), 9.1% good (5/55) and 3.6% fair (2/55). There was a significant improvement in mean American Knee Society score at 1 year and maintained at last follow-up (p< 0.05). Radiographically the lateral hinge was noted to be breached in 9.1% (5/55), but no incidence of non-union was identified. There was no significant change in IS index, however BP index diminished by a mean 15.3% (range, 7.4–28.2%). Opening wedge HTO provides a means of relieving stress distribution through the medial tibiofemoral compartment and results in effective relief of symptoms with improvement in functional outcome and quality of life.
Patellar instability is a common clinical problem affecting a young, active population. A large number of procedures have been described to treat patellar instability. We present the clinical results in a case series of 25 medial patellofemoral ligament reconstructions in 21 patients with up to 30 months follow-up (mean 7.3 months).
Reconstruction was performed using either the gracilis tendon (6 cases) or semitendinosus tendon (19 cases) autograft. At follow-up the Tegner activity scores, objective knee function, complications and reoperations were assessed.
No patella re-dislocations were observed. Five patients (20%) required a manipulation under anaesthetic but subsequently regained a satisfactory range of motion. Two patients (8%) had post operative complications. One patient developed a post operative infection which required a washout and one patient developed a neuroma related to the hamstring harvest site which was excised. Both subsequently returned to work with a full range of motion.
Medial patellofemoral reconstruction with both gracilis and semitendinosus tendon graft provided good postoperative patellar stability restoring the primary soft tissue restraint to pathological lateral patellar displacement.
Good perioperative analgesia following Total Knee Replacement facilitates rehabilitation and may reduce hospital stay. A multimodal drug injection has been shown to provide excellent pain control and functional recovery, and was introduced into the operating practice of one Arthroplasty surgeon during his Total Knee Replacements.
We compared the rehabilitation of 27 consecutive patients (group 1) following their Total Knee Replacement under spinal anaesthesia receiving the periarticular infiltration mixture, consisting of levobupivacaine, ketorolac and adrenaline at the end of surgery. Their rehabilitation was compared to group 2, a historical group operated on by the same surgeon before the introduction of the multimodal drug injection. These patients were age and sex matched and had received a Femoral and Sciatic block at the time of their operation.
Patients in group 1 had lower analgesic and anti-emetic requirements than group 2. Group 1 also had a shorter time to Strait Leg raise.
Periarticular multimodal drug injection can improve perioperative analgesia and mobilisation following Total Knee Replacement as well as reducing opioid side effects.
It has long been recognised that the periosteal membrane has osteogenic capability and experimental studies have concluded that periosteum transplanted to a distant site could also be osteogenic. This ability of periosteum to generate new bone at distant sites may have clinical application. In the laboratory setting however periosteal flaps in animals have demonstrated variable results. Little clinical work using the technique of periosteal transfer has been reported, with only individual case reports in the literature.
A clinical review of a series of three fracture patients in whom vascularised periosteal transfer has been used is presented. Cases involved a primary bony defect at the fracture site (first metatarsal), established non-union (tibia) or post-traumatic AVN (talar dome). The technique is described and clinical follow-up of the patients is presented.
In each instance evidence of lasting new bone formation was demonstrated clinically and radiologically.
The efficacy of this technique in forming new bone is demonstrated. The technique may have utility alongside other techniques in cases where new bone is required.
To determine if extended scope physiotherapists perform to the same standards as their orthopaedic colleagues with regards to diagnosing knee pathology and making appropriate referrals for arthroscopy.
Data was collected prospectively from Aug 2005. Patients were seen in a consultant led orthopaedic clinic by an Extended Scope Physiotherapist (ESP), a registrar or the consultant. All patients placed onto the waiting list for knee arthroscopy were considered for the study. The outpatient diagnosis and demographic data were recorded and compared against the arthroscopy findings. A single consultant surgeon performed the arthroscopies.
300 patients were included in the study (100 in each group). Each group was similar in terms of presenting complaint and demographics. There was no significant difference between the ESP’s and registrars in their ability to diagnose intraarticular pathology (CHI squared test: X 2.031, df 1, p=0.15). When only cruciate and meniscal pathology were considered there was also no significant difference between the ESP’s and the registrars (Fishers test p=0.12 and p=0.22 respectively, 2-tail test) The ESPs performed particularly well in their ability to diagnose cruciate injuries (sensitivity 100%, specificity 100% and PPV 100%). Both ESPs and registrars had high sensitivity but low specificity with regards to diagnosing meniscal pathology suggesting a low threshold for a positive diagnosis and a poor ability to correctly diagnose those patients who did not have a meniscal injury. Of the 300 patients only 9 unnecessary arthroscopies were requested. None were requested by the ESPs.
Extended scope physiotherapists perform a useful role in orthopaedic outpatients. They perform as well as orthopaedic registrars with regards to making the correct diagnosis and the selection of patients for arthroscopy.
Intervertebral discs (IVDs) are fibrocartilagenous ovoids located between the vertebral bodies of the spine that provide the sole source of flexibility in that structure. IVDs are clinically very important as degeneration has been shown to be strongly associated with lower back pain, sciatica, and disc herniation: potentially disabling conditions that affect a very large section of the UK population.
The aetiology of disc degeneration is poorly understood although upregulation of matrix metalloproteinase (MMP) activity is thought to be involved. Degradation products of the extra-cellular matrix are known to increase MMP production and activity in other tissues. This project concentrated on examining the effects of degredation products of elastin. Elastin fragments (κ-elastin peptides) have been shown to upregulate mRNA levels and increase expression of pro-MMP-1 in human skin fibroblasts, cells that are thought to be similar to those residing in the annulus fibrosus of intervertebral discs. This study examined their effect on disc cells and on skin fibroblasts.
Total MMP-2 and -7 activity produced by cells extracted from the annulus fibrosus of bovine intervertebral disc cells and cultured for 24 hours with 0–300μg/ml κ-elastin was determined using fluorimetric and zymographic analyses. κ-elastin was prepared from bovine ligamentum nuchae or bovine intervertebral discs.
Culture with κ-elastin prepared from bovine ligamentum nuchae caused skin and disc cell potential pro-MMP-2 activity to increase in a dose-dependent manner; the potential pro-MMP-2 activity of both cell types is more than doubled when cultured with 300μg/ml κ-elastin.
These findings suggest that in the bovine disc, matrix breakdown may cause a feedback loop with degraded elastin stimulating disc cells to increase production of pro-MMP-2, with the possibility of further degrading elastin and other proteins and contributing to IVD breakdown.
Failure of fracture healing is a significant problem, resulting in considerable morbidity and financial costs to the NHS. It is also a major complication of ballistic injuries.
We reviewed our experience in the management of non-union by revision of fracture fixation and use of Bone Morphogenic Protein at Ministry of Defence Hospital Unit Frimley Park. Bone Morphogenic Proteins have been identified as promoting osteogenesis and have been used to stimulate bone growth in fracture revision surgery and spinal surgery. BMP’s are a subgroup of the TGF-β family and consist of at least 20 different subtypes of which BMP 2 and BMP 7 are commercially available. Current preparations include a solution for application to a gel matrix and as a powder for reconstitution to a paste for implantation to the fracture site. Costs per graft are in the region of £2,000.
BMPs have been used at Frimley Park since 2005 in the management of 12 patients with established non-union. These included fractures of 4 femurs, 5 humerai, 2 clavicles and 1 metatarsal. Early results are encouraging and support continued use of BMP’s in fracture revision surgery for established non-union.
Non-union remains a difficult problem and even with this treatment there was a significant failure rate, often associated with failure of fixation.
The outcome of arthroscopic ankle fusion has been favourably reported in the literature. The technique allows for early weight-bearing and results in fusion earlier than that of open techniques. All authors state that it a demanding procedure that has a significant learning curve. The purpose of this presentation is to report on that learning curve by analysing the first two years experience of one surgeon. Technical details, difficulties encountered and outcomes are described.
We analysed the results of arthroscopic ankle fusion in 14 consecutive ankles in 13 patients over a two-year period. Average age at fusion was 59 years. There were 12 male patients and one female. Indication for surgery was osteoarthritis in all patients. All were non-smokers at the time of surgery. Anti-inflammatory drugs were not prescribed on discharge, All patients underwent pre-operative sciatic nerve block using a nerve stimulator. Fixation of the fusion was performed with two screws in 13 ankles and a single screw in one. Mean tourniquet time was 117 minutes (first 4 cases averaged 124 minutes; last 4 averaged 105 minutes). Mean hospital stay was a single night. All patients were treated post-operatively with plaster cast immobilisation for two weeks (non-weight bearing). Subsequently, they were instructed to fully weight bearing as tolerated in a removable walking boot.
Radiological union was achieved in 11 ankles within 3 months. One ankle fused at between 9–12 months post-operatively. One ankle failed to unite due to inadequate joint access and preparation and underwent later open revision with bone grafting. One case of superficial portal wound infection treated successfully with antibiotics. No thrombo-embolic events. All patients had excellent or good clinical results at last follow up.
Patient selection issues and intra-operative learning points are discussed. With adequate training, arthroscopic ankle fusion is a safe and reliable technique.
The level of accuracy and precision required for consistently good surgical results will vary depending upon the characteristics of surgical task being undertaken. Training surgeons to achieve these results rapidly and effectively is a continuing challenge. Resurfacing arthroplasty for cam type deformity (a common cause of early osteoarthritis) is a technically demanding operation. We considered it desirable that the operation should be performed within +/− 10¡ of the desired angular orientation, and +/− 6mm of entry point translation in 95% of cases. To achieve that level of accuracy, without learning slowly on real patients, technological aids are now available. Using 3 models of varying severity of cam, we assessed the efficacy of 3 systems of instrumentation in delivering the level of accuracy and precision that is needed to ensure the excellent results that this surgeon and patient group expects.
Our purpose wasto determine if oral midazolam reduces the anxiety of children undergoing removal of percutaneous Kirschner wires (K-wires) from the distal humerus in the Orthopaedic Outpatient Department.
This was a prospective double blind, randomised controlled trial. 46 children aged between 3 and 12 years who had supracondylar fractures of the distal humerus internally fixed with K-wires were randomised into 2 groups. 0.2mg/kg oral midazolam (active group) or the same volume of an oral placebo (control group) was administered 30 minutes prior to removal of K-wires.
Venham Situational Anxiety Score was performed before and immediately after removal of K-wires. University College London Hospital sedation score was recorded every 20 minutes.
42 children with an average age of 7.1 years (range 3.6–12.3 years) had complete documentation for analysis. The two groups had similar demographics. All wires were removed in the clinic with or without midazolam.
There was no significant difference in anxiety scores between the groups either before or after wire removal. The change in scores was not significantly different between the 2 groups. However, 45% of children in the active group had reduced anxiety levels in the active group compared to 18% of children given placebo but this difference was not significant (p=0.102). No child was excessively sedated but one in the active group became agitated and restless.
The anxiety scores before and after wire removal in the active group were not significantly different from the placebo group scores. We do not recommend the routine administration of midazolam (0.2 mg/kg) to all children requiring k-wire removal in the outpatient department.
To illustrate the incidence and epidemiology of fractures due to football.
All inpatient and outpatient fractures from a prospectively collected database for a defined population in 2000 were retrospectively analysed.
There were 396 football fractures, 96% male. Football caused 39% of the 1022 sports fractures in 2000. This represented 5% of the 8151 fractures in total. The incidence was 61/105. 115/105 in males and 5 /105 in females. The average age was 22.9 years; 22.8 in males and 26.6 in females. 77% of fractures were treated as outpatients. The top five fractures representing 84% of the injuries were Radius+Ulna 30%, Phalanx 19%, Tibial+Fibula 18%, Metacarpal 11% and Clavicle 5%. 71% were upper-limb fractures. The busiest two months were October and May 17% and 14% respectively. The quietest two months were February and December at 5%.
Although the epidemiology of football injuries will vary amongst different populations, these results can be generalized to similar population bases. Results will be valuable to medical professionals supporting football teams, enabling them to focus their attention on treating the most common injuries, the majority being treated as outpatients.
Football is the most common cause of fractures in sport. As participation increases, the incidence of fractures is likely to reflect this. Upper limb fractures account for over 2/3 rd of fractures with radius+ulna fractures accounting for up to a 1/3rd of fractures; the majority can be treated as an outpatient. Therefore medical teams should be familiar with standard treatment regimes, possible impact on players’ futures and time out of sport.
32 students of surgical technology were instructed in hip resurfacing, and shown detailed plans of the desired operative outcome for the 3 cam type hips. They then used conventional instruments, image-free navigation (brainlab) and image based navigation(Acrobot).
Only image based navigation performed well enough at navigating these difficult cam type hips with novice surgeons. Conventional instruments were not sufficient, with a tendency for the novice to put the hip in varus and translated low on the femoral neck. Image free navigation was more accurate than conventional instruments, avoiding the serious complication of notching but the range of error was 18mm and 10¡.
Image based navigation appears to be fit for purpose in delivering both the accuracy and the precision needed by the novice surgeon in the skills laboratory who needs timely feedback so his clinical experience may start substantially further along the learning curve of this or any other technically demanding operation.