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 settingsA longer stay in the hospital after primary total hip replacement is consistent with an increased morbidity and slower recovery for patients. In addition, it is among the more costly aspects of a total joint replacement. A process, which reduces the length of stay following this procedure and synchronically maintains the high standards of safe care would certainly improve the clinical practice and provide financial benefits.
Our objective was to evaluate the efficiency of a holistic perioperative, accelerated recovery programme following this procedure and in particular to assess its impact in the shot term patient’s recovery, morbidity, complications, readmission rate and cost savings for the NHS.
Eighty-nine patients participated in our rapid recovery programme, which is a comprehensive approach to patient care, combining individual pre-operative patient education, pain management, infection control, continuous nursing and medical staff motivation as well as intensive physiotherapy in the ward and the community. Forty-eight male and 41 female patients with an average age of 69 (range-50 to 87) underwent a total hip replacement in an NHS District General Hospital. The average BMI was 28 (range-18 to 39) and the average ASA 2.3 (range-1 to 4). The procedure was performed by 3 different surgeons using the same operative standards. A standardised post-operative protocol was followed and the patients were discharged when they were medically fit and had achieved the ward physiotherapy requirements. They were then daily followed up by a community orthopaedic rehabilitation team in patient’s own environment as long as it was required.
The average length of stay was reduced from 7.8 days to 5. There was no increase in complications–or readmissions rate while there were significant cost savings. The waiting list for this surgery was reduced and the patient’s satisfaction was high.
The rapid recovery programme for primary total hip replacement surgeries has been proved to be an efficient method of reducing the length of stay in hospital and consequently the financial costs while it ensures the safe and effective peri-operative management of patients.
The ‘gold standard’ for treatment of chronic ankle instability is Brostrom-Gould procedure, which is an ‘open’ surgery.
Most authors recommend this type of operation even after an arthroscopic inspection of the joint.
The arthroscopic methods, including thermal shrinkage, propose in the past didn’t received a widely spread support.
We present a method of arthroscopic lateral ligament ‘repair’ with an anchor placed in the fibula.
We used this technique on 31 consecutive patients (28 were available for follow-up).
21 patients were victims of work or traffic accidents and 3 had sport-related lesions.
The patients were evaluated after a 24,5 month follow-up.
The average post-op AOFAS score was 85,3 and average satisfaction was 3,77 (1 to 5)
We had two ‘relapses’ (another sprain without instability on the stress XR). On 3 patients we had some wound healing problems and we had 3 lesions of the superficial peroneal nerve, one of these is persistent. One patient developed a deep vein thrombosis post operatively.
With this method, we achieved good results with relatively few complications, even more considering that most of the patients were work-compensation cases. It’s a simple procedure, less ‘aggressive’ then the traditional one’s, producing an anatomical and functional repair of the lateral ligament.
We report 114 of 117 (97% follow up) consecutive metal-on-metal hip resurfacings in 105 patients with a minimum of 5 years follow up implanted between October 1999 and May 2002. Revision of either the femoral or acetabular component during the study period is defined as failure. No other revisions have been performed or are impending. We had 4 failures giving us survivorship at 5 years of 97% (95% confidence interval (CI) 94 – 100). The mean follow up was 72 months and the mean age at implantation was 54.5 years old (Range 35 – 75). All patients were followed up clinically and radiographically.
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 12 hips (10%) and we define a technique for measuring thinning. Heterotropic ossification was present in 17 hips and lucent lines around the femoral component in 10 hips.
This study confirms that metal-on-metal resurfacing produces an excellent clinical and functional outcome in the younger patient who requires surgical intervention for hip disease. The results compare favourably with those from the originating centre and confirm that resurfacing is well suited for younger higher demand patients. It is the first study with a minimum 5 year follow up from outside the originating centre.
Venous thromboembolism (VTE) is a potentially fatal complication after total hip replacement (THR) and may be associated with a considerable economic burden. In many centres, thromboprophylaxis using a subcutaneous (sc) anticoagulant in patients undergoing THR is restricted to 14 days or less. Rivaroxaban is a once-daily, oral, direct Factor Xa inhibitor in advanced clinical development for thromboprophylaxis after major orthopaedic surgery; it does not require monitoring or dose adjustment. In a phase III study, RECORD2, oral rivaroxaban 10 mg, given once daily for 35±4 days, significantly reduced the incidence of the primary endpoint (deep vein thrombosis, pulmonary embolism and all-cause mortality), compared with 40 mg sc enoxaparin, given for 14 days (2.0% vs 9.3%, respectively; relative risk reduction 79%; p< 0.001). The incidence of bleeding was low and similar in both groups, despite extended thromboprophylaxis with rivaroxaban. This analysis demonstrates the economic impact of extended thromboprophylaxis with oral rivaroxaban. The effect of rivaroxaban on healthcare costs was based on the primary efficacy results, and the associated reduced administration and monitoring costs, and includes non-drug costs only. The cost of symptomatic VTE was taken from published sources in the US and the UK 2007 NICE Guidelines. It was assumed that nurses spent 3 mins/day administering enoxaparin and training patients to self-inject for outpatient use. Hospital duration was 5 days. In the UK, full blood counts should be taken every 3 days when receiving enoxaparin. The total US health-care resource cost was $192/patient for enoxaparin and $39 for rivaroxaban (excluding drug costs). This saving of $153 was driven by reduced hospital costs associated with fewer VTEs when using rivaroxaban. In the UK, the total healthcare cost/patient was £44 with enoxaparin and £2 with rivaroxaban – savings driven equally by reduced hospitalization and monitoring costs with rivaroxaban prophylaxis. The different cost savings in the US and UK are due to higher US hospital costs. The costs of post-thrombotic syndrome (PTS) were excluded in this analysis. PTS has an estimated 5-year rate of 21% after asymptomatic VTE and 30% after symptomatic VTE, at a total cost/patient of more than $11,000 in the US and £4000 in the UK. Given the reduction in all VTE events with rivaroxaban, there are potential further healthcare cost savings due to reduced PTS. The RECORD2 study showed that extended prophylaxis (35 days) with rivaroxaban was significantly more effective than short-term enoxaparin (14 days) for the prevention of VTE, and was not associated with an increased risk of bleeding. This analysis illustrates an additional benefit of once-daily, oral rivaroxaban in the reduction in healthcare costs related to administration and monitoring.
extent of fracture in percentage along the intertrochanteric line angle of the fracture line.
Both these parameters were measured on a plain anteroposterior radiograph. To measure the length of fracture we have drawn a straight line along the medial border of femoral shaft extending proximally in to the pelvis. Then we measured the distance between the most superior point of the fracture line on the lateral cortex and the midpoint of lesser trochanter on the first line. Then we measured the length of the fracture starting from the most superior point on the lateral cortex. We estimated the percentage of this fracture length in relation to line.
To estimate the angle, again we have drawn a straight line along the medial border of femoral shaft extending proximally in to the pelvis. We have drawn another line in the direction of fracture staring from most superior point of fracture on the lateral cortex joining the first line. We measured the angle between these two lines (Fig 2). We used our Hospital PACS system to measure the angles and the length of the fracture.
Clostridium difficile associated diarrhoea (CDAD) has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. A major risk factor for the development of CDAD in patients who undergo operation for fracture neck of femur is the perioperative antibiotic exposure, with cephalosporins being particularly implicated. The type ‘027’ strains of C. Difficile are multi-resistant and cause severe morbidity and mortality. A retrospective audit was performed to study the effect of C. Difficile infection in operated fracture neck of femur patients.
There were 19 (55.5%) trauma admissions with fractures and 15 (45.5%) elective admissions. There were 12 (35.2%) patients with previous gastric problems. There were 20 (59%) patients who were on gastric irritant medications, out of which only 5 (25%) were on gastro protective medications. All 34(100%) patients were on low molecular weight heparin for thromboprophylaxis. There were 2 patients on steroids and 2 patients on warfarin.
Coffee ground vomitus occurred preoperatively in 4 (13.4%) and postoperatively in 26 (86.6%). It happened with in the first six hours after surgery in 25 (96.5%) patients. Only in one patient it happened after 3 weeks.
All patients were kept nil by mouth, started on fluid resuscitation and intravenous ranitidine followed by oral omeprazole. Patients who were haemodynamically unstable were investigated by endoscopy. 17 (50%) patients had oral gastroduodenoscopy. 2 patients had blood transfusion because of significant drop in haemoglobin and one died before the transfusion was started.
There were 5 (14.7%) deaths in our study group. The cause of 2 deaths was directly related to gastrointestinal bleeding and the other three were confirmed to have had concurrent chest infection.
We present a retrospective analysis of 50 cases of cuff tear arthropathy, treated over past seven year period by use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3 years. Mean (SD) age was 81.3 (9.2) years and female to male ratio was 5:1. Six patients had bilateral reverse geometry shoulder replacements. Patients were assessed with preoperative Oxford and American Shoulder and Elbow Scores Society score (pre-op ASES) and post-operative American Shoulder and Elbow Society Score (post-op ASES), Oxford, Constant and SF36 scores. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post operative Oxford score was 27.25 (95% CI: 18.4 – 27.6). Mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). X-ray review was performed to assess scapular notching and Sirveaux score was used to grade extent of notching. 11 patients had Sirveaux grade 0, 5 had grade 1, 6 had grade 2, 12 had grade 3 and 8 had grade 4 notching. Intra-operative complications included 2 glenoid fractures. Post-operative complications included 2 acromion fractures and 2 episodes of subsidence with dislocation. None of the patients developed post operative haematoma. There was one episode of infection in one patient that required further surgery. Iteration of approach with increasing experience over the years will be discussed. Ours is the biggest series of reverse geometry prosthesis used for irreparable rotator cuff tear arthropathy published so far in the literature and our results have shown superior results in terms of improvement in function and complications. We conclude reverse geometry shoulder replacement provides reasonable improvement in pain and function in elderly population with massive cuff tear arthropathy of shoulder.
Manoli and Schaeffer in 1987, showed that fixation by antiglide plate demonstrated superior static biomechanical properties compared to lateral plating.
However there are some shortcomings in their study and hence we decided to perform our biomechanical study. The shortcomings of the Manoli study are. They did not use an interfragmentary lag screw for lateral plate fixation. It was a cadaveric study where the bone does not accurately represent the live bone. The quality of the bone ranging from normal to osteoporotic bone varies from cadaver to cadaver and hence there is no uniformity between the samples.
These bones were custom made for the experiment. We used two sets of bones, one representative of normal bone (Set A n=10) and the other of osteoporotic bone quality (Set B n=10). Each of the sets A & B will have two types of fixations for artificially created Weber B Fractures.
Lateral plate with interfragmentary lag screw. Antiglide plate with interfragmentary lag screw.
The strength of the fixation was measured by restressing the bone until the fixation failed using an Instron machine which simultaneously applied torque and compressive forces to the fibular construct. The resulting data was analysed on a computer and statistical analysis was performed.
Single Photon Emission Computed Tomography – Computed Tomography (SPECT-CT) combines metabolic information with an exact anatomical localization. We hypothesised that diagnostic infiltration with a local anaesthetic of a painful hindfoot or midfoot joint showing 99mTc-DPD-uptake in SPECT-CT, leads to a positive OA pain response.
Periprosthetic humeral fractures are rare but their numbers tend to increase because of the development of shoulder prostheses. We analysed our cases to see if some therapeutic guidelines can be provided.
Histomorphological examinations including synovial cell coating, appearance of tendon and tissue interface, inflammation and scarring of the site of surgery were done. The results were analyzed statistically (Kruskal-Wallis-test; Jonckheere Terpstra-test).
Secondly, we proposed that fixation with alternate cortical screws from both sides of the cortices (2C) may confer a stronger mechanical stability than fixation with all screws from one side (1C).
The concept of tension band wiring is based on the fact that the distractive force applied to one surface of the bone will result in compression on the opposite articular surface.
Clinical outcomes of TBW are not equivocal. It is associated with significant morbidity such as non union, failure of fixation, especially in osteoporotic bone and infection which sometimes leads to amputation. Often a second procedure for removal of prominent metal work is required.
In our biomechanical study we investigated this concept as we believe that the forces generated by TBW construct do not generate significant compressive forces required for healing of fracture.
The advantage of using 4th generation composite bone model is that it provides uniformity which is not achievable in cadaveric studies. Two different bone models representative of Olecranon and patella were used. Transverse fractures were created in the bones and fixed with TBW technique as described in A.O. manual.
Two 0.062-inch Kirschner wires and figure of eight configuration of 18G Stainless steel wire with single knot technique was used. Micro motion transducers (DVRT: MicroStrain, Williston, Vermont) with an accuracy of ± 1μm were placed across the fracture site both anteriorly and posteriorly. Continuous information regarding fracture distraction and compression, as determined by the transducers was recorded from both sites simultaneously during the experiment.
The tension band wire construct was loaded up to a maximum force of 4000 Newtons for patella and 500 for the olecranon. The fractures were subjected to cyclic loading at 1Hz using a servo hydraulic materials-testing system (model 8500; Instron, Canton, Massachusetts). The results were analysed on a computer and statistical analysis performed.
The ability of hMSCs to differentiate into several mesenchymal cell lineages including the osteoblast lineage plays a key role in skeletogenesis and bone regeneration. Although the importance of physical factors in the development and maintenance of bone tissue has been recognized for many years and we previously demonstrated that mechanical strain constitutes an inherent stimulus for osteogenic differentiation of undifferentiated hMSCs, there is strong evidence to suggest that obesity is an independent factor in the risk of implant failure due to aseptic loosening or fracture after TJR. While mechanical complications and overload have been widely suggested, we hypothesized that the osteogenic mechanoresponse of hMSCs may be profoundly altered in obese patients.
hMSCs were isolated from bone marrow of 10 donors (BMI ranging from 18.7 to 37.6 kg/m2). The individual response of unidfferentiated hMSCs to cyclic tensile strain (CTS) was determined in a two-armed study design (strained versus unstrained (CTR)) using a 4-point bending device, where strain was restricted to a maximum of 3,000 μstrain. Phenotypic effects were characterized by analyzing cell numbers, cell viability and ALP activity; mRNA levels of marker genes related to early osteogenic differentiation (RUNX2, ALPL, SPARC, SPP1), protein synthesis (COL1A1), and cell cycle (MKI67) were determined by real-time RT-PCR. Possible contributions to anthropomorphometric variables and individual triglycerides, cholesterin, glucose, leptin, adiponectin, resistin, and estradiol levels were evaluated by linear regression analysis.
We found a significant up-regulation of the osteogenic marker genes due to CTS, including RUNX2 (1.9 fold), ALPL (2.4 fold), SPP1 (2.8 fold), and SPARC (4.1 fold), which was accompanied by an increase in cell-based ALP activity from 6.1 ± 1.2 μM/min/106 in CTR to 8.5 ± 1.7 μM/min/106 in CTS (plus 39.6 ± 9.8% SEM, P< 0.05). Cell density was significantly lower following CTS (minus 20.0 ± 4.7%, P< 0.05), which was also found for cell viability (XTT minus 17.8 ± 5.6%, P< 0.05). As a consequence, the phenotypic CTS response (ALP activity w/o normalization) ranged widely between donors (−30.8% to +60.1%) and was highly significant inverse correlated to donor’s BMI (r= −0.91, P< 0.0001). Additionally, leptin and estradiol levels determined within bone marrow plasma were significantly correlated with the phenotypic mechanoresponse (r=−0.71, P=0.028, and r=0.67; P=0.039; respectively).
The findings demonstrate that the osteogenic mechanosensitivity of hMSCs is highly affected by physiological factors related to donor’s BMI. Such an upstream imprinting process within bone marrow may be an important area of further research, since obesity-linked problems constitute increasing concerns in orthopaedic surgery within the western world.
Mesenchymal stem cells (MSCs) from bone marrow are multipotent cells capable of forming cartilage, bone, and other connective tissues. The objective of this study was to determine whether the use of allogenic mesenchymal stem cells could functionally heal defect in the distal femoral physis in rabbits without the use of immunosuppressive therapy. An iatrogenic defect was created in the lateral femoral condyle of thirty-two New Zealand white rabbits, 7 weeks old, that weighed 2.25 ? 0.24 kg. Each defect, 3.5 mm in width and 12 mm in length, in the right distal femoral physis was treated with allogenic mesenchymal stem cells in new composite hyaluronate/ collagen type I/fibrin scaffold. The healing response was evaluated radiographically, by MRI (at three weeks and four months after implantation), and also histologically, by Pearls’ reaction and with immunofluorescency (at four months after implantation). The results were compared with the data for the control defects (without stem cell implantation) in left distal femoral physes. In average, right femurs with damaged distal physis and transplanted MSCs grew more in length (0.55? 0.21 cm) as compared with left femurs with physeal defect without stem cell transplantation (0.46? 0.23 cm). Valgus deformity of right femurs with physeal defect and transplanted MSCs was mild (0.2? 0.1°). On the contrary, left femurs with physeal defect without transplantated MSCs showed significant valgus deformity (2.7? 1.6°). For defects treated with allogenic mesenchymal stem cell implants, no adverse immune response and implant rejection were detected in this model. Histologically, no lymphocytic infiltration occurred. At four months after transplantation, hyalinne cartilage had formed throughout the defects treated with allogenic MSCs. Labeled mesenchymal stem cells/diferentiated chondrocytes were detected in the physeal defects based on magnetic resonance imaging and immunofluorescency. The results of this study demonstrated that allogenic mesenchymal stem cells in a new composite hyaluronate/collagen type I/fibrin scaffold repaired iatrogenic defects in the distal femoral physes in rabbits without the use of immunosuppressive therapy. The use of allogenic mesenchymal stem cells for the repair of physeal defects may be an alternative to autologous MSCs transplantation. An allogenic approach would enable mesenchymal stem cells to be isolated from any donor, providing a readily available source of cells for cartilage tissue repair.
In finite element (FE) analysis of long bones it is now common practice to calculate the material properties based on CT data. Although a unique material property is calculated for each element, assigning each element an individual material property results in excessively large models. To avoid this, it is usual to group the elements based on their material properties and to assign each group a single material property (Zannoni 1998). No study has analysed the effect the number of material properties used in a long bone FE model has on the accuracy of the results.
The aim of this study was to evaluate the variation in the calculated mechanical environment as a function of the number of material properties used in an FE model.
An FE mesh of a cadaveric human tibia containing 47,696 ten-node tetrahedron elements and 75,583 nodes was created using CT scans. Material properties were calculated for each element of the mesh based on previous work (Rho 1995, 1996). Eleven FE models were created by varying the number of groups (1, 2, 4, 8, 16, 32, 64, 128, 256, 512, 1024) the elements were divided into. A single material property was assigned to each group. All models were subject to an axial point load of 300N applied on the medial condyle of the tibial plateau while the distal end was fixed. The variation in maximum and minimum principal strains and deflections, at 17 well distributed surface nodes and at 65 randomly distributed nodes within the bone were plotted against the number of element groups. The total strain energy was also plotted against the number of groups. The errors for strain, deflection, and total strain energy were calculated for each model assuming that the model using 1024 element groups was accurate.
The parameter to converge with the least number of element groups was the total strain energy. At 512 element groups the error was less than 0.001% (0.7% for the two material model). The next to converge were the displacements. Using 512 materials the maximum error in displacement at the surface nodes was 0.001% (4.7% for the 2 material model), while for the internal nodes the maximum error was 0.53% (36.7% for the 2 material model). The least convergence occurred for principal strains. The maximum errors when 512 materials were used were 1.06% (57.7% for the 2 material model) and 3.02% (104.5% for the 2 material model) for the surface and the internal nodes respectively.
This study demonstrates the relationship between the accuracy of calculated mechanical environment and the number of material properties assigned to the model. While this study will allow the analyst to make an informed decision on the number of material properties for modelling the human tibia it also helps examine the validity of previous studies which, usually due to limited resources, used fewer material properties.
The immunosuppressive drug rapamycin (RAPA) prevents rejection in organ transplantation by inhibiting interleukin-2-stimulated T-cell division. RAPA has also been suggested to possess strong anti-angiogenic activities linked to a decrease in production of vascular endothelial growth factor (VEGF). Because VEGF is a key growth factor in fracture healing, the present study was conducted to analyze the effect of RAPA on bone repair.
For the herein introduced study 35 SKH-1Hr mice were treated by a daily intraperitoneal (i.p.) injection of RAPA (1.5mg/kg/d) from the day of fracture until sacrifice. Two or five weeks after fracture, animals were killed and bone healing was analyzed using radiological (n=16 at 2 weeks; n=16 at 5 weeks), biomechanical (n=2x8), and histomorphometric (n=2x8)
X-ray analyses demonstrated that RAPA treatment inhibits callus formation after 2 weeks of fracture healing. The radiologically observed lack of callus formation after RAPA treatment was confirmed by histomorphometric analyses, which revealed a significantly diminished callus size and a reduced amount of bone formation when compared to vehicle-treated controls. Biomechanical testing further demonstrated that RAPA significantly reduces torsional stiffness of the callus (11.5±5.9% of the contralateral unfractured femur vs. 28.3±13.9% in controls; p< 0.05). Of interest, this was associated with a decrease of callus VEGF and PCNA expression. After 5 weeks of fracture healing, however, the negative impact of RAPA on fracture healing was found blunted and the radiological, histomorphometric and biomechanical differences observed after 2 weeks could not longer be detected.
We demonstrate that RAPA treatment leads to a severe alteration of early fracture healing. The negative action of RAPA on fracture repair at 2 weeks is most probably due to an inhibition of VEGF expression within the callus as suggested by the results of the Western blot analysis, demonstrating during the early phase of fracture healing a significantly reduced expression of VEGF and PCNA after RAPA treatment. This indicates a substantial alteration of cell proliferation and angiogenic vascularization during initial fracture healing. Since T-cells contribute to delayed fracture healing, RAPA may promote bone healing at later stages due to a reduction of interleukin-2-stimulated Tcell division.
A variety of scaffolds, including collagen-based membranes, fleeces and gels are seeded with osteoblasts and applied for the regeneration of bone defects. However, different materials yield different outcomes, despite the fact that they are generated from the same matrix protein, i.e. type I collagen. Recently we showed that in fibroblasts MMP-3 is induced upon attachment to matrix proteins in the presence of TGFbeta.
The reconstruction of bone defects with biomaterials represents a potential alternative to the transplantation of autologous and allogenic bone. Ceramic materials can be combined with growth factors (i.e. BMPs) to render them osteoinductive. Coating of biomaterials with growth factors has mostly been attempted by adsorption onto the material’s surface. The superficial deposition usually results in an immediate passive release of the proteins, thus restricting their temporal availability during bone healing. It was hypothesized that a co-precipitation of proteins onto calcium phosphate ceramics may provide the possibility to achieve a prolonged release of proteins from the material without impairing the biologic activity of growth factors.
Tritium labelled bovine serum albumin ([3H]BSA) and recombinant human BMP2 (rhBMP2) were coated onto biphasic calcium phosphate (BCP) ceramics using a coprecipitation technique of proteins together with calcium phosphate (Liu Y et al. 2001). The co-precipitation was compared to conventional adsorption of proteins to ceramic materials. The passive and cell-mediated release of [3H]BSA was investigated during 19 days. To analyze the cell-mediated protein release, murine bone marrow cells were seeded onto ceramics and differentiated to osteoclasts or to monocytes/macrophages. To assess whether rhBMP2 co-precipitated to BCP ceramics retained its biologic activity the growth factor’s ability to induce the differentiation of primary murine osteoblasts was studied.
After 19 days 71.7±5.3% of the adsorbed [3H]BSA was passively released (63.0±6.0% within 4 days). The passive liberation of [3H]BSA was effectively reduced using the coprecipitation technique (12.5±2.0% within 19 days, 10.1±2.3% within 4 days, p< 0.001). Further analysis demonstrated a sustained, osteoclast-mediated release of coprecipitated [3H]BSA from calcium phosphate ceramics which was blocked by the addition of calcitonin. Passive release of adsorbed and co-precipitated BMP2 led to a temporally restricted stimulation of murine osteoblasts. Cell-mediated liberation of co-precipitated BMP2 induced a sustained stimulation of the differentiation of osteoblasts.
The successful application of exogenously added growth factors depends critically on the mode of delivery. It has been shown that a sustained availability of BMP2 is beneficial for bone healing. Application of the co-precipitation technique resulted in a long-term release of proteins from BCP ceramics mediated by active resorbing osteoclasts without impairing the biologic activity of rhBMP2. Co-precipitating growth factors onto BCP ceramics provides a potential to shift the initial extensive liberation to a sustained release of bioactive proteins. This method of protein delivery may represent a possibility to achieve a more physiological availability of growth factors during bone regeneration.
Meniscal samples were processed for histology, immunohistochemistry and in situ hybridization, for assessment of cell density, cells actively dividing as well as apoptotic cells, distribution of COMP and estimate the proteoglycan content.
The main mode of failure of the acetabular component in total hip arthroplasty is aseptic loosening. Successive generations of cementation techniques have evolved to alleviate this problem.
This paper evaluates one such method, Negative Pressure Intrusion cementation. Two groups of machined bovine cancellous bone samples were created; experimental (n = 26) and control (n = 26). The experimental group was cemented using the negative pressure technique and control group was cemented in the absence of negative pressure. The relative cement intrusion depths were then assessed for each group using MicroCT. These samples were then further machined and tested to failure in torsion to estimate their mechanical properties.
Results show mean cement intrusion depth for the negative pressure group to be 8676μm and 6042 μm for the control group (p = 0.078). Mechanical testing also revealed a greater mean torque in the negative pressure group (1.6223Nm vs 1.2063Nm) (p = 0.095).
This work quantifies the effect of negative intra-osseous pressure on cement intrusion depth in cancellous bone and for the first time relates this to increased mechanical strength.
Physeal cartilage is known to have poor self-repair capacity after injury. Evaluation of the ability of cultured mesenchymal stem cells to repair damaged physis is the actual research topics. In 10 immature New Zealand white rabbits autogenous mesenchymal stem cells were transplanted into iatrogenic physeal defect in lateral portion of distal growth plate of the right femur. The same defect without stem cells transplantation in the left femoral distal physis served as a control. In our study, we used our own technique of implantation of MSCs with a newly modified gel scaffold (New Composite Hyaluronate/Collagen Type I/Fibrin Scaffold). The rabbits were euthanized 4 months after transplantation. Bone length discrepancy and valgus deformity were measured from femoral radiographs. Healing of the defect was investigated histologically. The ability of mesenchymal stem cells to survive and promote cartilage healing in the physeal defect was assessed by immunofluorescence. Average difference in femur length measured from surgery to euthanasia (4 months) was 0.61? 0.19 cm after preventive transplantation of MSCs in right femur, but only 0.11 ? 0.07 cm in left femur. Average angular (valgus) deformity of right femur with MSCs preventively transplanted to iatrogenically damaged distal femoral physis was 1.2? 0.72°. Valgus deformity in left femur was 5.4? 2.5°. Prophylactic transplantation of autogenous mesenchymal stem cells to iatrogenically damaged distal growth plate of rabbit femur prevented bone bridge formation and resulted in healing of the physeal defect with hyaline cartilage. Immunofluorescence examination showed that the chondrocytes newly formed in growth zone are the result of implanted MSCs differentiation. Femur growth in traumatized physis was maintained even after transplantation of autogenous MSCs. As compared with the opposite femur (with physeal defect but without transplanted MSCs), the bone showed no significant shortening or valgus deformity (p=0.018).
The torsion testing in Ibandronate had 51% greater toughness than placebo and 69% greater than the non-OVX group. Ibandronate increased trabecular number significantly over the placebo and was not significantly different from the non-OVX group. Trabecular separation was less in Ibandronate compared to the placebo group. Volume in the trabecular neck increased by 35% for the Ibandronate over the placebo.
For patients where curative surgery was an option, primary wide local excision (15 patients) or primary amputation (2 patients) was performed. The remaining 2 patients presented with unresectable disease due to the location and localised spread; an embolisation was performed for palliation in both cases. Revision surgery was needed in 9 patients for either a positive resection margin confirmed by histology, or a recurrence; these included 3 secondary amputations. A histologically proven recurrence occurred in 6 patients after an average of 15.8 (4 to 41) months. Local adjuvant radiotherapy was administered to 7 patients and a combination of radio–and chemotherapy was used in 2 patients for metastases. Mortality was 53% (9 patients) by the end of 36 months follow-up period.
Results: EndoTAG-1® treatment of AIA mice with developing or in established disease showed a strong attenuation of the course of the disease as well as a potent anti-inflammatory effect. Histological analysis of knee sections demonstrated a dramatic reduction of the pannus and infiltration of inflammatory cells. Enrichment of EndoTAG at the synovial vasculature of AIA mice was observed when compared with healthy mice. Treatment of AIA mice with EndoTAG-1® concomitant to disease induction showed a complete remission of the course of the disease as shown by a significant decrease of clinical scores compared to both control and Taxol® treated groups. A complete inhibition (98%) of neo-vascularisation was observed in the synovial vasculature of mice with AIA that were treated with EndoTAG-1® whereas Taxol® alone showed only 50% inhibitory effect. Rolling and adhesion of platelets were reduced to 53% (paclitaxel 5%) and 98% (paclitaxel 57%), respectively.
Conventional: UHMWPE gamma sterilized in inert, SXL: sequentially irradiated and annealed UHMWPE irradiated to a cumulative dose of 100kGy (33 kGy irradiation + 8 hour annealing in air, repeated 3 times) and gas plasma sterilized, and E-Poly: UHMWPE irradiated to 100kGy, stabilized with α-tocopherol, and gamma sterilized in inert.
Four specimens from each group were subjected to a reciprocating mechanical stress of 10 MPa at a frequency of 0.5 Hz in an environmental chamber maintained at 80°C. Control samples were placed in the chamber but not subjected to cyclic mechanical stress. When a visible crack was observed on a sample’s surface or when a sample fractured, it and its corresponding control sample were analyzed by FTIR to quantify oxidation.
Fibula autograft reconstruction, both vascularised (v) and non-vascularised (nv), has been established as a standard method in limb salvage surgery of bone and soft tissue tumours of the extremities. This study retrospectively analyses the results of fibula autograft procedures in general and in relation to vascular reconstruction or simple bone grafting.
Since the implementation of the Vienna Tumour Registry in 1969, 26 vascularised and 27 non-vascularised fibula transfers have been performed at our institution in 53 patients, 26 males and 27 females with an average age of 21 years (range 4 to 62 years). Indications included osteosarcoma in 18, Ewing’s Sarcoma in 15, adamantinoma in 5, leiomyosarcoma in 3 and others in 12. Thirty patients were operated for reconstruction of the tibia (8v/22 nv), 7 for the femur (6v/1nv), 7 for defects of the forearm (4v/3nv), 5 for metarsal defects (all v), 3 for the humerus (1v/2nv) and one patient was treated for a pelvic defect (nv).
Average follow-up was 63 months (range 2 to 259 months). 43 patients showed successful primary bony union of the autograft. In 12 cases pseudarthrosis indicated further surgical revision, 9 of these patients were primarily reconstructed by use of a nv autograft. 4 patients, 2 with v and 2 with nv reconstruction, suffered a fracture of the transplant and were operated for secondary osteosynthesis. 10 patients with v bone graft developed wound healing disturbances which led to surgery, 2 patients with nv grafts suffered such complications. In 2 patients recurrent infection of a nv and a v fibula transfer led to the implantation of a modular tumour prostheses or amputation, retrospectively. Function of all patients with primary bone healing was rated satisfactory.
The use of fibula autograft in limb-salvage surgery under oncological conditions allows biological reconstruction with good functional outcome, especially when primary bone healing is achieved. Vascularised bone grafting seems to have a better outcome in terms of primary bone healing than simple fibula bone grafting, and thus represents a feasible choice in the reconstruction of bone defects from tumour resection.
The study was designed to assess the reproducibility and reliability of Mirels scoring system and the conventional scoring system for impending pathological fractures. The results of both classification systems influence the choice of therapeutic procedures offered to these patients.
Blinded plain antero-posterior radiographs from forty-seven patients with bone metastases were scored by eight independent observers (four orthopaedic surgeons and four radiologists with varying clinical experience). Each observer scored the radiographs as per the Mirels and the conventional systems. After twelve weeks, the radiographs were scored again by the same observers. Inter– and intra-observer agreement was assessed based on the weighted kappa coefficient values for both systems.
For intra-observer reproducibility, kappa values for the conventional system had a mean of 0.495 (SD 0.12) showing a moderate agreement, while Mirels scoring system had a mean of 0.386 (SD 0.143) showing a fair agreement. For inter-observer reliability, kappa values for the conventional scoring system were 0.322 for the first test and 0.47 for the second test giving fair and moderate agreements respectively. For Mirels’ scoring system, kappa coefficient for inter-observer reliability was 0.183 for the first test and 0.218 for the second giving poor and fair agreements respectively.
The conventional scoring system showed a better inter and intra-observer agreement compared to Mirels’ scoring system. Consultants had a better intra-observer agreement compared to their registrars. We also found that radiologists, in our study, had better intra-observer agreement compared to orthopaedic surgeons. Radiographs should be scored cautiously by experienced doctors in a multi-disciplinary setting to achieve the best decision of whether to proceed with a prophylactic surgery or not.
Purpose of this paper was to review the Rizzoli experience in prosthetic reconstruction of the knee after resection of bone tumors with special attention to major complications and functional outcome.
Since abrupt data could be misleading due to the oncologic population and related deaths (although 2/3 of the patients were cured or long survivors), to censore the implant unrelated events a statistical analysis of the implant survival was performed and Kaplan-Meyer curves of implant survival were studied.
In 543 HMRS prostheses major complications were infection 8%, stem breakage 2%, aseptic loosening 4%, while revision for polyethylene wear components rated 7.4%.
Techniques of revisions were analyzed, as well as the outcome of revised cases, which showed that about 2/3 of the patients treated for major complications do well, although the risk for further complications is significantly incresed in revised implants.
Discussion: The reduction of major complication rate with the newer designs of the modular prosthesis was statistically significant and this seems to confirm that newer materials and a modified stem design positively affected the implant survival. Also the wear of polyethylene component was dramatically decreased in the newer prosthetic design. Functional results were satisfactory in most of the patients that did not experience major complications, with a trend to improvement in the newer design. Revision surgery is technically demanding and sometimes newer ‘hybrid’ techniques are suggested, implying the use of bone allografts.
Appropriate timing of revisions is crucial. An early treatment of complications can improve the final outcome.
The 38 procedures were identified from September 1995 to June 2007 and included 17 distal femoral replacements, 12 proximal femoral replacements, 4 proximal humeral replacements, 2 distal humeral replacements, 2 hemi-pelvic replacements and 1 total femoral replacement. EPR survivorship was calculated using a Kaplan-Meier survival curve. The quality of patients’ mobility and performance of activities of daily living was used to assess functional outcome.
87.4% of patients who underwent a lower limb EPR achieved a satisfactory or very satisfactory functional outcome. 100% of patients achieved a satisfactory or very satisfactory functional outcome in the upper limb EPR group.
3 implants failed, 2 as a result of infection and required staged revisions, 1 eventually requiring amputation, and 1 failed as a result of aseptic loosening. 2 patients dislocated their proximal femoral replacements, both were treated successfully by closed reduction. Despite the salvage surgery subsequent amputation was only required in one patient.
Ewing’s sarcoma family tumors (ESFT) express the EWS-FLI1 fusion gene generated by the chromosomal translocation t(11;22)(q24;q12). Expression of the EWS-FLI-1 fusion protein in a permissive cellular environment is believed to play a key role in ESFT pathogenesis. However, EWS-FLI1 induces growth arrest or apoptosis in differentiated primary cells and the identity of permissive primary human cells that can support its expression and function has until now remained elusive. Here we show that expression of EWS-FLI1 in primary human mesenchymal stem cells (hMSC) is not only stably maintained without inhibiting proliferation, but that it induces a gene expression profile bearing striking similarity to that of ESFT, including genes that are among the highest ESFT discriminators.
Expression of EWS-FLI-1 in MSCs may recapitulate the initial steps of Ewing’s sarcoma development, allowing identification of genes that play an important role early in its pathogenesis. These observations are consistent with our recent findings using mouse mesenchymal progenitor cells and provide compelling evidence that hMSCs are candidate cells of origin of ESFT.
We prospectively assessed a consecutive series of patients undergoing MTPJ arthroplasty with the MOJE prosthesis. All patients entered into the study were assessed preoperatively with the AOFAS 100-point Hallux Meta-tarsophalangeal-Interphalangeal Joint Scale and the range of motion was recorded. Patients were assessed on table postoperatively for range of motion (ROM) and then at 3, 12 and 24 months with AOFAS scores and ROM.
Forty-two toes (40 patients) were recruited into the study. There were 24 women and 16 men. The mean patient age on the day of surgery was 59 (range 37 to 73). 18 operations were carried out on the left hallux and 24 on the right. All operations were carried out for a diagnosis of hallux rigidus (although one patient also had hallux valgus, with an intermetatarsal angle of 24° and a hallux valgus angle of 40°).
The mean pre-op AOFAS score increased from 36.0 to 82.2 at 3 months (p< 0.001) and was 87.0 at 12 months and 84.2 at 24 months. There was no significant change in scores from 3 months onwards. Only 2 patients had a follow-up of 36 months; both of them had AOFAS scores of 95.
The mean arc of motion reduced from 70.8° on-table to 33.3° by 24 months (p< 0.001). The difference in arc of motion from 3 months to 12 months was a decrease from 45.6 to 40.0 which was borderline significant.
In 4 radiographs there was evidence of progressive loosening (figure 4). This was at 24 months in all 4 cases. For 3 of the patients the AOFAS score was 85. For the 4th patient the AOFAS score was 65
One patient had a spontaneous fusion of the toe. There were also three episodes of wound breakdown, one patient had intra-operative division of the EHL tendon that was repaired. We also noted post-operatively that: three feet developed Morton’s neuromata; one patient developed tarsometatarsal joint osteoarthritis of the great toe, one sesamoid osteoarthritis and one plantar fasciitis.
At the most recent follow-up appointment 33 out of 40 patients (82.5%) were satisfied with the results of their operation, 2 were dissatisfied (5%) and results regarding satisfaction were not available for 5 patients.
The results obtained in this paper demonstrate good, prospective, short-term results with the press-fit zirconium ceramic Moje implant. We believe that in the correct patient group good short term results can be achieved in the treatment of 1st MTPJ osteoarthritis as an alternative to fusion, particularly in those patients who are unwilling to have permanent stiffness in this joint for cosmetic or functional reasons
Fractures were Classified based on the Weber’s system. Pre-operative medial clear space measurement was done by 2 independent observer using PACS measurement tool. Intraoperative details for the method of fixation and the medial soft tissue were analysed.
Most common method of fixation is Neutralisation plate for the lateral side. In Weber B type 1/3 rd of the cases had both plate on the lateral side and syndesmotic screw fixation. 2/3rd of them had only plate fixation.
In Webers C type, only syndesmotic screw in n=3, Plate and screw n=4, only plate in n=9 cases
Radiological measurement of medial clear space average = 9.08mm, range= 5 –22 mm Less than 50% of the patients only had medial clinical signs. 26.6% had soft tissue (periosteal injury) and only 6.6% had deltoid ligament injury Out come assessment criterias: The failure of fixation or any on going medial symptoms in group A. – one case of failure of fixation. Final clinical assessment with ankle score (Olerud and Molander score.) at 6 months average (between 3–18 months). No significant difference in the score, on follow up.
Medial clear space does not correlate with any degree of medial soft tissue injury. Exploration is indicated if widening persist after lateral side fixation. Routine exploration of the medial side has no long term impact on the clinical outcome.
if subjects with medial tibial stress syndrome demonstrate increased navicular drop and medial longitudinal-arch deformation during quiet standing and gait compared to healthy subjects, the relationship between medial longitudinal-arch deformation during quiet standing and gait.
Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle.
17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode.
The duration of follow up was 12 to 84 months The average age was 33 years (Range 7–71). The mean length of the defect was 4.5 cm (Range 1–12).
Union of the fusion site occurred in 88% (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29).
Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation.
Complications – Two non-union.
Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus.
Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection.
Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centers for highly motivated patients to achieve good functional results.
Between January 1996 and December 2006, 130 patients were operated on for acquired varus equinus foot deformity. The most frequent aetiologies were stroke or brain damage due to head trauma. The primary indications for surgery included pain, caused by pressure of the foot or toes on the floor or in shoes, ankle instability due to varus deformity, or difficulty wearing orthopaedic shoes or braces. Split anterior tibial transfer was generally done after lengthening of Achillis tendon and tenotomy of long and short toe flexors during the same session. The author did compare preoperative and postoperative autonomy, and shoe or orthosis requirements. The results of this study include significant improvement in patient autonomy demonstrated by an improved ability to ambulate independently and a decreased need to wear orthopedic shoes and orthoses, as well as an increased ability to wear normal shoes, or the ability to ambulate bare foot. Adequate knee flexion during swing phase of the stride was the best indicator for better result. This procedure is safe and yields good results with minimal complications. The indications are very common, inasmuch as the number of young hemiplegic patients surviving after a stroke or head injury is increasing. This procedure can result in definite improvement for these disabled patients and can increase their autonomy.
From Jul 1999 to Jan.2006 77 patients were treated according to the above technique.
5 revisions were performed; 2 for stiffness (1 tibial component, 1 insert), 2 for stress fractures (tibial component only) and 1 insert fracture. 3 of these cases required further surgery following their first revision (1 fusion for deep infection, 1 insert exchange for edge loading and one arthoscopic debridement plus calcaneal osteotomy for painful varus deformity).
There were no primary revisions for aseptic loosening or deep infection. 3 radiographs demonstrated non-progressive lucent lines behind the tibial component.
Further surgery was required in 8 other ankles (6 calcaneal osteotomies and 2 arthroscopic debridements). Complete correction of pre-operative deformity was ultimately achieved in all but 4 ankles.
The mean postoperative American Orthopaedic Foot and Ankle Society Score was 77.
Protocol 1: 6 weeks NWB, 3 weeks partial weight bearing (PWB), 3 weeks FWB in plaster. Protocol 2: 2 weeks NWB, 4 weeks PWB, 6 weeks FWB in plaster.
The advantages of this technique over single K wire are:
Less post operative complications like pain and pin tract infection. Achieving normal biomechanics of the foot by fixing the PIP joint at 15–20 degrees of flexion. Using two K wires gives more rotational stability of the toes and reduces the complications of over riding, under riding and hyperextension of the toes. 15–20 degrees flexion at PIP joint will give good digital purchase and push off in stance phase. As the K wire engages the cortex of proximal phalanx, there is almost negligible chance of loosening of K wires which is a common problem in large single K wire which usually is driven in to the medullary cavity of proximal phalanx.
Objective parameters of AOFAS scale like adduction/ abduction, flexion, rotational deformities are significantly less with two wire fusions compared with single wire procedures (Coughlin et al). Radiological analysis of the foot showed that 97% had bony union compared 81% with single pin, and only 3% had fibrous union compared to 19% with single wire. Both the procedures didn’t have any non-unions. Only one patient had superficial wound infection, and surprisingly none had pin tract infection.
The long term results of Total Ankle Arthroplasty still remain largely unsatisfactory and Ankle Arthrodesis remains the gold standard treatment for severe degenerative ankle joint disease resulting from trauma and other causes. We describe the method and results of ankle fusion performed with a single anterior midline incision using the standard AO T-Plate.
18 patients underwent fusion of the tibio-talar joint with this technique over the past 5 years with a follow up range of 10 months to 5 years (mean-19 months). Though the commonest indication was post-traumatic degenerative joint disease (this included 6 patients who had previous internal fixation), other causes included primary osteoarthritis, rheumatoid arthritis, neuro-pathic joint (Charcot’s) and failed arthrodesis with other
There was radiological union in all 18 patients. Excellent clinical results were finally achieved in 16 (89%). Complications included persistent pain(1), delayed union(2), infection(2, including one deep) and 2 under-went removal of plate with good final result.
This technique is a modification of that described previously by Rowan and Davey. In our practice the plate is contoured to the surface of talus and the distal screws are directed more vertically towards the sustenaculum talus. We found it helpful to obtain more compression of adjacent surfaces.
With the use of an anterior T-plate not only a better stability in biomechanical terms is achieved, less dissection and better soft tissue cover of the metalwork help in overall patient satisfaction. Though we have performed ankle arthrodesis with different
Hallux varus is a rare cause of pain in the foot mostly occurring after failed hallux valgus surgery. We reviewed 12 patients with unilateral hallux varus treated with soft tissue techniques (4x), arthrodesis of the first metatarso-phalangeal joint (3x) or with a distal chevron osteotomy (5x) with medial transposition of the first metatarsal head and reconstruction of the soft tissues on the lateral side of the metatarsophalangeal joint. 10 patients had previous hallux valgus surgery, in 2 cases the deformities were of unknown origin. 1 male and 11 female patients were followed up on average 26.4 months postoperatively. AOFAS hallux score improved from 46 (range 10–75) to 86 (range 72–95) points. The metatarsophalangeal angle measured with the center-head to center-base method was reduced from −16.1° (range −35° to −8°) to 5.1° (range −15° to 21°). The intermetatarsal angle increased from 5.8° (0–11°) t o 10.5° (0–19°). All patients were subjectively satisfied with the procedure. Our results indicate that joint preserving operation techniques are viable methods in the correction of mild and moderate symptomatic hallux varus deformities. Mild remaining varus deformities are well tolerated.
In case of severe varus deformity or major signs of osteoarthritis in the first metatarsophalangeal joint MTP arthrodesis provides good results.
Twenty-five Regnauld’s procedures were performed in 20 patients with painful hallux valgus. This procedure involves the removal of proximal one-third of the proximal phalanx which is fashioned into a ‘hat-shaped graft’ and replaced as an osteochondral autogenous graft. The average age at operation was 56 years (range 39–76). After a mean follow-up of 3 years, 4 months (range 2.5–5.7 years), all the patients were assessed clinically and radiologically. The mean hallux valgus angle preoperatively was 29.3° (range 20–50°). At follow-up, a mean correction of 16.9° was obtained. In our study, 92% of patients were satisfied with the operation, but 8 patients (40%) showed progression of osteoarthritis of the first metatarsophalangeal joint. At 10 year follow up all these patient are satisfied with procedure and doing well. In view of the high incidence of degenerative changes in the first metatarsophalangeal joint, this procedure should be reserved for those patients over the age of 65 years or those with early osteoarthritic changes in the first metatarsophalangeal joint.
Between October 2006 and September 2007, eight consecutive patients with syndesmotic diastasis of the ankle had Tight Rope suture –endobutton fixation. We present our early results following this fixation. There were 3 males and 5 females with a mean age of 42 years (range 21 – 67). All were followed up for a mean of 7 months. Five patients had right side involvement. Majority were twisting injuries. These patients were compared with a cohort group (10 patients) who had diastasis screw fixation for similar fractures during the same period.
We recommend the use of this new suture endobutton fixation for ankle diastasis with promising early functional results. Further prospective studies are needed to evaluate this new type of fixation device.
Hallux rigidus is a common condition involving the first Metatarsophalyngeal (MTP) joint. Total joint arthroplasty is an acceptable modality of treatment. A number of different prosthesis have been used. Our study aims to evaluate the outcome of uncemented ceramic on ceramic (MOJE) prosthesis, in the treatment of painful hallux rigidus.
Between March 2000 and June 2005, 38 patients (53 feet) with painful hallux rigidus were treated with uncemented ceramic on ceramic (MOJE) prosthesis. There were 30 female and 8 male patients. The hallux meta-tarsophalangeal-interphalangeal scoring scale, by the American Orthopaedic Foot and Ankle Society, was used to assess these patients, pre-operatively and at follow up. A total score of 100 is possible in a patient with no pain, full range of MTP joint movement and good alignment.
The average follow up was for 34 months (range 12–68 months). Three revisions were carried out in three patients, 2 for deep infection, and 2 for persisting pain. Five patients showed radiological signs of osteolysis but had no symptoms. There was one late subluxation after 32 months. One patient developed a superficial infection, which was treated successfully.
The average AOFAS score pre-operatively was 45, compared to 91 post-operatively (p< 0.05). 23 patients (36 feet) classed the outcome as excellent to good. Ten of the patients subjectively described the out come of the procedure as excellent.
The preop range of movement (combined dorsiflex-ion and plantarflexion) was improved from a mean of 22 degrees to 68 degrees postoperatively.
The ceramic/ceramic (MOJE) total arthroplasty gave excellent results in 77% of patients. The early outcome is encouraging. We ewcommend continued use of this prosthesis for painful hallux rigidus.
This study assesses the pre and post-operative pedal pressures during stance phase of dynamic gait cycle to identify objective biomechanical factors which influence the final outcome.
Pedobarography was performed before and 8 months after surgery, on an average. Sole was divided into eight segments i.e. heel, midfoot, lateral forefoot, central forefoot, medial forefoot, II–V toes, hallux and total sole area. Variables compared were contact area, peak pressure, mean pressure and contact time. Manchester-Oxford foot questionnaire (MOXFQ) was used to assess the clinical disability. The inter-metatarsal and metatarso-phalengeal angles were measured radiographically. Both clinical and radiological assessments were performed pre and post-operatively.
The inter-metatarsal angle reduced from 15 to 7 (p 0.001) and the metatarso-phalengeal angle reduced from 32 to 9 (p 0.001).
There was significant reduction in heel contact area (p 0.002), the medial forefoot (p 0.030) and II – V toes (p 0.048) contact time.
We prospectively enrolled and evaluated 30 patients with unilateral or bilateral hallux valgus. At the time of our preliminary follow-up, 8 patients (14 feet) with unilateral or bilateral hallux valgus who had either a Scarf or a combined Scarf-Akin procedure from June 2006 to December 2006 were evaluated. Three surgeons practicing within one practice performed the procedures. Exclusion criteria for this study included concomitant forefoot pathology, such as hammertoes, clawtoes, and transfer metatarsalgia, which required concomitant surgery. We also excluded patients with excessive first ray instability which would have required 1st metatarsal-cuneiform fusion. The average age of the patients at surgery was 37.8 years (range, 14–76 years).
Average follow-up time was 6.5 months. Four of the eight patients (8/14 feet) required an Akin osteotomy in addition to the Scarf procedure. Patients showed an average improvement of AOFAS score from 65.7 to 86.3. The ACFAS 1st ray score improved from 63.2 to 86.8. The intermetatarsal and hallux valgus angles improved from mean pre-operative values of 14.3° and 25.9° to 9.5° and 10.2°, respectively. Similarly, the 1st metatarsal declination angle also improved from a mean of 38.7° pre-operatively to 20.9° post–operatively. There was no significant change in first metatarsal dorsiflexion before and after surgery (64.5 to 68.7). Pre op and post op plantarflexion was also assessed. The mean hallux plantarflexion remained virtually identical at 11.3 degrees of motion. Pedobarographic analysis showed medialization of peak plantar pressure following surgery. Peak plantar pressure increased under the hallux (Increasing from 91.5 kPa to 144.6 kPa) and first metatarsal while decreasing under the 2nd, 3rd, 4th, and 5th metatarsals following surgery. Average time to return to work and to activities of daily living were 2.6 weeks and 3 weeks respectively.
We conclude that the Scarf osteotomy and Akin closing wedge osteotomy of the proximal phalanx of the great toe appear to be safe and effective for the treatment of hallux valgus and restoration of normal forefoot pressure. Our data suggest the Scarf osteotomy normalizes the function of the hallux during the propulsive phase of the gait cycle. This was reflected in the increased peak pressure under the first metatarsal head and the reduction of peak pressure under the second metatarsal head. We have found pedobarography to be useful as a pre-operative tool and to assess outcomes in forefoot surgery.
Many studies have evaluated bilateral versus unilateral surgery in large joints, however, limited research is available to compare outcomes of bilateral-staged foot surgeries versus synchronous-bilateral foot surgery. 186 consecutive cases of first metatarsophalangeal joint surgery were prospectively included in this study; 252 procedures were performed: 120 were unilateral or staged-bilateral, and 66 were synchronous-bilateral operations. Patients were evaluated at 6–and 12-weeks for specific early complications, and surveyed about there return to work, activities of daily living, shoe gear requirements, satisfaction, and reasons for choosing staged or synchronous surgery. Additionally, a cost analysis was performed on all surgical scenarios. Student-t test showed no statistical significance between groups in all clinical settings to a 95% confidence level. Complication rates were similar and few in all situations. Patients were very satisfied when choosing bilateral-synchronous surgery and would elect to repeat it the same way 97% of the time. The economic costs to the health system average 25% greater when patients undergoing first metatarsophalangeal joint surgery have the procedure performed one foot at a time. Combined with the time lost from work, this reveals a significant economic cost to both society and patient.
The remainders (10 patients) had a delayed reloading on the lower limb.
In this study the clinical and radiological results of the fracture group were compared to those of a control group of 15 patients.
Postoperative complication rate (deep venous thrombosis, infection, dislocation) were not different between the groups.
There was a significant increase of duration of the stay of the patient in the rehabilitation center (p=0.007) in the fracture group and the patient spend more time with the physiotherapist (p=0.001)as they left the center.
The fracture rate was lower when the patients were operated by a senior surgeon (p=0.021).
One of the best procedures to prevent haemarthrosis in haemophilia has been radioactive synovectomy (synoviorthesis). Since the first report of radioactive synovectomy in haemophilia of Ahlberg in 1971, (7) many centers adopted this procedure as the one of choice to, through fibrosing the synovial membrane, prevent further haemarthrosis.
Since 1976 we have performed 119 such radioactive synoviorthesis in 110 patients with age from 3 to 40 years with a mean of 10 years of age, 71 of these patients were under 12 years of age. The knees were injected in 71 cases, elbow in 29 cases, ankles in 16 and shoulders in 3 cases. The clinical results of this procedure gives an 80% of excellent results with no further bleeding. In case of failure a new injection can be given in the same joint at a 6 month interval, or an injection for the same purpose in other joint. One of the criticisms against this method is the possible chromosomal damage induced by the radioactive material.
In our center, 4 studies have been made in order to see whether these changes, in case of appearance, are everlasting and all have demonstrated that chromosomal changes are reversible. The radioactive material used in the 2 first studies was 189 Au. In 1978, 354 metaphases were studied with 61 ruptures, 17.23%, (non premalign) and 6 structural changes -considered premalign-, 1.69%. Any number below 2% is considered non dangerous. A further study was done in 1982, in the same group of patients with a result of 21 ruptures, 3.34% and
Rivaroxaban is a novel, oral, once-daily, direct Factor Xa inhibitor in advanced development for the prevention and treatment of venous thromboembolism (VTE). This study analysed the potential economic benefit attributable to the use of oral rivaroxaban relative to subcutaneous enoxaparin for extended VTE prophylaxis (35±4 days) after total hip replacement (THR). In RECORD1, rivaroxaban reduced the incidence of the composite primary efficacy endpoint (total VTE, including all-cause mortality) by 70%, compared with enoxaparin (p< 0.001). Symptomatic VTE occurred in 0.3% and 0.5% (p=0.22) of patients receiving rivaroxaban and enoxaparin, respectively. Major bleeding was low and similar in both groups: 0.3% and 0.1% (p=0.18), respectively.
Potential savings associated with oral rivaroxaban were based on any reduction in the incidence of symptomatic VTE events, and reduced administration and monitoring costs. Analyses for both the US and the UK included only non-drug costs incurred by the healthcare sector. It was assumed that nurses spent 3 minutes/day administering enoxaparin and training patients to self-inject; assumed duration of hospital stay was 5 days. UK costs (based on the 2007 NICE Guidelines) also included full blood counts (FBCs) every 3 days, for up to 14 days, in patients receiving enoxaparin.
Two analyses were performed: one assumed no difference in the occurrence of symptomatic VTE between treatments; the other assumed that the observed difference was real, but did not reach statistical significance.
In the first analysis, assuming no difference in symptomatic VTE incidence, the total resource cost in the US was $46/patient for enoxaparin and $42.5/patient for rivaroxaban: a saving of $3.5/patient. For the UK, the total resource cost was £33/patient for enoxaparin and £7.5/per patient for rivaroxaban: a saving of £25.5/ patient. Savings were driven by reduced monitoring (FBCs) and administration costs.
In the second analysis, assuming the observed difference in symptomatic VTE incidence was real, the US total resource cost was $57/patient for enoxaparin and $42.5/patient for rivaroxaban: a saving of $14.5/patient. For the UK, the total resource cost was £30/patients for enoxaparin and £7.5/patient for rivaroxaban: a saving of £22.5/patient. Savings were again driven by reduced monitoring and administration costs, and also reduced VTE incidence.
Over 400,000 US patients undergo THR, and ~60,000 patients in England and Wales undergo THR annually. Thus, the potential cumulative cost savings with rivaroxaban are considerable.
Recent changes in health care policy relating to pre hospital triage and closure of acute services in district general hospitals have placed unanticipated strains on financially challenged larger trusts in London. The financial implications for the presumed ‘designated’ regional trauma centre have previously not been scrutinised. Our study investigates how these changes and the resultant ‘out of area’ trauma has impacted on workload at our London teaching hospital and looks at the financial implications for the Trauma and Orthopaedics department.
A retrospective analysis of all attendances to the A& E department over a four month period (July – October) in 2006 was compared to a similar period in 2005. All admitted, major orthopaedic trauma cases bought in by ambulance or HEMS services were included. Review of case notes and phone interviews were used to ascertain how many of the incidents had occurred outside our region of referral.
An 83% increase in major trauma admissions was observed (32 cases in 2005, 53 cases in 2006; P value = 0.03). Of these cases, 27/32 and 46/53 could be assessed. Two patients in 2005 (7%) and twelve patients in 2006 (26%) were out of area (P value = 0.07). As these patients were bought in as ‘local’ cases, and not as regional referrals for treatment, the Trust was not reimbursed appropriately. Fiscal analysis of the out of area trauma cases was carried out to ascertain the shortfall incurred by the department.
This study surveys our patients to determine their experiences at airport security, establishes the detectability of common orthopaedic implants in an airport security scanner
A volunteer with metal implants strapped on and patients with implants in-situ walked through a gate scanner at a UK airport. Also, standard operating procedures at UK airports were ascertained.
There were 111 total knee replacements (TKR), 20 unicompartmental knee replacements (UKR), 2 bilateral UKR replacements, 17 bilateral TKR.
Unlike previous studies from the U.K., virtually all patients with a TKR activated the gate scanner. Conversely, those with unicompartmental replacements did not.
Patients are concerned about this possibility but are not informed at time of surgery and do not know what the procedures are if their implant is detected.
The patient with the bilateral UKR did not set off the scanners where as the patient with the TKR did.
A variety of surprisingly large trauma implants escaped detection.
Mechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of thomboembolic disease following major orthopaedic surgery procedures. Recent studies have suggested that simultaneous use of graduated compression stockings (GCS) may hinder the pneumatic compression effect of foot pumps. The hypothesis of this prospective study was that the use of foot-pumps without GCS does not affect the efficacy of DVT prophylaxis, and improves patient compliance. 846 consecutive patients admitted at a single institution undergoing total hip (THR) or knee replacement (TKR) were included in the study. The A-V Impulse System® foot-pump units (Orthofix Vascular Novamedix, Andover, UK) was used in all patients. Forty-six patients discontinued the use of foot-pumps, leaving 400 patients who received foot-pumps in combination with GCS and 400 patients with foot pumps alone. Eleven patients of the stocking group (2.7%) and 9 patients of the no-stockings group (2.3%) developed postoperative symptomatic DVT (p=0.07). DVT was more frequent in TKR (10 of 364; 2.7%) than in THR (10 of 436; 2.3%). Non-fatal pulmonary embolism occurred in 4 patients out of 20 with symptomatic DVT, 2 each of the stockings and no stockings groups. The foot pump discontinuation rate of patients treated with stockings was 7%, versus 4% of patients treated without stockings (p< 0.05). In conclusion, management of patients with foot-pumps without GCS does not reduce efficacy of DVT prophylaxis after THR and TKR, and improves patient compliance.
Thirty-eight patients were treated with scaphoid excision and 4-corner fusion using dorsal circular plate. Thirty-nine patients were treated with total wrist fusion using one single, dorsal, precontoured and tapered plate for osteosynthesis and third carpometacarpal joint (CMCJ-3) was included. All patients were immobilised in a cast for 4 weeks after surgery.
Postoperative complications, pain (visual analogue scale), clinical and functional outcome based on Green and O’Brien score, grip strength, X-ray evaluation, time to return to work and activity level were evaluated and compared.
The average time to return to work was 17 weeks (4-corner) and 16,2 weeks (total fusion). All patients return to work. Twelve percent of four-corner fusion and 72% of total wrist fusion return to the same work level with restrictions (until 33% of activity). Twenty-two percent of 4-corner fusion and 28% of total wrist fusion were unable to return to their previous activity level, performing lower intensity work activities. Overall satisfaction was high in both groups with 85% (4corner) and 93% (total fusion).
Total wrist fusion had less surgical failures, better level of satisfaction, lesser lost of force than 4-corner fusion, with less potential for further deterioration with time. However, 4-corner fusion allows return to work with a similar activity level and preserve a functional range of motion in patients with high levels of activity.
Recent NICE guidelines have recommended that heparin should be routinely administered to patients under-going THR to prevent thromboembolism, although it is unclear from the existing evidence if heparin is the most effective. However, research has suggested that aspirin, which is a low cost prophylactic agent, is effective in preventing DVT and PE after orthopaedic surgery. The aim of this study was to determine the 90-day mortality rate after THR using aspirin as a prophylactic agent.
Primary THR One patient (0.04%) died within 30 days of surgery and a further 3 (0.13%) died between day 30 and day 90, giving a total mortality at 90 days of 0.17% (4/2,286). One patient (0.04%) died from PE and the other 3 patients (0.13%) died from non-vascular causes. Revision hip replacement One patient (0.27%) died within 30 days of surgery and a further 1 patient (0.27%) died between day 30 and day 90, giving a total mortality at 90 days of 0.54% (2/367). Both patients died from non-vascular causes.
80 porcine deep flexor tendons were harvested from adult porcine forelimbs and randomized into four groups of twenty tendons. Three groups were repaired using either a two, four or six strand repair, and the remaining group was repaired with the new device. Half of each group was repaired using a core technique alone; the remainders were supplemented with a Silfverskiöld Peripheral Cross Stitch.
The repairs were pre-loaded to 1N in a Zwick Linear Tensiometer, with subsequent distraction to failure at 10mm/min. When preloaded the tendon dimensions were measured at the repair site as well as above and below in order to assess repair site bulk. During loading the Force to Produce 3mm Gap (FPG) was recorded as was the Ultimate Strength (US) following failure.
The FPG of the new device was superior to the Cruciate when used alone and was equivalent to the Savage when augmented with a peripheral repair. The US of the new device was superior to the Cruciate both with and without a peripheral repair.
We plan to continue development of the device to optimize its hold on the tendon. We also plan to perform cyclical testing in physiological conditions
In addition, it seems that the radiological findings do not walk along with the clinical features and the wrist functionality in a major percentage. Our results indicate the importance of anatomical reduction and especially the restoration of radial length in order to obtain good functional future outcome.
The aim of this study was to investigation how the rotational axis of the wrist moves as the hand goes from full ulna to full radial deviation.
End-to-side neurorraphy (4 groups) Group A bFGF (20ng) Group B NGF (25ng) Group C (normal saline) Group X [bFGF (20ng) + NGF (25ng)] Negative control group (G) Animal keeping was conform to standard conditions set by the NIH (appropriate cages for housing; standard rat chow and water ad libitum; 12h – light/darkness exposure).
All experimental procedures were performed under the supervision of a veterinarian and were prospectively approved by the Animal Experimental Ethics Committee.
We observed similar effect in individual domains of pain, mobility and range of motion. Survival of the implant at nine years with revision due to any reason was 93.5%. We observed a significant difference in survival of procedures done by pioneer surgeons and by non pioneering surgeons (p < 0.01) (log rank test). There were 119 complications of which there were 30 fractures, 21 occurring within the first six months of operation.
110 patients completed the study, with 2 comparative groups for epidemiologic and radiological criteria (n = 63 for pins and 57 for external fixator).
Correlation between Crowe, Hartofilakidis and Eftekhar classifications with distance between ideal and postoperative center rotation and medial bone bulk were calculated using Pearson correlation. Correlation was also analyzed using information about distance between ideal acetabular roof point and medial pelvic rim.
The incidence of cancer needs to be interpreted with caution and can only be ascertained by a prospective study.
Metal-on-metal articulations are increasingly used in THR. Hypersensitivity reactions to the metal ions can occur. The symptoms and signs are similar to a patient presenting with an infected prosthesis. Correct diagnosis before revision surgery is crucial to implant selection and operation planning. We present a practical approach to this diagnostic problem.
The history, clinical findings, hip scores, radiology, serum metal ions, ESR, C-RP, hip arthroscopy and aspirate results, synovial fluid metal ion levels, labelled white cell/colloid scan, 99m-technetium scan, revision hip findings and histology of a typical patient who had an allergic response to a metal-on-metal hip articulation are presented, and how the findings differ from a patient with an infected implant. Clinical examination, hip scores and serum metal ion levels were repeated one year after revision of the metal-on-metal hip articulation to a ceramic-on-ceramic.
In hypersensitivity, the periarticular tissues undergo lymphocyte-dominated infiltration, the histology differs from that found in infection. The white cell labelled/colloid scan also uses this difference for diagnosis. Hip aspiration is the single best investigation for infection.
We report the difficulties encountered during surgery, and the long term results of patients who had Crowe 3 or 4 DDH and a technically difficult primary hip arthroplasty using the modular S-ROM stem.
4 patients had a technical complication during surgery. The average pre-op Harris Hip Score was 37, at 5 years it was 83, and at 10 years 81. The SF12 measure of physical and mental wellbeing was 43.90 physical/54.48 mental at 5 years, and 41.64 physical/54.03 mental at 10 years. The WOMAC average score (the lower the score the better the outcome) was 27 at 5 years and 23 at 10 years.
None of the S-ROM stems had been revised, 2 hips had undergone acetabular revision and one hip had a liner exchange. None of the S-ROM stems were loose at latest follow-up. Four hips had osteolysis in Gruen zone 1, one hip had osteolysis in zone 7, and one hip had osteolysis in zone 1 and 7. There was no evidence of osteolysis around or distal to the sleeve.
S-ROM stem/sleeve modularity allows femoral component anteversion independent of the position of best fit in the proximal femur, and helps overcome the technical difficulty in these patients.
For RSA, the wear rate for the 28mm femoral head group was 0.05±0.02 while the 36mm femoral head group was 0.03±0.02, p=0.13.
For the Martell analysis, the average steady-state wear rate was −0.002 ± 0.01 mm per year and −0.026 ± 0.13 mm per year for 28mm and 32mm head sizes, respectively, p=0.62. There was no correlation between wear and time in situ or femoral head size for any of the clinical studies.
In comparing the Martell and Devane programs, the total average wear rates were significantly different, 0.07±0.05 and 0.03±0.06mm/year respectively, p=0.01. However, when the absolute values of the Martell results were used, there was no difference, p=0.22.
In 2006 the standard prosthesis for hip hemiarthroplasty in our unit was changed from the traditional Thompson prosthesis used for over 20 years to the monobloc Exeter Trauma Stem (ETS). The principle anticipated advantages were ease of stem implantation, improvement of orientation positioning and a consistency with modern proven femoral THR stem design.
All patients selected for hemiarthroplasty replacement for a displaced subcapital fracture of the hip were eligible for inclusion. Failed previous surgical cases were excluded.
The last 100 Thompson’s prostheses used before and the first 100 Exeter Trauma Stems undertaken after the changeover date were studied. Outcomes measured included surgical complications including infection, dislocation, fracture, necessity to ream etc. and technical adequacy of implant positioning based upon post-operative radiographs. Surgeon grade was recorded. There were no changes in surgical personnel.
206 consecutive patients were included in the study (age range 76–96); 67 men and 139 women. Data were collected prospectively as part of a comprehensive hip fracture audit.
Initial results show that the rate of surgical complications is similar in both prosthesis groups. Radiographs demonstrate the presence of a learning curve in the use of the new prosthesis. On six occasions after December 2006 the Thompson prosthesis was used – this was due to unavailability of ETS prosthesis or where a very large femoral head (56mm) was required.
The introduction of the ETS for hip hemiarthroplasty was successful. Initial conversion problems involved maintaining sufficient stock of the most commonly used size of prosthesis. Advantages were a low dislocation rate despite the greater potential for erroneous implant version and a reduction in the amount of femoral preparation required including reaming. Limitations of this study are the lack functional outcome and long term survivorship analysis.
Analyses of six different cementing techniques (cemtech) were performed using high viscosity (HVC) (Smart Set GHV, DePuy, Blackpool, England) and low viscosity cement (LVC) (Endurance, DePuy, Blackpool, England):
Manual application HVC ¼filling of the component with LVC and manual appl. ¼filling HVC and manual appl. ½filling LVC ½filling HVC Complete filling with LVC
A force of 150N was used to press five shells in each cemtech group on foam specimens. During seating cement pressures and polymerization heat 5 mm under the foam surface were measured.
Specimens were cut into quarters, surfaces were digitalized and cement penetration areas and depths were quantified using a pixel-analysis-software. The effects of the cemtech were examined by Kruscal-Wallis and Mann-Whitney-U-tests (two-sided, p-value< 0.05, SPSS)
Maximum temperatures were A) 36.0± 4.1°C, B) 45.0±5.7°C, C) 36.2±4.2°C, D) 53.5±2.5°C, E) 48.3±6.5°C and F) 53.2±12.6°C. D, E and F exceeded 50°C.
A provided even cement penetration over the available fixation area without involvement of the internal area and the stem. Cemtech that used LVC cement (B, D and F) showed higher interior area cement contents than HVC (A, E and C). The cement content in the interior area was A) 39.3±26.4mm2, B) 72.1±16.9mm2, C) 37.7±10.5mm2, D) 99.0±24.6mm2, E) 67.5±15.6mm2 and F) 121.0±29.0mm2.
A showed mainly complete seating with a cement mantle thickness of 0.5±0.7 mm. All other cemtech had incomplete seating in all specimens with significantly thicker polar cement mantles (p=0.032) up to a maximum of 4.6±1.2mm for E.
Metal-metal hip resurfacing offers the advantage of conservation of femoral bone stock. In addition, the implant may offer enhanced resistance to dislocation in comparison with conventional total hip arthroplasty.
We present a series of 32 female patients with one to 4 year follow up (mean age 57 ranges 50–70 at time of surgery)
All patients required hip arthroplasty. Careful preoperative selection was carried out with particular attention paid to estimation of bone density. A standard resurfacing operation was carried out. Patients had pre and postoperative WOMAC and SF36 scoring. All patients were followed closely in the post operative period. No significant complications were noted at follow up.
In our study we have shown that given careful patient selection Birmingham hip resurfacing can be safe and reliable form of arthroplasty.
We developed a mathematical model of the pelvis to evaluate the influence of the pelvis movements on anteversion and inclination of an acetabular cup arbitrarily implanted with 10° of anteversion and 45° of abduction. Measurment were particularly focused on evaluating the influence of a −15 to 15 degrees pelvic rotation around the three space axes.
When considering the anteroposterior axis, the ranges of variation are almost 30° for abduction and 6° for anteversion. When considering vertical and mediolateral axes, the magnitude of variation is 30° for anteversion and 3° for abduction
We demonstrate a close relationship between acetabular cup anteversion and pelvic rotations in all planes. In contrast, acetabular cup abduction is mainly related to the rotation around the anteroposterior axis. The influence of the pelvic position on the evaluation of acetabular cup alignement requires very precise CT measurement protocols to make the evaluation accurate and reproductible.
Acetabular centre positioning in the pelvis has a profound effect on hip joint function. The force–and moment-generating capacities of the hip muscles are highly sensitive to the location of the hip centre. We describe a novel 3D CT-based system that provides a scaled frame of reference (FOR) defining the hip centre coordinates in relation to easily identifiable pelvic anatomic landmarks. This FOR is more specific than the anterior pelvic plane (APP) alone, giving depth, height and width to the pelvis for both men and women under-going hip surgery.
CT scans of 22 normal hips were analysed. There were 14 female and 8 male hips. The APP was used as the basis of the coordinate system with the origin set at the right anterior superior iliac spine. After aligning the pelvis with the APP, the pelvic horizontal dimension (Dx) was defined as the distance between the most lateral points on the iliac crests, and its vertical dimension (Dy) was the distance between the highest point on the iliac wing and the lowest point on ischial tuberosity. The pelvic depth (Dz) was defined as the horizontal distance between the posterior superior iliac spine and the ipsilateral ASIS. The ratios of the hip centre’s x, y, and z coordinates to their corresponding pelvic dimensions (Cx/Dx, Cy/Dy, Cz,Dz) were calculated. The results were analysed for men and women.
For a given individual the hip centre coordinates can be derived from pelvic landmarks. We have found that the mean Cx/Dx measured 0.09 ± 0.02 (0.10 for males, 0.08 for females), Cy/Dy was 0.33 ± 0.02 (0.30 for males, 0.35 for females), and Cz/Dz was 0.37 ± 0.02 (0.39 for males and 0.36 for females). There was a statistically significant gender difference in Cy/Dy (p=0.0001) and Cz/Dz (p=0.03), but not in Cx/Dx (p=0.17). Anteversion for the male hips averaged 19° ± 3°, and for the female hips it was 26° ± 5°. Inclination measured 56° ± 1° for the males and 55° ± 4° for the females. Reliability testing showed a mean intra-class correlation coefficient of 0.95. Bland-Altman plots showed a good inter-observer agreement.
This method relies on a small number of anatomical points that are easily identifiable. The fairly constant relationship between the centre coordinates and pelvic dimensions allows derivation of the hip centre position from those dimensions. Even in this small group, it is apparent that there is a difference between the sexes in all three dimensions. Without the need for detailed imaging, the pelvic points allow the surgeon to scale the patient’s pelvis and thereby know within a few millimetres the ‘normal’ position of the acetabulum for both men and women. This knowledge may be of benefit when planning or undertaking reconstructive hip surgery especially in patients with hip dysplasia or bilateral hip disease where there is no reference available for planning the surgery.
We report the results of cementless total hip arthroplasty using the Bi-metric titanium femoral stem at a minimum follow up of 10 years and a mean of 12.2 years (range 10–17).
64 hips (43 male/21 female) were implanted consecutively into 54 patients between 1988 and 1995. The mean age at operation was 54.3 years (range 42–65). All patients had a Bi-metric uncemented stem (Biomet UK). The first 13 patients received a metal backed screw in acetabular cup (TTAP-ST, Biomet UK) with the remainder receiving metal backed pressfit cups (Universal, Biomet UK).
All patients were followed up annually and assessed using the Hip Society Score (HSS; max 40 points) to record pain, function and mobility. Survivorship was calculated using the Kaplan-Meier method.
57 hips were followed up for a minimum of ten years. There were 4 deaths (6 hips) before completion of follow up and 1 patient was lost to follow up.
Using revision for any reason as the end point of the study; survivorship for the total hips at 10 years was 89.5% (95% confidence interval: 78.1–96.1%) with a mean Hip Society Score of 34.9 (range 20–40) compared to 14.5 (range 8–24) pre-operatively (p< 0.01 student t test).
Survivorship for the femoral stem in isolation was 100% at 10 years (95% CI 93.7–100%) and there continues to be no revisions to date at a mean follow up of 12.2 years.
The screw fix cup performed poorly with 3 acetabular revisions (including 1 liner change) before the 10 year follow up, a failure rate of 23.1%. There has sub-sequently been a further 4 acetabular revisions.
Ten year survivorship for the pressfit cup is 93.5% (95% CI 82.0–98.8%) with 3 revisions (including 2 liner changes) at ten years. There has subsequently been one further acetabular revision and 9 further liner changes (29.5% failure rate).
There have been no recorded infections and no instances of thigh pain.
Radiographs at ten years showed all the femoral stems were stable with no evidence of migration. Two stems had small radiolucent lines at the bone-implant interface but no signs of loosening. One stem had an area of osteolysis in Gruen zone 7 but didn’t require revision. Rates of osteolysis were extremely low given the large amounts of particulate debris in the hip from the worn acetabular liners.
In conclusion, although neither cup has proved to be particularly successful the Bi-metric stem has performed well at 10 year follow up and continues to do so. This is inspite of the fact they were implanted into a young and active group of patients.
A clinical and radiographic study was conducted on 97 total hip arthroplasties (79 patients) performed for congenital hip dislocation using three-dimensional custom cementless stem. The mean age was 48 years (17 to 72). The mean follow up was 123 months (83 to 182).
According to Crowe, there were 37 class 1, 28 class 2, 13 class 3 and 19 class 4. The average lengthening was 25 mm (5 to 58 mm), the mean femoral anteversion 38.6° (2° to 86°) and the correction in the prosthetic neck −23.6° (71° to 13°). The average Harris hip score improved from 58 to 93 points. Six hips (6.2%) required a revision. The survival rate was 97.7% ± 0.3% at 13 years.
Custom cementless stem allows anatomical reconstruction and good functional results in a young and active population with disturbed anatomy, while avoiding a femoral osteotomy.
The purpose of this study was to evaluate the clinical and radiological findings in patients with avascular necrosis of the femoral head after implantation of a porous tantalum implant combined with autologous growth factors (AGF).
The study included 40 hips in 30 patients. Of the 40 hips, 1 hip was stage I, 9 hips were stage II, 22 hips were stage III, and 8 hips were stage IV, according to the Steinberg classification system. Follow-up was 2 to 4 years. The porous tantalum (diameter of 10 mm, length ranging from 70 –110 mm) was implanted in the center of the necrotic area under fluoroscopic control.
Clinical evaluation using the Harris hip score showed an increase from 66 to 96 points preoperatively to postoperatively in hips with stage II disease, from 60 to 85 points in hips with stage III, and from 60 to 80 points in hips with stage IV (p< 0,001). Of the 40 hips, the radiological stage in 20 hips (50%) remained stable, 17 (42.5%) progressed to an advanced stage and 3 hips (7.5%) underwent total hip arthroplasty (p< 0,001). Of the 17 hips that progressed, 7 were stage II, 7 were stage III, and 3 were stage IV. No material damage or implant migration was observed.
Although failures are still observed with the use of porous tantalum, the minimal invasive technique and short operative time make tantalum a reasonable alternative in the treatment of AVN of the femoral head.
In a qualitative analysis the head-neck contour of all femora was assigned to one of the following four groups: regular waisting, mildly reduced waisting, reduced to distinctly reduced waisting or completely lacking waisting. In a quantitative analysis, angle alpha according to Nötzli et al. (2002) was measured. Furthermore, the CCD angle was measured to assess the orientation of the femoral neck in the frontal plane as well as the LCE-angle according to Wiberg and the acetabular index of the weightbearing zone to rule out any acetabular anomalies.
TAD is <
25mm. To establish whether there was a correlation between TAD and surgeon grade or fracture type. To establish positions of screws on both radio graphs. To ensure SHS are used in the correct fracture types.
The majority of cases were operated on by Registrars 67%, Staff grade 15%, Research fellows 9%, SHOs 6% and Consultant grades 3%. Registrars achieved Centre–Centre positions in 62% of cases with staff grade 47% of cases. The majority of SHS were performed for Types 2 and 4 according to Jensen & Michaelson classification. SHS implants were used in one subtrochanteric fracture and zero reverse oblique fractures. 21 cases had a TAD> 25mm and one of these has gone on to failure, requiring THR.
It is unclear which length of thread may be most advantageous for the internal fixation of an intracapsular fracture with cancellous screws. We have compared the 16mm versus the 32mm threads on cancellous screws within a randomised trial for 432 patients. All fractures were fixed with three screws and patients followed-up for a minimum of one year from injury.
The characteristics of the patients in the two groups was similar with a mean age of 76 years. 23% were male. The most common complication encountered was non-union of the fracture which for undisplaced fractures occurred in 7/107(6.5%) of short threaded screws versus 11/133(8.3%) of long threaded screws. For displaced fractures the figures were 29/104(27.9%) versus 24/89(27.0%). Other complications for the short versus long threaded group were avascular necrosis (two cases versus five cases) and fracture below the implant (two cases in each group). Elective removal of the screws for discomfort was undertaken in five and three cases respectively. None of these differences between groups was statistically significant. In summary there is no difference in fracture healing complications related to the length of the screw threads.
While squeaking ceramic bearings in total hip arthroplasty are increasingly reported in the literature, the etiology remains unclear. Cup inclination and anteversion have been correlated with the phenomenon but even amongst well positioned cups bearing noise is observed. Most studies do not distinguish between different types of noise or incidence rate and do only investigate actively complaining patients. This study analysed the incidence of ceramic bearing noise in a single type of hip implant and investigates correlations with patient, implant and surgery parameters.
In a consecutive series of 145 ceramic-on-ceramic primary hips (Stryker ABG-II, 28mm head) in 132 patients (m/f=72/60, avg. age=54yrs) and an average follow-up of 3.0 (1–7) years, noisy bearings were identified by a patient questionnaires stating the type of noise (squeaking, clicking, scratching, combinations), time of initial incidence, incidence rate (permanent, often, sometimes, rare) and type of movement. Patient demographics (age, gender, height, weight, BMI, side of surgery, leg length difference), implant parameters (cup and stem size, neck length) and surgery parameters (cup and stem position, leg length correction) were recorded and compared between the noisy and silent groups (t-test, Fisher Exact test).
Twenty-eight noisy hips (19.3%) were identified with 14 patients reporting squeaking, 16 clicking and 5 scratching including 7 with a combination of noises. Quasi permanent noises were reported for 7 hips (2 often) but in 17 cases the noise appeared only sometimes (2 rare). The average time of first incidence was 1.74 years port-op with 7 hips reporting noise directly after operation and 15 after 2 years or more. Silent and noisy hips were statistically not different regarding age, gender, follow-up time, side of operation, height, weight, BMI, cup and stem size, leg length difference or stem position. Significant differences were identified with the noise group having a steeper cup inclination (49.9° vs 46.9°, p< 0.05) and less frequent shorter (−2.7mm) necks (0 vs 22%, p< 0.01) but more frequent longer (+4mm) necks (50% vs 37%, p< 0.05). Leg length correction was performed less frequent (31 vs 55%, p< 0.01). In the noise group 5 (17%) and in the silent group only 1 (0.9%) cup revisions was performed (p< 0.01).
The incidence of noisy ceramic bearings was higher than usually reported (< 5%) as not only actively complaining subjects but all patients were interviewed. Cup position was confirmed to be a contributing factor but patient weight, height or BMI did not play a role. However, the use of long necks, the absence of short necks and less frequently performed leg length corrections significantly contributed to producing bearing noise. Biomechanical restoration, preoperative planning and soft tissue tension seem to be important factors in bearing noise etiology.
A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores by analysing prospectively collected data of 4654 consecutive patients (1003 males/3473 females). 3.8% developed pressure sores in the sacral, buttock or heel areas.
Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (4.65 versus 5.76), diabetes mellitus (pressure sore incidence 10.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor.
While the time interval between fall and admission was not significant, the time interval between admission and surgery was found to be an extremely significant risk factor. A fall in blood pressure during surgery (5.6%) was found to increase risk. Patients who underwent a dynamic hip screw were more likely to develop pressure sores (incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery or type of anaesthesia. Our incidence of pressure sores is lower than previously reported (30%). Whilst determining factors that increase the risk of pressure sores may not be sufficiently reliable to be used for the individual patient, taking appropriate preventative measures can reduce the incidence, particularly with reference to (optimising the patient pre-operatively and) reducing delays to surgery.
The health care system has to deal with substantial health care costs, which are expected to continue to rise due to the increasingly elderly populations. One way of saving has been a reduction of the amount of beds at hospitals. The consequence is that acute patients inappropriately are admitted to non specialized wards because of limited beds. These patients are also known as ‘outliers’. In this study consecutive patients with a hip fracture treated at the orthopaedic department (n=273) are compared with patients treated at other departments (n=147) according to incidence of complications and length of stay (LOS) before and after introduction of an evidence based clinical pathway. There was no medical difference between the populations. However the strict demands of saving costs, with limited beds, have resulted not only in economic consequences with prolonged hospitalization, but also in patient suffering and inconvenience of postoperative complications because of an increasing number of complications.
Patients treated at non specialized wards had an extra LOS of stay of 3.7 days in the acute hospital settings and furthermore 13.6 days of LOS including rehabilitation compared to patients treated at the orthopaedic department. In addition we consider the implemented evidence based clinical pathway to be successful since the number of complications was reduced. It is a major challenge to establish effective treatment and rehabilitation for patients after a hip fracture aiming to avoid complications and reduce LOS. Theses fragile patients with a hip fracture ought to be treated at the orthopaedic department, or at departments with geriatric and rehabilitation knowledge. Physiotherapists, occupational therapists and nurses specialising in orthopaedics and geriatricians should take an active part in these patients care, to improve the quality of care and patient safety in patients with a hip fracture.
Hip fractures constitute a major cause of hospital admission and length of stay in the elderly, resulting in increased disability and mortality. In this study the influence of optimized treatment of consecutively included patients with hip fracture on time to operation, bed days, reoperations and mortality within one year were investigated. The study period was April 1st 2003 and March 31st 2004. Comparisons are made between the 210 first patients and the 210 last patients who followed the new clinical pathway introduced at the University Hospital in Lund, Sweden. Early surgery, within 24 hours, was not associated with reduced mortality, but it was significantly associated with reduced length of stay (p< 0.001). Significantly more patients operated with osteosynthesis for femoral neck fracture, were reoperated compared to all other types of surgery (p< 0.001) also when reoperations with extraction of the hook-pins in healed fractures were excluded. Mortality was higher in men than in women at four (p = 0.025) and twelve months (p = 0.001) after the fracture. Mortality was significantly higher in medically fit patients with administrative delay to surgery compared to patients with no delay (p< 0.001).
The presentation is based on the results of the nursing intervention program by using telephone contact to elderly patients with hip replacement after discharge.
Due to an ageing population the numbers of patients with hip fractures are increasing. They often suffer from concomitant diseases and are therefore prone to be affected by complications such as pressure ulcers. The prevention of pressure ulcers among patients with a hip fracture is crucial. The aim of this study was to improve the quality of care and patient safety in patients with a hip fracture. A new evidence based clinical pathway was introduced to prevent hospital acquired pressure ulcers. Furthermore the purpose was to bring the staff’s attention to pressure ulcer prevention and to facilitate changes in clinical practice to improve quality of care and patient safety. A total of 478 patients with a hip fracture were consecutively included between April 1st 2003 and March 31 st 2004. The new evidence based clinical pathway was introduced on October 1st 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article. In the intervention group hospital acquired pressure ulcers decreased by 50% (p< 0.007). It is possible to reduce the development
We evaluated used sizes of standard and offset stems and cups, neck length, material of bearing surfaces and on the AP X-ray postoperative in standing position the inclination and anteversion angle of the cup as well as the stem position, postoperative leg length and Trendelenburg sign.
The range of cup inclination angle was in safe zone with an average of 45,8°, neutral stem position in 92,2%.
Leg length equal in 73% and lengthening or shortening +/−in average 8,4mm and 6,5 mm.
The Trendelenburg sign was negativ in 93% at the time of removal of skin sutures.
Patients were allocated a deprivation category by retrospective application of the Scottish Index of Multiple Deprivation (SIMD) quintiles.
Femoral stress shielding in cementless THA is a potential complication commonly observed in distally loading press-fit stems. This prospective study describes long-term femoral bone remodeling in cementless THA at a mean of 17 years (range: 15 to 20) in 208 consecutive fully HA-coated stems (Corail, DePuy Int. Ltd, Leeds, UK). All THA were performed by one group of surgeons between 1986 and 1991. The concept of surgical technique included impaction of metaphyseal bone utilizing bland femoral broaches until primary stability was achieved without distal press-fit. Radiographic evaluation revealed a total of five (2.4%) stems with periprosthetic osteolysis, which were associated with eccentric polyethylene wear. They were either revised or awaiting revision surgery. The remaining 97.6% stems revealed biologic load transfer in the metaphysis alone (52%) or in both metaphysis and diaphysis (48%). Stem survival of 97.6% after 15 to 20 years without stress shielding were considered to be related to: impaction of metaphyseal bone, bland broaches, HA coating, and unique prosthetic design.
Hip fractures are one of the leading causes of morbidity in the elderly population. A large reduction in morbidity can be achieved if these individuals can have definitive treatment rapidly. However, this is not always achievable to a multi factorial host of contributing factors. Therefore, to enable us to understand some aspect of why these delays, if any occur, the following study was undertaken.
The purpose of the study is to relate the place at which the patient fell, to the time of day for admission to casualty. This will enable us to ascertain whether there is a relationship between the location of injury and the time taken to admission into hospital; if there is such a correlation, then it will enable us to identify factors which will expedite an individuals attendance to hospital.
Despite advances in total hip arthroplasty, failure of acetabular cup remains a concern. The role of bone marrow stromal cells (BMSCs) to aid osseointegration of orthopaedic implants have been recently studied. We investigated the hypothesis that autologous BMSCs sprayed on the surface of acetabular cups would improve bone formation and bone implant contact.
Total hip replacements were implanted in 11 sheep, randomly assigned to receive either acetabular implants sprayed with autologous BMSCs suspended in fibrin (study group) or fibrin only (control group). Sheep were sacrificed after six months and the acetabulum with the implant was retrieved and prepared for undecalcified histology. Implant bone contact in both groups was compared microscopically, by noting the presence or absence of new bone or fibrous tissue along the implant at 35 consecutive points (every 1000 μm). The observers undertaking the histological analysis were blinded.
Significantly increased bone implant contact was noted in the BMSC treated group 30.71% ± 2.95 compared to the control group 5.14% ± 1.67 (p = 0.014). The mean thickness of fibrous tissue in contact with the implant was greater at the periphery 887.21mm ± 158.89 and the dome 902.45mm ± 80.67 of the implant in the control group compared to the BMSC treated group (327.49mm ± 20.38 at the periphery and 739.1 mm ± 173.72 at the centre). Conversely, direct bone contact with the implant surface was significantly greater around the cups with BMSCs.
Our data demonstrate that BMSC sprayed on surface of acetabular implants improves bone implant contact. Spraying acetabular cups using stem cells could be used in humans where acetabular bone contact is compromised such as in revision procedures.