Bipolar hemiarthroplasty (BHA) for idiopathic osteonecrosis of the femoral head (ONFH) is performed at our institution. The purpose of this study was to evaluate the clinical and radiographic findings after BHA for the treatment of steroid -induced ONFH.
Thirty-seven hips in 27 patients were assessed (seven men, 11 hips; 20 women, 26 hips), average patient age at the time of surgery of 42.6 (range 20–83) years, with steroid-induced ONFH treated with BHA between 1995 and 2005. The mean follow-up duration was approximately ten (range five to15) years. Patients were evaluated according to the Japan Orthopaedic Association (JOA) hip score. Kaplan–Meier survivorship was calculated to examine revision arthroplasty failure rate. Radiographic analysis of loosening included radiolucent lines and osteolysis of the acetabulum or femur. Causes of loosening were analysed using multiple logistic regression.
JOA hip score increased from 53 points (preoperative) to 87 points (final follow-up). Survival rates were 96.8 % and 78.6 % at ten and 15 years, respectively. Prosthesis loosening occurred on the acetabular side in five hips (13.5 %). No femoral-component loosening was observed. BHA had poor results in patients with Association Research Circulation Osseous (ARCO) stage IV ONFH and in patients under 40 years of age.
BHA, with strict surgical indications, may be a good option for treating ONFH. Based on these results, total hip arthroplasty is recommended for patients with ARCO stage IV ONFH or for patients under 40 years of age.
Multimodal thromboprophylaxis includes preoperative thromboembolic risk stratification and autologous blood donation, surgery performed under regional anaesthesia, postoperative rapid mobilisation, use of pneumatic compression devices and chemoprophylaxis tailored to the patient’s individual risk. We determined the 90-day rate of venous thromboembolism (VTE), other complications and mortality in patients who underwent primary elective hip and knee replacement surgery with multimodal thromboprophylaxis.
A total of 1,568 consecutive patients undergoing hip and knee replacement surgery received multimodal thromboprophylaxis: 1,115 received aspirin, 426 received warfarin and 27 patients received low molecular weight heparin and warfarin with or without a vena cava filter.
The rate of VTE, pulmonary embolism, proximal deep vein thrombosis (DVT) and distal DVT was 1.2, 0.36, 0.45 and 0.36 %, respectively, in patients who received aspirin. The rates in those who received warfarin were 1.4, 0.9, 0.47 and 0.47 %, respectively. The overall 90-day mortality rate was 0.2 %.
Multimodal thromboprophylaxis in which aspirin is administered to low-risk patients is safe and effective following primary total joint replacement.
Osteoporosis mainly involves cancellous bone, and the spine and hip, with their relatively high cancellous bone to cortical bone ratio, are severely affected. Studies of bone mesenchymal stem cells (BMSCs) from osteoporotic patients and animal models have revealed that osteoporosis is often associated with reduction of BMSCs’ proliferation and osteogenic differentiation. Our aim was to test whether polylactic acid-polyglycolic acid copolymer(PLGA)/collagen type I(CoI) microspheres combined with BMSCs could be used as injectable scaffolds to improve bone quality in osteoporotic female rats.
PLGA microspheres were coated with CoI. BMSCs of the third passage and were cultured with PLGA/CoI microspheres for seven days. Forty three-month-old female non-pregnant SD rats were ovariectomized to establish osteoporotic animal models. Three months after being ovariectomized, the osteoporotic rats were randomly divided into five groups: SHAM group, PBS group, cell group, microsphere (MS) group, and cell+MS group. Varying materials were injected into the intertrochanters of each group’s rats. Twenty rats were sacrificed at one month and three months post-op, respectively. The femora were harvested in order to measure the intertrochanteric bone mineral density (BMD) with DEXA and trabecular thickness (Tb.Th), percentage of trabecular area (%Tb.Ar), bone volume fraction (BV/TV) and trabecular spacing (Tb.Sp) with Micro CT. One-way ANOVA and Kruskal-Wallis tests were used.
BMSCs seeded on PLGA/CoI microspheres had a nice adhesion and proliferation. At one month post-op, the BMD (0.33 ± 0.01 g/cm2), Tb.Th (459.65 ± 28.31 μm), %Tb.Ar (9.61 ± 0.29 %) and Tb.Sp (2645.81 ± 94.91 μm) of the cell+ MS group were better than those of the SHAM group and the cell group. At three months post-op, the BMD (0.32 ± 0.01 g/cm2), Tb.Th (372.81 ± 38.45 μm), %Tb.Ar (6.65 ± 0.25 %), BV/TV (6.62 ± 0.25 %) and Tb.Sp (1559.03 ± 57.06 μm) of the cell + MS group were also better than those of the SHAM group and the cell group.
The PLGA/CoI microspheres combined with BMSCs can repair bone defects more quickly. This means that PLGA/CoI microspheres combined with BMSCs can promote trabecular reconstruction and improve bone quality in osteoporotic rats. This scaffold can provide a promising minimally invasive surgical tool for enhancement of bone fracture healing or prevention of fracture occurrence which will in turn minimize complications endemic to patients with osteoporosis.
Eighty per cent of severe fractures occur in developing countries. Long bone fractures are treated by conservative methods if proper implants, intraoperative imaging and consistent electricity are lacking. These conservative treatments often result in lifelong disability. Locked intramedullary nailing is the standard of care for long bone fractures in the developed world. The Surgical Implant Generation Network (SIGN) has developed technology that allows all orthopaedic surgeons to treat fracture patients with locked intramedullary nailing without the need for image intensifiers, fracture tables or power reaming. Introduced in 1999, SIGN nails have been used to treat more than 100,000 patients in over 55 developing world countries. SIGN instruments and implants are donated to hospitals with the stipulation that they will be used to treat the poor at no cost. Studies have shown that patients return to function more rapidly, hospital stays are reduced, infection rates are low and clinical outcomes excellent. Cost-effectiveness analysis has confirmed that the system not only provides better outcomes, but does so at a reduced cost. SIGN continues to develop new technologies, in an effort to transform lives and bring equality in fracture care to the poorest of regions.
Losing a limb (or a part of a limb) usually leads to loss of functionality and subsequent disability. This paper aims at pointing out the importance of comprehensive and multidisciplinary care that includes early, direct or indirect, involvement of rehabilitation service providers even in an emergency context.
We underline the links between amputation and disability as well as the milestones and main purposes of the rehabilitation process following amputation. We then emphasise the influence that the level of amputation has on functional outcomes.
In order for functional outcomes to balance purely medical factors when identifying the best site for amputation in emergency settings where preoperative involvement of a rehabilitation professional is difficult due to limited resources, we enunciate five general rules to be used as guidelines by the medical team in the absence of a rehabilitation service provider. These five rules, remaining general enough to apply to most contexts and patients, still need to be balanced against contextual and personal factors that can only be identified at the time of the amputation.
The main expectations of people who undergo surgery are, usually, to remain actors in the society and regain functional abilities. Therefore, surgical outcomes are closely related to functional outcomes. In order for the functional and personal factors to be taken into account, we recommend, even in an emergency context, preoperative involvement of rehabilitation care providers.
Circulating TGF-β1 levels were found to be a predictor of delayed bone healing and non-union. We therefore aimed to investigate some factors that can influence the expression of TGF-β1. The correlation between the expression of TGF-β1 and the different socio-demographic parameters was analysed.
Fifty-one patients with long bone fractures were included in the study and divided into different groups according to their age, gender, cigarette smoking status, diabetes mellitus and regular alcohol intake. TGF-β1 levels were analysed in patient’s serum and different groups were retrospectively compared.
Significantly lower TFG-β1 serum concentrations were observed in non-smokers compared to smokers at week 8 after surgery. Significantly higher concentrations were found in male patients compared to females at week 24. Younger patients had significantly higher concentrations at week 24 after surgery compared to older patients. Concentrations were significantly higher in patients without diabetes compared to those with diabetes at six weeks after surgery. Patients with chronic alcohol abuse had significantly higher concentrations compared to those patients without chronic alcohol abuse.
TGF-β1 serum concentrations vary depending upon smoking status, age, gender, diabetes mellitus and chronic alcohol abuse at different times and therefore do not seem to be a reliable predictive marker as a single-point-in-time measurement for fracture healing.
Performing total knee replacement, accurate alignment and neutral rotation of the femoral component are widely believed to be crucial for the ultimate success. Contrary to absolute bone referenced alignment, using a ligament balancing technique does not automatically rotate the femoral component parallel to the transepicondylar axis. In this context we established the hypothesis that rotational alignment of the femoral component parallel to the transepicondylar axis (0° ± 3°) results in better outcome than alignment outside of this range.
We analysed 204 primary cemented mobile bearing total knee replacements five years postoperatively. Femoral component rotation was measured on axial radiographs using the condylar twist angle (CTA). Knee society score, range of motion as well as subjective rating documented outcome.
In 96 knees the femoral component rotation was within the range 0 ± 3° (neutral rotation group), and in 108 knees the five-year postoperative rotational alignment of the femoral component was outside of this range (outlier group). Postoperative CTA showed a mean of 2.8° (±3.4°) internal rotation (IR) with a range between 6° external rotation (ER) and 15° IR (CI 95). No difference with regard to subjective and objective outcome could be detected.
The present work shows that there is a large given natural variability in optimal rotational orientation, in this study between 6° ER and 15° IR, with numerous co-factors determining correct positioning of the femoral component. Further studies substantiating pre- and postoperative determinants are required to complete the understanding of resulting biomechanics in primary TKA.
To compare the results of Extracorporeal shock wave (ESWT) with a modified endoscopic plantar fasciotomy technique for the treatment of recalcitrant heel pain.
Sixty-five patients suffering from chronic heel pain that failed to respond to standard nonoperative methods were randomized to undergo either high-energy extracorporeal shock wave therapy (group 1), or modified endoscopic plantar fasciotomy (group 2). The primary outcome measure was the reduction of pain in the two groups from base line to month three post intervention at the first few steps in the morning. In addition, patients' functions were assessed using American Orthopedic Foot and Ankle-Hindfoot Scale (AOFAS) at week three, month three, and month 12 post-intervention, and finally, Roles and Maudsley scores were assessed. The primary analysis was intention-to-treat and involved all patients who were randomly assigned.
Both groups achieved improvement from the base line at 3 weeks, 3 months and 12 months post-intervention. The success rate (Roles and Maudsley score excellent and good) in the ESWT group at month 12 was 70.6 %, while in the fasciotomy group, the success rate was 77.4 % (p = 0.19).
In patients who had experienced failure of conventional treatment of plantar fasciopathy, both endoscopic plantar fasciotomy and shock wave therapy can be potentially helpful lines of management.
The purpose of our study is to evaluate the clinical results of anatomical reconstruction of the lateral ligaments with semitendinosus allograft.
Thirty-six patients with chronic lateral instability underwent anatomical reconstruction of the lateral ligaments of the ankle with semitendinosus allograft. The American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale score (AOFAS score) and the Karlsson score were used to evaluate the clinical results before and after surgery.
A total of 35 patients (97.2 %) (36 ankles) were followed up for a mean of 37.9 months. The mean AOFAS score improved from 42.3 ± 4.9 points preoperatively to 90.4 ± 6.7 postoperatively. The mean Karlsson score improved from 38.5 ± 3.2 preoperatively to 90.1 ± 7.8 postoperatively.
Anatomical reconstruction of the lateral ligaments with semitendinosus allograft achieves a satisfactory surgical outcome for chronic ankle instability.
NELL-1 is a novel osteoinductive growth factor that has shown promising results for the regeneration of bone. Moreover, NELL-1 has been used successfully in bone regeneration in the axial, appendicular and calvarial skeleton of both small and large animal models. Despite increasing evidence of NELL-1 efficacy and future usefulness as an alternative to traditional bone graft substitutes, much has yet to be understood regarding the mechanisms of action of this novel protein. The activation of the mitogen-activated protein kinase (MAPK) pathway has been well studied in the setting of growth factor-mediated changes in osteogenic differentiation.
In this study, we provide evidence of the involvement of MAPK signalling pathways in NELL-1-induced terminal osteogenic differentiation of Saos-2 human osteosarcoma cells. Activation of extracellular signal-regulated kinase (ERK1/2), P38 and c-Jun N-terminal kinase (JNK) pathways were screened with MAPK signalling protein array after recombinant human (rh)NELL-1 treatment. Next, the mineralisation and intracellular phosphate levels after rhNELL-1 stimulation were assessed in the presence or absence of specific MAPK inhibitors.
Results showed that rhNELL-1 predominantly increased JNK pathway activation. Moreover, the specific JNK inhibitor SP600125 blocked rhNELL-1-induced mineralisation and intracellular phosphate accumulation, whereas ERK1/2 and P38 inhibitors showed no effect.
Thus, activation of the JNK pathway is necessary to mediate terminal osteogenic differentiation of Saos-2 osteosarcoma cells by rhNELL-1. Future studies will extend these in vitro mechanisms to the in vivo effects of NELL-1 in dealing with orthopaedic defects caused by skeletal malignancies or other aetiologies.
The purpose of this study was to assess the clinical and radiographic results of a total hip arthroplasty with the double tapered Mallory-Head system.
The clinical and radiographic results of a consecutive series of 81 total hip replacements in 75 patients were reviewed 10–15 years (average 11.4 years) postoperatively. The patients’ underlying conditions were avascular necrosis in 46 hips (57 %), osteoarthritis in 12 hips (15 %), RA in nine hips (11 %), and others. Clinical results were evaluated based on the modified Harris hip score and modified Merle d’Aubigné-Postel score. A radiographic analysis was performed.
The average modified Harris hip score improved from a preoperative score of 56 points to a postoperative 92 points. The average modified Merle d’Aubigné-Postel score was 15 points at the latest follow up, and 55 hips (68 %) were classified as the clinical grades of excellent or good results. One acetabular component was revised because of loosening, and one was revised for recurrent dislocation.
The clinical and radiological evaluations of the total hip replacements using the Mallory-Head system showed good results.
ADVANCE® Medial-Pivot (MP) (Wright Medical Technology, Arlington, TN, USA) total knee arthroplasty (TKA) was developed to replicate normal tibiofemoral knee joint kinematics, allowing medial-pivot knee motion. The design concept of the prosthesis is unique; therefore, the influence on the patellofemoral knee joint remains unclear at present. The purpose of this study was to determine the in vivo patellofemoral kinematics with ADVANCE® MP TKA and compare them with the pre-operative conditions.
ADVANCE® MP TKA was performed in ten subjects with osteoarthritis (OA). At before and one month after surgery, lateral radiographs with weight-bearing at maximum extension, 30, 60 and 90° were taken, and patella flexion angle (PF), tibiopatellar angle (TP) and estimated patellofemoral contact point (PC) were evaluated, according to a previously reported method.
In PF and TP, there was no statistically significant change between pre-operative and postoperative values. Pre-operative PC reached its peak at 90°; however, its peak was at 60° at one month after surgery. Postoperative PC at maximum extension was significantly higher compared to before surgery.
The results in this study indicated that ADVANCE® MP TKA changed patellofemoral joint kinematics compared to before surgery. Early postoperative evaluation is the limitation of this study; however, we consider that the results in this study might be one of the keys to resolving the kinematic features of this prosthesis, helping clinicians to comprehend this prosthesis.
Indications for amputation in natural disasters are not the same compared to our daily practice. They must be determined by those with great surgical experience and good knowledge of military or disaster surgical doctrine. Unfortunately, nowadays few surgeons have this experience. In fact, some volunteer surgeons may be interested in providing care for civilian victims of war or disaster in developing countries. However, there are significant differences between the type and the management of cases seen in this context versus those seen at home. The problems of amputations cannot be solved schematically. Amputation will depend on several factors: the form of warfare or disaster, the conditions for surgery, the skill of the surgical team and the experience of the surgeon, and the length or duration of the mission.
Here is a schematic showing the three main situations: civilian practice, war practice and disaster context. These three different situations require different strategies for treating the wounded and for making amputation decisions.
In the case of a natural disaster, there are many wounded civilians, they arrive at the medical facility late and there is usually only one surgeon and a single, limited medical facility to provide all treatment. He must make quick, wise choices, economising limited blood supplies and the use of surgical procedures. The decision to proceed with limb salvage or amputation for patients with severely injured limbs will be a source of continued debate. Amputation, radical and irreversible intervention, is a frequent and essential procedure in the disaster context and one of the standard means to successful treatment of limb wounds.
We propose to reflect on the following questions: why to amputate, how to perform amputation under these conditions and how to pass on a doctrine to the voluntary surgeons who lack experience in a disaster context.
Haemophilic pseudotumour was defined by Fernandez de Valderrama and Matthews as a progressive cystic swelling involving muscle, produced by recurrent haemorrhage into muscles adjacent to the bone. The pseudotumour mainly occurs in the long bones and the pelvis. The treatment of the haemophilic pseudotumour poses a challenge, and extensive clinical experience is essential to appropriately address this serious complication in patients with haemophilia. Consequently, the aim of this study is to present our own clinical experience and treatment results of the haemophilic pseudotumour.
We retrospectively reviewed the records of 87 patients with bleeding disorders treated between 1967 and 2011 for musculoskeletal complications of congenital bleeding disorders. We identified six patients with a haemophilic pseudotumour who were treated at our department.
The mean age at surgery was 45.9 (range, 40–61) years. The iliac bone was affected in three patients (one right, two left), the right tibia (distal diaphysis) in one, the right thigh in two and the right ulna (proximal part) in one patient. One patient had two pseudotumours. The perioperative course was easily controllable with adequate factor VIII substitution. At the latest follow-up after 8.4 (range, 4–24) years, normal healing with no recurrence was observed.
The haemophilic pseudotumour is a rare but severe complication of hereditary bleeding disorders. In the international literature the resection and postoperative course are described as challenging and difficult, requiring detailed preoperative planning. It is advisable to perform such operations in specialised centres with close co-operation between surgeons and haematologists.
The popliteus tendon is known to play a key role in the stability of the posterolateral corner of the knee. While prior work suggests that isolated sectioning of the popliteus tendon has little consequence for the static stability of the knee following TKA, no studies have evaluated the effect of iatrogenic popliteal tendon injury on patient oriented outcome and knee function following TKA. The aims of this study are (1) to compare patient-oriented outcome scores of patients who suffered an iatrogenic injury to the popliteus tendon with a control group without such an injury and (2) to identify risk factors associated with iatrogenic injury to the popliteus tendon.
Fifteen patients with an iatrogenic complete transection of the popliteus tendon during TKA were compared to the 666 patients who underwent TKA during the same time period without popliteus tendon injury.
Postoperatively, IKS knee scores were similar between the two groups; however, significantly lower IKS function scores were noted in the study group (71 ± 31) compared to the control group (86 ± 19) (p = 0.0036). Iatrogenic popliteal tendon injury was only noted to occur in patients in whom components of size four or smaller were used.
Intraoperative complete section of the popliteus tendon during the performance of TKA results in decreased IKS functional scores two to three years postoperatively. Patients with smaller knees may be at higher risk for this complication.
Although intramedullary fixation of closed simple (type A or B) diaphyseal tibial fractures in adults is well tolerated by patients, providing lower morbidity rates and better mobility, it is associated with some complications. This study evaluated the results of managing these fractures using percutaneous minimal internal fixation using one or more lag screws, and Ilizarov external fixation.
This method was tested to evaluate its efficacy in immediate weight bearing, fracture healing and prevention of any post-immobilisation stiffness of the ankle and knee joints. This randomised blinded study was performed at a referral, academically supervised, level III trauma centre. Three hundred and twenty-four of the initial 351 patients completed this study and were followed up for a minimum of 12 (12–88) months. Patient ages ranged from 20 to 51 years, with a mean of 39 years. Ankle and knee movements and full weight bearing were encouraged immediately postoperatively. Solid union was assessed clinically and radiographically. Active and passive ankle and knee ranges of motion were measured and compared with the normal side using the Wilcoxon signed rank test for matched pairs. Subjective Olerud and Molander Ankle Score was used to detect any ankle joint symptoms at the final follow-up.
No patient showed delayed or nonunion. All fractures healed within 95–129 days.
Based on final clinical and radiographic outcomes, this technique proves to be adequate for managing simple diaphyseal tibial fractures. On the other hand, it is relatively expensive, technically demanding, necessitates exposure to radiation and patients are expected to be frame friendly.
A rupture of the Achilles tendon may heal in continuity, resulting in a lengthened Achilles tendon. The elongated structure must be shortened to restore effective push off. We report the results of a longitudinal study using Z-shortening of ruptured Achilles tendons that healed in continuity but were elongated.
Nine patients underwent surgery for elongation of a healed Achilles tendon rupture. All participants were prospectively followed up for two to five years, and final review was performed at 32 ± 14 months from operation. Clinical and functional assessment (anthropometric measurements, isometric strength, postoperative total rupture score) was performed.
All patients were able to walk on tiptoes, and no patient used a heel lift or walked with a visible limp. No patient developed clinically evident deep-vein thrombosis or sustained a rerupture. Two patients were managed conservatively following a superficial surgical wound infection. At final review, maximum calf circumference remained significantly decreased in the operated leg. The operated limb was significantly weaker than the nonoperated one.
Managing a healed Achilles tendon rupture using Z-shortening is safe and effective, providing good recovery and early weight bearing and active ankle mobilisation. Such patients should be warned that they are at risk for postoperative complications and that their ankle–plantar flexion strength is likely to be permanently reduced.
Amputation is a commonly performed procedure during natural disasters and mass casualties related to industrial accidents and military conflicts where large civilian populations are subjected to severe musculoskeletal trauma. Crush injuries and crush syndrome, an often-overwhelming number of casualties, delayed presentations, regional cultural and other factors, all can mandate a surgical approach to amputation that is different than that typically used under non-disaster conditions. The following article will review the subject of amputation during natural disasters and mass casualties with emphasis on a staged approach to minimise post-surgical complications, especially infection.
Muscle atrophy is a commonly encountered problem in osteoarthritis (OA). The aim of this study was to estimate the amount of muscle atrophy and fatty degeneration of the lower leg muscles related to ankle OA by magnetic resonance imaging (MRI).
Twenty-one patients with unilateral ankle OA were included in this cohort study. Calf circumference of the affected and healthy lower leg was documented. The degree of OA was classified in conventional radiographs. The cross-sectional areas and fatty degeneration of the muscles of the lower leg were measured in bilateral MRI.
We found a significantly reduced calf circumference of the affected vs. healthy leg (p = 0.016). MRI showed a significantly lower cross-sectional area of the entire lower leg musculature in OA (p = 0.013). Sub-analysis of muscle groups revealed that only the M. soleus had a significant cross-sectional area decrease (p < 0.01). All muscles showed a significant fatty degeneration (p < 0.01).
We conclude that unilateral ankle joint osteoarthritis leads to an overall lower leg muscle atrophy, but significant atrophy of the M. soleus. All muscles of the affected leg undergo a fatty degeneration.
Avulsion of the abductors from the hip can be an infrequent but debilitating complication after total hip arthroplasty performed through a trans-gluteal approach. This can result in intractable pain, limp, Trendelenberg lurch and instability of the hip. There have been various methods described for repairing or reconstruction of this abductor muscle complex including direct trans-osseous repair, muscle transfers, muscle and tendon sling, bone tendon allograft reconstruction and endoscopic repair techniques.
In a prospective study at our institution we evaluated the results of a surgical technique in 12 patients using a trans-osseous repair of gluteus medius and minimus insertions augmented by a Graft Jacket® allograft acellular human dermal matrix (Graft Jacket®; Wright Medical Technology, Arlington, TN) over the anterior and anterolateral aspects of the greater trochanter. Diagnosis of hip abductor avulsions was made by evaluation of the history of presenting complaint, clinical examination and confirmed by ultrasound or MRI scans.
Evaluation of results included pain scoring, gait evaluation, Trendelenberg test, and the Harris hip score. There was a significant improvement in pain (VAS mean values 8.25 to 2.33; p value < 0.0001), limp and gait along with abductor strength. The Trendelenberg test became negative in all but one. At the mean follow up of 22 months Harris hip scores improved from 34.05 to 81.26 (p value <0.0001).
Overall this procedure appears to be safe and associated with high patient satisfaction, without the morbidity of any tendon or muscle transfers.