Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA. A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d’Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented.Aims
Methods
Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening. In all, ten hips in ten patients with PPRP with fixed pelvic obliquity who underwent THA as per an algorithmic approach in two centres from January 2014 to March 2018 were followed-up for a minimum of two years (2 to 6). All patients required one or more additional soft tissue procedures in a pre-determined sequence to correct the pelvic obliquity. All were invited for the latest clinical and radiological assessment.Aims
Methods
The advent of trabecular metal (TM) augments has revolutionized
the management of severe bone defects during acetabular reconstruction.
The purpose of this study was to evaluate patients undergoing revision
total hip arthroplasty (THA) with the use of TM augments for reconstruction
of Paprosky IIIA and IIIB defects. A retrospective study was conducted at four centres between August
2008 and January 2015. Patients treated with TM augments and TM
shell for a Paprosky grade IIIA or IIIB defect, in the absence of
pelvic discontinuity, and who underwent revision hip arthroplasty
with the use of TM augments were included in the study. A total
of 41 patients with minimum follow-up of two years were included
and evaluated using intention-to-treat analysis.Aims
Patients and Methods
The advent of trabecular metal (TM) augments has revolutionized the management of severe bone defects during acetabular reconstruction. The purpose of this study was to evaluate patients undergoing revision total hip arthroplasty (THA) with the use of TM augments for reconstruction of Paprosky 3A, 3B defects and defects associated with pelvic discontinuity. A retrospective study was conducted of the cases performed at four centers between August 2007 and January 2015. Patients treated with TM augments for Paprosky 3A, 3B or chronic pelvic discontinuity were included in the study. All surgeries were performed through a posterior approach. A total of 57 patients (Male 34 (69%), Female 23(31%)), mean age 54 years (range, 28–94 years), with minimum follow up of one-year were included and evaluated using intention to treat analysis. There were 44 (77%) patients with a 3A defect, 11(19%) patients with a 3B defect (6 had an associated pelvic discontinuity), and 2 (3.5%) with a 2C defect and associated pelvic discontinuity. The mean follow-up was 37 months (range, 12–96 months). One (2%) patient died after 8 years of unrelated causes. Three (5.5%) patients had acetabular component loosening requiring revision; Two failures were (3.5%) due to aseptic loosening and one (2%) due to septic loosening. Fifty-four patients had a radiologically stable integration of the components at latest follow-up - survivorship was 94.7%. The results of this multi-center study demonstrate encouraging short and mid-term results for the use of TM augments in the management of Grade 3A and 3B defects, and defects associated with a chronic pelvic discontinuity.
Giant cell tumour is the most common aggressive
benign tumour of the musculoskeletal system and has a high rate of
local recurrence. When it occurs in proximity to the hip, reconstruction
of the joint is a challenge. Options for reconstruction after wide
resection include the use of a megaprosthesis or an allograft-prosthesis
composite. We performed a clinical and radiological study to evaluate
the functional results of a proximal femoral allograft-prosthesis
composite in the treatment of proximal femoral giant cell tumour
after wide resection. This was an observational study, between 2006
and 2012, of 18 patients with a mean age of 32 years (28 to 42)
and a mean follow-up of 54 months (18 to 79). We achieved excellent
outcomes using Harris Hip Score in 13 patients and a good outcome
in five. All allografts united. There were no complications such
as infection, failure, fracture or resorption of the graft, or recurrent
tumour. Resection and reconstruction of giant cell tumours with
proximal femoral allograft–prosthesis composite is a better option
than using a prosthesis considering preservation of bone stock and excellent
restoration of function. A good result requires demanding bone banking techniques, effective
measures to prevent infection and stability at the allograft-host
junction. Cite this article:
Metastatic spinal disease is a common entity of much debate in terms of ideal surgical treatment. The introduction of MIS can be a game-changer in the treatment of MSD due to less peri-operative morbidity and allowing earlier radiotherapy and/or chemotherapy. Less invasive techniques have always been welcome for management of patients with ‘Metastatic Spinal Disorders’. This is because these patients can be poor candidates for extensive / major invasive surgery even though radiologically, there may be an indication for one. The aim of the treatment with Minimal Invasive Fixation (MIS) systems is mainly for ‘pain relief’ than to radically decrease tumour burden or to achieve near total spinal cord decompression, which could be major presentations in these patients. These procedures address the ‘spinal instability’ very well and they can address pain associated with compression fractures resulting from metastatic disease from a solid organ as well as multiple myeloma with minimal complications. These procedures can be combined with radiology and chemotherapy without much concern for wound problems in the way of infection or dehiscence. They also have a great advantage of timing of adjunct therapy closer to the index procedure. The disadvantage, however, are they do not allow thorough decompression of the spinal cord. There could also be problem in addressing patients who have severe vertebral height loss or loss of integrity of the anterior column where anterior column reconstruction may be required. There is a risk of inadequate fixation or implant loosening or failure. We aim to examine the results of MIS surgery in our department and support the rationale for its use.Summary
Introduction
We retrospectively reviewed 54 patients (92 hips) who underwent cementless total hip arthroplasty for bony ankylosis in ankylosing spondylitis between September 1988 and 2002. Clinical assessment was done at follow-up, which envisages assessment of the pain, function, deformities and range of motion using the Harris Hip Score. Radiographic analysis was done. Kaplan-Meier survivorship analysis was done at 5 and 8.5 years using the revision for the removal of femoral component, acetabular component or both due to any cause as the end point. The mean age of the patients was 25.5 years. The mean duration of follow up was 8.5 years. The average preoperative Harris Hip Score of 49.5 improved to 82.6 post operatively. Post operatively 10 hips had mild to moderate pain. Anterior dislocation occurred in four hips (4.3 %) and sciatic nerve palsy in one hip. Heterotopic ossification was seen in 12 patients, reankylosis rate was 0%. Thirteen arthroplasties were revised due to aseptic loosening. Kaplan-Meier survivorship analysis with revision as end point revealed 98.8% survival at 5 years and 85.8% survival at 8.5 years 11 follow up. Cementless THA in osseous ankylosis in ankylosing spondylitis is a worthwhile surgical intervention in bony ankylosis. Newfound mobility, manoeuvrability and improved ability to sit comfortably were the outcomes, which alleviated the patients’ daunted morale. However, the technically demanding nature of the procedure should not be underestimated.
A prospective, randomized, controlled trial was performed to compare the outcome of treatment of unstable fractures of the proximal part of the femur with either a sliding hip screw or a short proximal femoral nail antirotation (PFNA-XS, Synthes). Eighty one patients (April 2007 – May 2008) presenting with unstable fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a short proximal femoral nail antirotation (n=42) or a sliding hip screw (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Follow-up was undertaken at 3, 6, and 12 postoperative months and yearly thereafter. Plain AP and lateral radiographs were obtained at all visits. All changes in the position of the implant, complications, or fixation failure were recorded. Hip range of motion, pain about the hip and the thigh, walking ability score and return to work status were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. Mean Operative time was significantly less in PFNA group (Mean 25 min, range 19 – 56 min) than DHS group (Mean 38 min, range 28 – 70 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. 6 patients in DHS group had implant failure as compared to none in PFNA group. The functional outcome was also better in PFNA group. When compared to DHS, PFNA-XS provides better functional outcome for unstable trochanteric fractures with less operative time, less blood loss and less complications, however one year mortality rate remains the same.
A prospective, randomized, double-blind study was done on 50 patients undergoing primary cementless total hip arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements. 50 patients were randomized to tranexamic acid (15 mg/kg) given as a bolus intravenous injection or placebo (normal saline) given intravenously, 15 minutes before the incision. The intraoperative and postoperative blood loss (at removal of the drain 24 hours after the operation) and the number of blood transfusions required were recorded. The patients were screened for deep venous thrombosis with bilateral compression Ultrasonography using Colour Doppler imaging on the tenth postoperative day. The Hemoglobin level was measured preoperatively and on the 3rd postoperative day. The D-dimer levels were measured preoperatively and 24 hrs postoperatively. Patients receiving tranexamic acid had a mean intraoperative blood loss of 410 ml (range, 300–510 ml) versus 615 ml (range, 515–750ml) (p value<0.05) in patients receiving placebo, a postoperative blood loss of 210 ml(range, 150–325ml) versus 490 ml(range, 370–540ml) (p value<0.05), and a total need for 8 blood transfusions versus 30. Only 6 out 25 patients in tranexamic acid group required blood transfusion whereas 18 out of 25 patients in the placebo group required transfusion. In the group receiving placebo the mean fall in hemoglobin was 2.9g/dl (range, 2.5–3.2) and in the group treated with tranexamic acid 1.6 g/dl (1.3–2) (p<0.05). At 24 hrs postoperatively, mean plasma D-dimer concentration in the Tranexamic group was half of that in the control group. No patient in either group had any evidence of deep vein thrombosis on bilateral compression Ultrasonography using Colour Doppler imaging done on the tenth postoperative day. Tranexamic acid 15 mg/kg given as a single preoperative bolus dose reduces peroperative and postoperative and total blood loss, and transfusion requirements in primary cementless total hip replacement surgery without any increased risk of thrombus formation.
We compared pain relief after total hip arthroplasty using periarticular intraoperative injection along with single dose post operative injection of local anesthetic (THA) with the well-established practice of epidural infusion. 70 patients undergoing elective THA under combined spinal anaesthesia were randomly assigned to receive either (1) continuous epidural infusion (group B) or (2) infiltration around the hip joint with a mixture of 100 ml of bupivacaine (2 mg/ml) + 1ml ketorolac (30mg/ml) and 0.5ml epinephrine (1mg/ml) at the conclusion of surgery combined with one postoperative intraarticular injection of 20 ml. of Bupivacaine 0.5% + 1ml ketorolac (30mg/ml)+ 0.5 ml. epinephrine (1mg/ml) through an intraarticular catheter (group A). All patients received acetoaminophen 1gm 8 hourly for 72 hrs and injection ketoralac 30mg every 6 hourly IV(15mg if >65 yr 30mg if <65 yr). Breakthrough pain in any group (VAS >7) was treated by injection fentanyl 20 μg bolus at 10 min. interval till VAS reduced to < 4. If VAS 4–7 injection tramadol 50mg IV was given if VAS continued to be >4 after 15 min. then injection fentanyl 20 μg bolus was given at 10 min interval till VAS <4.Background
Methods
Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications.
Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months.Introduction
Material & Methods
Locking plates have been especially useful in the treatment of osteoporotic fractures. This study aimed to investigate the role of locking plate in femoral fractures in patients with osteogenesis imperfecta. 6 male patients with osteogenesis imperfecta were operated for femoral fractures using locking compression plate. Their age ranged between 4 and 14 years. They were kept non weight bearing till the fracture united.Introduction
Material & Methods
We compared standard NexGen Cruciate substituting-flex prosthesis with gender-specific NexGen Cruciate substituting flex prosthesis in patients undergoing bilateral total knee arthroplasty with regard to Coverage of the bone by femoral component, Clinical outcome, Radiographic outcome, Survival and complication rates, with special emphasis on patellofemoral complications. 30 female patients with osteo-arthritis of the knees with similar deformity and preoperative range of motion were randomized to have one knee replaced with a gender non-specific Nexgen Cruciate substituting (Zimmer) prosthesis and the other with Gender Cruciate substituting (Zimmer) prosthesis. Follow-up clinical evaluation was done at 6, and 12 months postoperatively and then at yearly interval using “Knee Society” Recommendations. Clinical assessment of the patellofemoral joint of the replaced knees was done with the help of “Hospital for Special Surgery” patellar scoring system. The overall patient satisfaction after surgery was evaluated with use of the British Orthopaedic Association patient satisfaction score.Introduction
Material & Methods
Tranexamic acid is an inhibitor of fibrinolysis that blocks the lysine-binding site of plasminogen to fibrin, and thereby decreases blood loss in patients undergoing surgery. A prospective, randomized, double-blind study was done on 100 patients undergoing primary cemented Unilateral Total Knee Arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements.Introduction
Aims and objectives
25 patients in age group (25–40yrs), 15 males, 10 females were implanted with a short metaphyseal cementless stem (‘Proxima’®, Depuy) and cementless acetabular cup. The average follow up was 2.3 years (1.4–2.5 yrs). Clinical evaluation using Harris Hip Score, Radiological evaluation and Bone Mineral Density were evaluated at 2weeks, 6 months, 12 months and yearly thereafter. a new zonal method suitable for short stem was used for radiological evaluation. The mean Harris Hip score improved from 44 to 95 at final follow up. There was no evidence of any radiolucent lines or osteolysis around the stems. All the stems showed evidence of osseointegration at one year follow up. There was no decrease in bone mineral density around the stems. The Short Metaphyseal cementless femoral stem is a bone conserving as well as bone preserving option for young patients especially in those in whom surface replacement is not an option.
Twenty total hip arthroplasty were performed with use of a cementless cup in 17 patients and cemented cup in a cage in 3 patients for the treatment of posttraumatic osteoarthritis following acetabular fracture. The average age of the 4 women and 16 men was 49 (range, 26 to 86 years) at the time of the arthroplasty. The median interval between the time of injury and the total hip arthroplasty was 37 months (range, 8 to 144 months). The average operative time was 120 minutes and average intraoperative blood loss was 700 ml. Eight patients had previous open reduction and internal fixation of the acetabular fracture and twelve had been treated nonoperatively. Following total hip replacement, each patient was evaluated clinically and radiographically at six weeks, three months, six months and twelve months, and then yearly following total hip replacement. The average duration of clinical and radiographic follow-up was 40 months (range, 26 to 60 months). At the time of final follow-up, of twenty acetabular components, 10 had no evidence of periacetabular radiolucency, 7 components had a partial radiolucency that was <1 mm wide, 2 had a complete radiolucency <1 mm wide and 1 component was surrounded by a complete radiolucency of >2 mm in width without showing component migration. According to Engh's criteria, 16 (80%) femoral stems had bony ingrowth and 4 (20%) stems had stable fibrous ingrowth. The average preoperative Harris hip score improved from 35 points to 78 points at the time of final followup. Total hip arthroplasty for arthritis following acetabular fractures, technically difficult because of extensive scarring, heterotopic bone, retained internal fixation devices, and residual deformity of the acetabulum.
Periprosthetic fractures after total knee arthroplasty is a potentially serious and challenging complication and the incidence is continuously rising. The purpose of this study was to analyse the prevalence and analyse effectiveness of the various treatment methods for management of periprosthetic fracture of the distal femur after total knee arthroplasty, and to determine the clinical and radiographic results of patients following surgical treatment of these injuries. We reviewed all patients with periprosthetic fractures after total knee arthroplasty treated surgically between 2003 and 2008 from the prospective hospital database. Medical and radiographic records were reviewed for patient characteristics, fracture characteristics, implant details, healing, and complications. Antero-posterior and lateral radiographs were reviewed at the time of admission, post-operatively and at follow up visits. Fractures were classified according to the Lewis and Rorabeck, Orthopaedic Trauma Association and the methods of Su and DeWal.PURPOSE OF STUDY
METHODS
Chronic infection of bone with nonunion is traditionally treated by a 2-stage procedure involving initial debridement and antibiotic delivery and then definitive internal fixation. Alternatively, external fixators are used to provide stability. A technique with which single stage antibiotic cement-coated intramedullary nails are prepared in the operating room with the use of Kuntscher Nails and materials that generally are available is described herein. Although useful for all infected nonunions this technique is particularly useful for patients who are not ideal candidates for external fixation and for those who do not want to have an external fixator applied. We evaluated 10 cases treated with antibiotic cement-coated K nail with application of an additional unicortical plate in 7 cases. Autologous iliac crest bone grafting was done in all cases and additional bone substitutes used in 2 cases. 9 patients had stable union with complete control of infection. One patient had persistent infection at the time of last follow
We compared the safety and outcome of one-stage bilateral total hip arthroplasty with those of a two-stage procedure during different admissions in a prospective, randomised controlled trial in an Asian population. Of 168 patients included in the study, 83 had a single- and 85 a two-stage procedure. Most of the patients (59.9%) suffered from inflammatory arthritis. The intra-operative complications, early systemic complications, the operating time, positioning of the components, the functional score, restoration of limb length and survival rates at 96 months were similar in the two groups. The total estimated blood loss was significantly lower in patients undergoing a one-stage procedure than in patients who had a two-stage procedure, but the transfusion requirements were significantly higher in the former group (p = 0.001). The hospital stay was significantly shorter in the one-stage group, 7.25 days (
We present seven patients with recurrent haemarthroses after total knee arthroplasty, caused by an inherent platelet function defect. These patients developed painful knee swelling, persistent bleeding and/or wound breakdown, a platelet factor 3 availability defect being identified in all cases. Surgical exploration, with joint debridement, lavage and synovectomy, was performed in four patients who did not improve with conservative therapy. Histopathological examination of synovium revealed a focal synovial reaction with histiocytic infiltration, and occasional foreign-body giant cells. One patient required an early revision because of aseptic loosening of their tibial component. The condition was treated by single-donor platelet transfusions with good results. The diagnosis, management, and relevance of this disorder are discussed.
Giant-cell tumour of the tendon sheath, also called pigmented villonodular synovitis, is a benign tumour with a high incidence of recurrence. We have tried to identify risk factors for recurrence. Of the 48 patients included in the study, 14 received radiotherapy after surgery. Only two (4%) had a recurrence. This compares favourably with previously reported incidences of between 25% and 45%.
We have reviewed 26 patients treated by trapezius transfer for deltoid paralysis due to brachial plexus injury or old poliomyelitis. We assessed the power of shoulder abduction and the tendency for subluxation. There were good results in 16 patients (60%); five were fair and five poor. Trapezius transfer appears to give reasonable results in the salvage of abductor paralysis of the shoulder.
