Fractures of the distal femur are an important cause of morbidity.
Their optimal management remains controversial. Contemporary implants
include angular-stable anatomical locking plates and locked intramedullary
nails (IMNs). We compared the long-term patient-reported functional
outcome of fixation of fractures of the distal femur using these
two methods of treatment. A total of 297 patients were retrospectively identified from
a State-wide trauma registry in Australia: 195 had been treated
with a locking plate and 102 with an IMN. Baseline characteristics
of the patients and their fractures were recorded. Health-related
quality-of-life, functional and radiographic outcomes were compared
using mixed effects regression models at six months and one year.Aims
Patients and Methods
We describe the routine imaging practices of
Level 1 trauma centres for patients with severe pelvic ring fractures, and
the interobserver reliability of the classification systems of these
fractures using plain radiographs and three-dimensional (3D) CT
reconstructions. Clinical and imaging data for 187 adult patients
(139 men and 48 women, mean age 43 years (15 to 101)) with a severe
pelvic ring fracture managed at two Level 1 trauma centres between July
2007 and June 2010 were extracted. Three experienced orthopaedic
surgeons classified the plain radiographs and 3D CT reconstruction
images of 100 patients using the Tile/AO and Young–Burgess systems.
Reliability was compared using kappa statistics. A total of
115 patients (62%) had plain radiographs as well as two-dimensional
(2D) CT and 3D CT reconstructions, 52 patients (28%) had plain films
only, 12 (6.4%) had 2D and 3D CT reconstructions images only, and
eight patients (4.3%) had no available images. The plain radiograph
was limited to an anteroposterior pelvic view. Patients without
imaging, or only plain films, were more severely injured. A total
of 72 patients (39%) were imaged with a pelvic binder Interobserver reliability for the Tile/AO (Kappa 0.10 to 0.17)
and Young–Burgess (Kappa 0.09 to 0.21) was low, and insufficient
for clinical and research purposes. Severe pelvic ring fractures are difficult to classify due to
their complexity, the increasing use of early treatment such as
with pelvic binders, and the absence of imaging altogether in important
patient sub-groups, such as those who die early of their injuries. Cite this article:
Accurate prosthetic cup placement is very important in total hip arthroplasty (THA). When the surgeon is impacting the acetabular cup, it is assumed that the patient's pelvis is perpendicular to the operating table. In reality the pelvis may not be truly lateral, and error in patient positioning may influence the resultant cup orientation. The primary aim of this study was to examine the accuracy of patient positioning prior to THA. A secondary aim was to see if patient BMI influenced the accuracy of positioning.Introduction
Objectives
Past research has focused on complications of bony fixation of navigation reference frames such as fractures and cutting errors. This study investigates the consequences of the use of iliac crest percutaneous navigational array pins in terms of pain, irritability and the impact on quality of life.Introduction
Objective
Leg length and offset are important considerations in total hip arthroplasty (THA). Navigation systems are capable of providing intra-operative measurements, which help guide the surgeon in leg length and offset adjustment. This controlled study investigates whether the use of computer navigation leads to more accurate achievement of pre-operative leg length and offset targets in THA.Introduction
Objective
Leg length and offset are important considerations in total hip arthroplasty (THA). Navigation systems are capable of providing intra-operative measurements of leg length and offset, and high accuracy has been shown in experimental studies. This Introduction
Objective
Traumatic disruption of the pelvic ring has a high risk of mortality. These injuries are predominantly due to high-energy, blunt trauma and severe associated injuries are prevalent, increasing management complexity. This population-based study investigated predictors of mortality following severe pelvic ring fractures managed in an organised trauma system. Cases aged greater than 15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based state-wide Victorian State Trauma Registry for analysis. Patient demographic, pre-hospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged greater than 65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15–34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), while patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). The findings highlight the importance of the need for effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches.
A Physiotherapist-led Joint Replacement Surgery (JRS) Clinic was pioneered at the Royal Melbourne Hospital (RMH) Australia to improve the efficiency of the review process following hip and knee arthroplasty surgery and improve outpatient access to orthopaedic consultation. A credentialed physiotherapist conducted specified post-operative reviews in place of orthopaedic surgeons. A protocol for the JRS Clinic was developed collaboratively by the Orthopaedic Surgery and Physiotherapy Departments at RMH. The orthopaedic surgeons conducted the initial 6 week post-operative review and the physiotherapist conducted subsequent reviews at 3, 6 and 12 months, and annually thereafter. Routine radiological imaging occurred immediately post-operatively, and at 1 year, 5 years, 10 years and then annually. Radiological credentialing allowed the physiotherapist to assess and manage patients independently. Collocation with the orthopaedic clinic facilitated immediate surgical input when required. Between October 2009 and January 2011, 156 patients were offered a total of 246 appointments in the JRS clinic. This included 174 primary joint replacements (99 hip and 75 knee), 19 revisions (16 hip and 3 knee), and 3 re-surfaced hips. The attendance rate for the clinic was 82.9%. The physiotherapist discussed 20 cases with the surgeons with only 6 patients requiring transfer back to the Orthopaedic unit for ongoing management. Two of these patients have been wait-listed for revision surgery, 2 are undergoing further investigations and the remaining patients are yet to attend their scheduled review. Four patients declined further follow up in the JRS clinic. There were no adverse outcomes reported and no nursing input for wound issues was required. A patient survey demonstrated high levels of satisfaction with the service particularly related to improved access and time efficiencies. Physiotherapist-led JRS Clinics in partnership with the Orthopaedic Surgery Department are an efficient and effective alternative model of care for the long term review of patients following arthroplasty surgery. The clinics assist in addressing the growing demand for arthroplasty services by increasing the surgeons’ capacity to manage new referrals.
FAI has been implicated in the progression of osteoarthritis (OA) and early detection may allow for treatment, which can slow or halt progression. FAI is a difficult condition to image and there is little objective evidence about imaging accuracy. We aim to measure the accuracy of five imaging modalities. Three blinded observers retrospectively reviewed five different modalities from two age and sex matched groups: A patient group referred to the outpatient clinic with a clinical diagnosis of FAI and a control group who had had CT scans of the pelvis for suspected trauma, where the Pelvic scan had been reported as showing no injuries. The imaging modalities were: Standard x-ray; Antero-Posterior, Lateral; Condition-specific x-ray projections; Dunn view, lateral internal rotation; Standard Computer Tomography (CT) multiplanar reconstruction (MPR); axial, sagittal and coronal; Condition-specific CT MPR; angled axial, angled coronal; 3D modelling; and surface rendered dynamic. We found marked variations in the sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictiive Value (NPV) for each of the following imaging modalities: Standard X-ray; Sensitivity 51.9; Specificity; 57.1; PPV; 40; NPV; 68.3 Special X-rays; Sensitivity; 66.7; Specificity; 57.1; PPV; 46.1; NPV; 75.7. Standard CT MPR; Sensitivity; 40.7; Specificity; 75.5; PPV; 47.8; NPV; 69.8 Special CT MPR; Sensitivity; 48.1; Specificity; 57.1; PPV; 46.4; NPV; 70.8 Dynamic 3D CT models; Sensitivity; 55.6; Specificity; 69.3; PPV; 42.8; and NPV; 71.8. The Dynamic 3D CT models (where the observer can manipulate the model in real time three dimension to control the perspective) proved to be the most accurate, closely followed by the special X-Ray views, which were also the most sensitive. The Standard CT MPRs were the most specific but had a low sensitivity. This is the first study to measure sensitivity, specificity and PPV and NPV for these imaging modalities in FAI. We recommend the use of condition-specific X-Ray views as well as 3D CT Models for optimal imaging accuracy in this condition. Standard X-Ray views and CTs proved less useful.
Accurate implant alignment, prolonged operative times, array pin site infection and intra-operative fracture risk with computer assisted knee arthroplasty is well documented. This study compares the accuracy and cost-effectiveness of the pre- operative MRI based Signature custom made guides (Biomet) to intra-operative computer navigation (BrainLab Knee Unlimited). Twenty patients from a single surgeon's orthopaedic waiting list awaiting primary knee arthroplasty were identified. Patients were contacted and consented for the study and their suitability for MRI examination assessed. An MRI scan of the hip, knee and ankle was performed of the operative side following a set scanning protocol. Following MRI, patient specific femoral and tibial positioning cutting guides were manufactured. Patients then underwent arthroplasty and intra-operative computer navigation was used to measure the accuracy of the custom made, patient specific cutting guides. A cost analysis of the signature system compared with computer navigation was made. Our provisional results show that the accuracy of the pre-operative MRI patient specific femoral and tibial positioning guides was comparable to computer navigation. Pre-operative, patient specific implant positioning cutting guides were as accurate as computer navigation from analysis of our preliminary results. The potential advantages of the MRI based system are accurate pre-operative planning, reduced operating times and avoidance of pin site sepsis. However, further larger studies are required to examine this technique.
Open reduction and internal fixation of acetabular fractures demands detailed preoperative planning, and given their frequent complexity, a thorough understanding of their three-dimensional (3D) form is necessary. This study aims to assess if the use of dynamic 3D models will improve preoperative planning of acetabular fractures. In this study, three experienced pelvic trauma surgeons were provided with computer based dynamic 3D models in addition to preoperative radiographs, CT scans and static 3D reconstructions of 17 acetabular fractures operatively managed at the Royal Melbourne Hospital. Surgeons, blinded to any previous operative plan or patient detail, then classified fracture type and made preoperative surgical plans. Comparison was then made to classification and operative approach documented in the patient's operation notes. Comparison was then made with regard to surgical plan and planning time with or without access to dynamic 3D models. In complex cases the additional information provided by dynamic 3D modelling was found to reduce planning time and, in some cases, change the surgical plan. For complex acetabular fractures we recommend that surgeons should have access to computer-based dynamic 3D models of the injuries for pre-operative planning.
As there is currently no evidenced-based and systematic way of prioritising people requiring JRS we aimed to develop a clinically relevant system to improve prioritisation of people who may require JRS. An important challenge in this area is to accurately assign a queue position and improve list management. To identify priority criteria areas eight workshops were held with surgeons and patients. Domains derived were pain, activity limitations, psychosocial wellbeing, economic impact and deterioration. Draft questions were developed and refined through structured interviews with patients and consultation with consultants. 38 items survived critical appraisal and were mailed to 600 patients. Eleven items survived clinimetric and statistical item reduction. Validation then included co-administration with standardised questionnaires (960 patients), verification of patient MAPT scores through clinical interview, examination of concordance with surgeon global ratings and test-retest. Ninety-six Victorian surgeons weighted items using Discrete Choice Experiments (DCEs). The DCE scaling generated a scale, which clearly ranked patients across the disease continuum. The MAPT differentiated people on or not on waiting lists (p<0.001), and was highly correlated with other questionnaires, e.g., unweighted-MAPT vs WOMAC (r=0.78), Oxford Hip/Knee (r=0.86/0.75), Quality of Life (r=0.78), Depression (r=0.64), Anxiety (r=0.60), p<0.001 for all. Test-retest was excellent (ICC=0.89, n=90). Cronbachs reliability was also high 0.85. The MAPT is now routinely administered across all Victorian hospitals undertaking arthroplasty where the response rate is generally above 90%. In the hands of clinicians the MAPT has been used to facilitate fast-tracking of patients with the greatest need, monitoring for deterioration in those waiting for surgery or having a trial of non-operative treatment and deferment of surgery for those that may benefit from further non-operative treatments. The MAPT is short, easy to complete and clinically relevant. It is a specific measure of severity of hip/knee arthritis and assigns priority for surgery. It has excellent psychometric and clinimetric properties evidenced by concordance with standard disease-specific and generic scales and widespread use and endorsement across health services.
Long waiting times and a growing demand on services for joint replacement surgery (JRS) prompted the Victorian Department of Human Services to fund a University of Melbourne/Melbourne Health partnership to develop and implement an osteoarthritis (OA) hip and knee service delivery and prioritisation system for those who may require JRS. The service delivery model consists of a multidisciplinary team providing, comprehensive early assessment, evidence-based interventions, including support for patient self-management, continuity of care processes, and prioritisation for both surgical assessment and JRS. Prioritisation occurs via clinical assessment and the Hip and Knee Multi-Attribute Prioritisation Tool (MAPT), a patient, clinician, or proxy-administered 11-item questionnaire, resulting in a 100-point scale ranking of need for surgery. The Hip and Knee MAPT was developed using intensive consultation with surgeons, state-of-the-art clinimetrics and with input from patients, hospital management groups. Ninety-six surgeons contributed to the developing the final scoring system. Over 4000 patients per year are entering the system across 14 hospitals in Victoria. Under the supervision of the orthopaedics unit, musculoskeletal coordinator (MSC), typically an experienced physiotherapist or nurse, as part of the multidisciplinary team, undertakes early comprehensive assessment, referral and prioritisation of patients with hip or knee OA referred to orthopaedic outpatient clinics. In addition, the MSC coordinates the monitoring and management of patients on the orthopaedic surgery waiting list. The processes enable patients who are most needy (via higher MAPT score and clinical assessment) to be fast-tracked to orthopaedic surgery; conversely those patients with lower scores receive prompt conservative management. Time to first assessment and waiting times to see a surgeon for many patients have reduced from 12+ months to weeks. Patients seen by surgeons are more likely to be ready for surgery and have had more comprehensive non-operative optimisation. Patients placed on the surgical waiting list receive quarterly reassessments and evidence of deterioration is used as a basis for fast-tracking to surgery. The OWL system is a whole of system(tm) approach informed by patients needs and surgeons needs. Clinicians have developed confidence in the clinical relevance of the MAPT scores. Uptake of the OWL model of care has been very high because it facilitates better care and better patient outcomes.
Percutaneous cannulated screw placement (PCSP) is a common method of fixation. In pelvic trauma neurovascular structures are in close proximity to the screw path. Pre-operative planning is needed to prevent injury. This study aims to the safety margin and accuracy of screw placement with computer navigation (CAS). A control had no pathology in the pelvis but CT scans were performed for suspected trauma. The treated group had pelvic and acetabular fractures and were treated with CAS PCSP at our institution. Using a new technique involving CT 3D modelling of the whole (3D) safe corridor, the dimensions of the Posterior elements (PE) of the pelvic ring and the anterior column of the acetabulum (AC) were measured in the control group. The accuracy of screw placement (deviation between the actual screw and planned screw) was measured in treated patient using a screenshot method and post-operative CTs. There were 22 control patients and 30 treated patients (40 screws). The mean ± (standard deviation, SD) minimum measurement of the safe corridor at the PE was 15.6 ± 2.3 mm (range 11.6 mm to 20.2 mm) and at the AC was 5.9 ±1.6 mm (range 3.0 mm to 10.0 mm). The mean ± (SD) accuracy of screw placement was 6.1 ± 5.3 mm and ranged from a displacement of 1.3 mm to 16.1 mm. There was a notable correlation between Body Mass Index, duration of surgery and inaccuracy of screw placement in some patients. The largest inaccuracy of screw placement was due to reduction of the fracture during screw insertion, causing movement of the bone fragments relative to the array and therefore also the computerised screw plan. There were no screw breakages, non-unions, neurological or vascular complications. CAS PCSP is a safe and accurate technique. However, the safe corridor is variable and often very narrow. We recommend that the dimensions of the safe corridor be assessed pre-operatively in every patient using 3D modelling to determine the number and size of screw that can be safely placed.
The Osteoarthritis Hip and Knee Service (OAHKS) was introduced in 2006 and the aim of this service was to ensure early assessment and monitoring, optimise non-operative and pre-operative management, and ensure equitable access to surgical treatment. Patients were prioritised and monitored for disease deterioration using the Multi-Attribute Arthritis Prioritisation Tool (MAPT). All patients who were referred for assessment by the OAHKS between December 2006 and April 2009 were identified. Data was collected from the OAHKS computer database, hospital patient information computer system and the Department of Health databases. Scores were identified for patients who underwent joint replacement surgery (JRS) following pre-operative MAPT. Demographic and clinical data was collected prospectively and statistically analysed. Demographic data included sex, age and ethnicity. Patient clinical data included referral source and time to initial OAHKS appointment, BMI, co-morbidities, MAPT scores, referrals to other healthcare professionals and outcome of OAHKS appointment. In total, 768 patients (296 males and 472 females) were referred to OAHKS between December 2006 and April 2009. Patients ranged in age from 20 to 94 years with a mean age of 68.22 years at initial review. Patients referred were from 20 different ethnic backgrounds. The median time to initial appointment was 80.5 days (IQR 36.5-99 days). There were 656 (85.4%) patients referred from their GP and 89 referrals were from other sources. Eighty-nine per cent of patients (n=686) were screened for co- morbidities. Of these patients, 58% had hypertension, 20.8% had diabetes mellitus, 19.3% had ischaemic heart disease, and 19.8% had a psychosocial illness. The mean body mass index (BMI) was 32.71 (median 32.01). Only 42.3% patients had some form of conservative management modality prior to attending OAHKS. A total of 1061 referrals to other healthcare professionals were made. Physiotherapy (48.6%), hydrotherapy (40%) and dietician (16.1%) were the most common referrals. Referrals to the orthopaedic surgeon accounted for 15.7% total referrals. MAPT scores increased in 229 patients, decreased in 306 patients and were unchanged in 25 patients. From December 2006–March 2009, 269 patients had MAPT scoring assessment pre-operatively. Of those patients who had surgery 52% had TKR, 40.5% THR, 5.5% UKR and 1.85% hip resurfacing. The OAHKS has enabled patients with osteoarthritis to be rapidly assessed leading to a reduction in outpatient waiting times. Patients suitable for JRS are prioritised according to clinical need and MAPT scores. Thus, patients with greatest clinical need have received surgery much sooner than previously.
With the advent of digital radiology, our institution has introduced digital templating for preoperative planning of total hip arthroplasty (THA). Prior studies of the accuracy of digital templating had contradictory results. This study compares the accuracy of digital and analog templating for THA. Ninety patients were recruited. Sixty-eight patients had analog pre-operative templating while 22 patients had digital templating. A retrospective review of medical records obtained the sizes of hip implants inserted during THA and patient demographics. The templated hip sizes were compared with the actual hip implants inserted. Accuracies of both templating methods were compared in four outcomes: prediction of acetabular cup size, prediction of femoral stem size, prediction of femoral offset and prediction of femoral neck length. Digital templating was more accurate than analog templating in predicting acetabular cup size, femoral stem size and femoral offset. Analog templating was more accurate in predicting femoral neck length. However, only the comparison of femoral offset achieved statistical significance (p-value = 0.049). After stratifying the data by BMI, digital templating was more accurate than analog templating in predicting acetabular cup and femoral stem sizes for patients with high BMI. For patients with BMI = 25-30, accuracy of digital templating was 100.0% for cup and 80.0% for stem while accuracy of analog templating was 74.1% for cup and 74.1% for stem. For patients with BMI > 30, accuracy of digital templating was 84.6% for cup and 69.2% for stem while that of analog templating was 75.0% for cup and 66.7% for stem. Digital templating outperformed analog templating in all the outcomes except femoral neck length. In addition, digital templating was significantly more accurate in predicting femoral offset. This study showed that digital templating has the potential to reduce errors in pre-operative planning for THA.
Perthes disease often leaves young adults with hip joint incongruency due to femoral head asphericity, (extra-articular extrusion and superior flattening). This causes femoro-acetabular impingement, a reduced range of movement and early degenerative change. We report a novel method for restoration of femoral head sphericity and femoro-acetabular congruency. Two males (aged 21 and 22 years) presented with groin pain and severe hip stiffness after childhood Perthes disease. Imaging confirmed characteristic saddle shaped deformities of the femoral head, with cartilage loss overlying a central depression in the superior section of the head. A new method of treatment was proposed. Both cases were treated in the same manner. A surgical dislocation was performed with a trochanteric flip osteotomy. The extra-articular bump was removed with osteotomes and a burr to reduce femoro- acetabular impingement. The sphericity of the femoral head was restored using a HemiCap partial re-surfacing (Arthrosurface, MA, USA). The radius of the implant was selected to match that of the acetabulum. Restoration of the height of the flattened portion of the weight-bearing surface of the femoral head reduces abnormal loading of the acetabular articular cartilage by improving congruency of the joint. Both patients recovered without incident and were mobilised with crutches, restricted to touch weight-bearing for six weeks to protect union of the trochanteric osteotomy. At a minimum of three year follow-up both patients had sustained improved range of movement, pain and Oxford hip score. Repeated imaging shows no evidence of joint space narrowing or loosening at this stage. We conclude that this novel treatment functions well in the short term. Further surveillance is on-going to confirm that this treatment results in improved long term durability of the natural hip joint after Perthes disease.
Restoration of the height of the flattened portion of the weight-bearing surface of the femoral head reduces abnormal loading of the acetabular articular cartilage by improving congruency of the joint. At a minimum of 3 year follow up both patients had sustained improved range of movement, pain and Oxford hip score. Repeated imaging shows no evidence of joint space narrowing or loosening at this stage.
This study aims to develop a pre-operative protocol for the Australian population, regarding the safe number of screws and size of screw that may be placed. Additionally, results from the study may help identify patients at increased risk of injury during PCSP.
Safe corridor measurements of the PE and AC were taken in the control patients. Pelvic CT scans, taken as part of trauma protocol, were reconstructed using 3D modelling and the dimensions of the whole (3 dimensional) safe corridor measured. The accuracy of screw placement was determined in each treated patient. Accuracy was assessed by the screenshot method, the post-operative CT method or by both methods. In both methods, accuracy was taken as the deviation between the positions of the actual screw and planned screw.
The mean ± (standard deviation, SD) minimum measurement of the safe corridor at the PE was 15.6 ± 2.3 mm (range 11.6 mm to 20.2 mm) and at the AC was 5.9 ±1.6 mm (range 3.0 mm to 10.0 mm). The mean ± (SD) accuracy of screw placement was 6.1 ± 5.3 mm and ranged from a displacement of 1.3 mm to 16.1 mm.
