Aims

There is evidence that prior lumbar fusion increases the risk of dislocation and revision after total hip arthroplasty (THA). The relationship between prior lumbar fusion and the effect of femoral head diameter on THA dislocation has not been investigated. We examined the relationship between prior lumbar fusion or discectomy and the risk of dislocation or revision after THA. We also examined the effect of femoral head component diameter on the risk of dislocation or revision.

Total knee arthroplasty (TKA) is known to lead to a reduction in periprosthetic bone mineral density (BMD). In theory, this may lead to migration, instability and aseptic loosening of the prosthetic components. Bisphosphonates inhibit bone resorption and may reduce this loss in BMD. We hypothesised that treatment with bisphosphonates and calcium would lead to improved BMD and clinical outcomes compared with treatment with calcium supplementation alone following TKA. A total of 26 patients, (nine male and 17 female, mean age 67 years) were prospectively randomised into two study groups: alendronate and calcium (bisphosphonate group, n = 14) or calcium only (control group, n = 12). Dual energy X-ray absorptiometry (DEXA) measurements were performed post-operatively, and at three months, six months, one, two, four, and seven years post-operatively.

Mean femoral metaphyseal BMD was significantly higher in the bisphosphonate group compared with controls, up to four years following surgery in some areas of the femur (p = 0.045). BMD was observed to increase in the lateral tibial metaphysis in the bisphosphonate group until seven years (p = 0.002), and was significantly higher than that observed in the control group throughout (p = 0.024). There were no significant differences between the groups in the central femoral metaphyseal, tibial medial metaphyseal or diaphyseal regions of interest (ROI) of either the femur or tibia.

Bisphosphonate treatment after TKA may be of benefit for patients with poor bone quality. However, further studies with a larger number of patients are necessary to assess whether this is clinically beneficial.

Cite this article: Bone Joint J 2015;97-B:337–45.

Objective: Hospital volume is a known indicator for orthopaedic adverse events in patients undergoing total hip replacement. The aim of the current study was to evaluate the effect of hospital volume on the length of stay, re-admissions and complications of THR on a population-based level in Finland.

Methods: Using the information from the Hospital Discharge Registry and that of four other National databases, 28,218 THRs performed for primary osteoarthritis were identified for the period covering 1998 to 2005. Hospitals were classified into four groups according to the number of primary and revision hip and knee replacements performed on an annual basis over the whole study period: 1–100 (Group 1), 101–300 (Group 2), 301–600 (Group 3) and 601 or over (Group 4). Logistic regression analysis and generalized linear models were used to study the effect of hospital volume on the length of stay, unscheduled re-admissions, re-operations, dislocations and infections.

Results: The lengths of both the surgical treatment period and the uninterrupted institutional care were shorter for the very high volume hospitals (Group 4) than for the low volume hospitals (Group 1) (p< 0.0001). The odds ratio for dislocations (0.71, 95% CI 0.56–0.91) was significantly lower in the high volume hospitals (Group 3), than in the low volume hospitals (Group 1, the reference group).

Conclusion: Specialization of hip replacements by high volume hospitals should reduce costs by significantly shortening length of stay, and may reduce the dislocation rate.

Preliminary results using Trabecular Metal (TM) acetabular component (made of tantalum) in primary and in revision total hip arthroplasty are encouraging in few published papers in the literature.

Patients and Methods: The outcome and survivorship of a TM revision uncemented acetabular cup were assessed in 85 consecutive patients (Male 48, Female 37, mean age 70,9 years, range 54–92) undergoing revision THA in the time period from 13.5.2004 to 8.6.2006. Years from previous operation to revision arthroplasty was in average of 10,0 years (range 1–23). Acetabular bone defects were assessed using Paprosky grading system. Monoblock TM cup was used in 26 operations(Paprosky grade I=13; grade IIa=1; Grade IIb=6 and Grade IIc=6). Modular revision TM cup was used in 59 operations (Paprosky grade I=7; Grade IIa=5; Grade Ibis=15;Grade IIc=24; Grade IIIa=5 and Grade IIIb=3). 55 allografts (femoral heads) were used to fill bone defects in 39 acetabulums. TM augment was needed in 4 operations. In 17 operations also the femoral component was revised. Seven of these operations were re-revision operations. Full weight-bearing was allowed after 44 operations, partial weight-bearing after 37 operations and no weight-bearing after 4 operations. In four operations, where TM cup was initially tried to use, the fixation was found to be insufficient. Consequently, the method of revision was changed either to plating and TM-cup (Paprosky grade IIIB, n=2) or protection cup-system (Paprosky grade IIc, n=2).

Results: Subjectively, the patients were satisfied with this operation at the follow-up (mean 14 months, range 3–26). 58 (68%) patients were painless and 72 (85%) patients walked without any support. X-ray studies showed good TM-cup fixation into acetabular host bone and bone defect filling in 84 out of 85 cases in this short follow-up.

Complications: 7 dislocations, 1 deep infection and 1 sciatic nerve injury. These complications were concentrated to alcoholic and patients with many other health problems.

Conclusion: TM implant has very good primary fixation properties in host bone. The cup shows reliable ingrowths and defect filling with host bone. Our good short-term results with TM-cup are similar to the few previously published papers. Further clinical investigation is needed to show the durability and functionality of this new prosthetic material.

Aim of the study: We compared Aircast versus standard plastic cast immobilisation methods after ankle fractures surgery. Materials and methods: 32 patients who had had a low energy uni- or bimalleolar fracture were included into this prospective study in Kuopio University Hospital. They were randomised to use either standard cast or Aircast for 6 weeks after surgery. 18 patients (10 women and 8 men) average age 41 (20 – 63) years used Aircast and 14 patients (8 women and 6 men) average age 48 (19–69) years used standard cast. All fractures were treated operatively using standard A-O techniques. Patients were followed for 6 months; clinical and radiographic evaluation was carried out at nine and 26 weeks after surgery by senior doctors. The function of ankle joint after injury was evaluated as proposed by Kaikkonen et al. (Am J Sports Med 4:462–69, 1994). Results: All fractures healed without complications. There were no statistical difference between the study groups when evaluating the ability to walk or run, climbing down stairs, rising on heels or on toes with injured leg, single limb stance with injured leg, laxity of the ankle joint or range of foot dorsifl exion during the follow-up. The subjective assessment of the injured ankle was significantly better in the Aircast group nine weeks after the injury. In the Aircast group 13 patients had mild and 5 moderate symptoms but in the standard cast group 4 patients had mild, 9 moderate and 1 severe symptoms (p = 0.013). Rising on heels with injured leg was also remarkably different between the groups after nine weeks follow-up despite (p = 0.052). Conclusion: Aircast immobilisation seems to be safe method to immobilise ankle fractures after surgery. It seems to improve patient satisfaction and may not disturb function of ankle joint as much as the standard cast immobilisation.

Aims: Prevalence and risk factors of osteoarthritis in the carpometacarpal joint of the thumb have been amply explored in previous studies. However, no study has focused on CMC OA as a predictor of disability and mortality. We investigated CMC OA for its associations with risk factors, disability and with life expectancy in a extensive health survey. Methods: In 1978–80, a representative population sample of 8,000 Finns aged 30 or over were invited to participate in a comprehensive health examination; 90% complied. Hand radiographs were taken from 3,595 subjects and the clinical status was completed for 3,434 subjects. By the end of 1994, 897 subjects with hand radiographs had died. Results: The age adjusted prevalence rate of CMC OA of Kellgren’s grade 2 to 4 was 7% for men and 15% for women. Adjusted for alleged risk determinants, body mass index was directly proportional to the prevalence of CMC OA in both sexes, OR =1.29 (95% confidence interval 1.15–1.43) per each increase of 5 kg/m2 in body mass index. Smoking seemed to carry a protection against CMC OA in men but not in women. No significant association was found between history of workload and CMC OA. Restricted mobility, tenderness and swelling were frequently found in the presence of radiological CMC OA, but no significant increase occurred in the prevalence of disability. In men CMC OA of Kellgren’s grade 3 to 4 significantly predicted total mortality (adjusted relative risk 1.32, 95% confidence interval 1.03–1.69). Conclusion: In line with previous studies, body mass index strongly determines the prevalence of CMC OA. CMC OA is highly prevalent, but its impact on disability in the general population is scanty.

Aims: The purpose of this study was to investigate interactions of vitamin D receptor gene (VDR) polymorphisms and regular physical exercise on BMD in a four-year randomized, controlled intervention trial in Finnish middle-aged men. Methods: The TaqI, FokI, and ApaI RFLP-markers of the VDR gene were evaluated. BMDs of the lumbar spine (L2–L4), femoral neck, and total proximal femur were measured with a dual-energy X-ray absorptiometry (DXA). Results: In the entire study group, the subjects with the VDR gene TaqI Tt or tt genotype had a greater body height and higher femoral neck BMD values than the TT subjects (p=0.001, p=0.003, respectively). After adjustment the femoral neck BMD for body height, the association remained (p=0.021). There was no difference in BMD values between the reference and exercise groups during intervention. Conclusions: We suggest that the VDR gene TaqI polymorphism may be affecting bone mass through an influence on body growth. The present findings also suggest that the VDR polymorphisms do not modify the effect of regular aerobic exercise on BMD.

Vertebral fracture (VF) is a common complication of osteoporosis. Patients with osteoporotic VFs are often without symptoms and many of these fractures are detected by chance. Only one third of VFs is clinically diagnosed. However, osteoporotic VFs may also be very painful and cause severe discomfort during several weeks. In both genders low bone mineral density (BMD), prevalent VF and increasing age are strong predictors of VF. About one fifth of the patients with a VF suffer a new VF during the following year.

Clinical consequences of VF include acute and chronic back pain, decreased quality of life and increased mortality. The care of patients with VF includes proper pain management and early rehabilitation. The use of elastic lumbosacral brace reduces pain when mobilising patient after VF. Calcitonin has been shown to have an analgetic effect. Sometimes the vertebral fracture causes a diagnostic problem and reasons other than osteoporosis should be ruled out (e.g. myeloma, lymphoma, metastases, other malign diseases). If feasible, the diagnosis of osteoporosis should be confirmed by BMD measurement. Osteoporotic VFs are seldom unstable requiring operative treatment. In case of neurological complications operative decompression and stabilisation should be considered. Impaired bone quality causes problems in pedicle screw fixation. Cement augmentation and special anchorage screws may provide increase in holding power in osteoporotic bone. Percutaneous vertebroplasty and balloon kyphoplasty are mini-invasive procedures that provide immediate and long lasting pain relief in VF patients. These techniques are technically demanding and require careful patient selection. Recent, prospective, randomized studies have shown that antiresorptive drugs can prevent new fractures in patients who had experienced previous fractures.