Abstract

Abstract

Abstract

Abstract

Background of study

Medial patellofemoral ligament (MPFL) reconstructions are often performed using gracilis autografts, this can be associated with donor site morbidity and complications. The use of synthetic material can circumvent a harvest operation and have previously been demonstrated to be effective in other types of reconstructive procedures and may be effective in MPFL reconstruction. We report our experience and clinical results with the use of FiberTape (FT) in MPFL reconstruction and compare it to the same surgical technique using standard autografts.

Oxford Medial Unicompartmental Knee Replacement (OMUKR) is a well-established treatment option for isolated medial compartment arthritis, with good patient reported outcome measures (PROMs).

We present our results of the Oxford Domed Lateral Unicompartmental Knee Replacement (ODLUKR) to establish if patients benefit as much as with OMUKR.

Retrospective review of prospectively collected data of a single surgeon series of consecutive UKR from 2007 to 2014 were collated with a minimum 2 years follow-up. PROMs data were collected using pre- and post-operative Oxford Knee Scores (OKS) (best score of 48).

One hundred and twenty-eight OMUKR and 27 ODLUKR were performed in the study period. There was no significant difference in the age at time of surgery, but there were significantly more women in the ODLUKR group (74% vs 53%). There was no significant difference in pre-op OKS between the groups (OMUKR = 16/48; ODLUKR = 20/48), or the improvement in OKS post-op (OMUKR = 19 points; ODLUKR = 17 points). One ODLUKR was revised to Total Knee Replacement (TKR) for pain. There were three (11.1%) bearing dislocations, which were treated with thicker bearing exchange, with no subsequent problems. There were no bearing dislocations in the OMUKR. Four OMUKR were revised to TKR due to pain. The overall implant survivorship was 96.3% for ODLUKR and 96.9% for OMUKR.

ODLUKR is a good treatment option for isolated lateral compartment arthritis and gives results equivalent to OMUKR. There is, however, an increased risk of bearing dislocation so should be performed by a high volume UKR surgeon.

Intramuscular injections of botulinum neuro toxin A (BoNT-A) have been a cornerstone in the treatment of spasticity for the last two decades. In India, the treatment is now offered to children with spastic cerebral palsy (CP). However, despite its use, the evidence for its functional effects is limited and inconclusive. The objective of this study is to determine whether BoNT-A makes walking easier in children with CP. We hypothesize that injections with BoNT-A will not reduce energy cost during walking, improve walking capacity, reduce pain or improve self-perceived performance and satisfaction.

Between the period of 2012 and 2014, 35 children with spastic CP less than 10 years of age were included. The patients were classified according to their gross motor function classification system (GMFCS) and their pre-and post-injection gait analysis were performed. Spasticity assessed by Modified Ashworth Score [MAS]. Trained parents were utilised for the post injection physiotherapy as these children will be more complaint to them. GMFCS and MAS scoring done every three months till one year follow up.

Therapeutically, effect was found in 90% of the patients, an average duration of the medical effect was 6–12 months. The improvement in GMFC functional score in serial measurements was seen in these patients though some deterioration in spasticity scores at one year. Despite mild recurrence in spasticity, majority maintained independent (42%) or assisted ambulation (48%) at one year. No major side effects occurred. Botox may prove a useful adjuvant in conservative management of the spasticity of cerebral palsy. Apart from being very cost effective in these financially deprived populations, successful management with these injections may allow delay of surgical intervention until the child is older and at less risk of possible complications, including the need for repeated surgical procedures.

Introduction

The removal of a well fixed cement mantle for revision of a total hip replacement (THR) can be technically challenging and carries significant risks. Therefore, a cement-in-cement revision of the femoral component is an attractive option.

The Exeter Short Revision Stem (SRS) is a 125 mm polished taper stem with 44 mm offset specifically designed for cement-in-cement revisions. Only small series using this implant have been reported.

Aims of study: The aim of this study was to analyze the results of oxford unicompartmental knee replacement in a distrct general hospital in UK.

Methods of study: A prospective study of 50 patients undergoing minimally invasive oxford unicompartmental knee replacement for osteoarthritis was conducted between 2001 and 2005. All patients were operated by the senior author of the study. Oxford Phase III medial unicompartmental (meniscal bearing) instrumentation and implants used in all cases.

Pre-op oxford knee score was recorded in all the patients. Post-op scores were recorded annually and at final follow up. X-rays were analyzed for implant positioning and loosening. Data were analyzed using SPSS version 12.

Results: Mean age of patients in our group was 65 years (range 44–78 years). There were 32 females and 18 males in the study. There were no intra-operative complications in any of the patients. Average duration of follow up was 16 months (range 6 months–4 years). Significant improvement in Oxford Knee score was noted after the surgery (43.7 vs. 20.8) (p< 0.05). Average duration of hospital stay was 4 days (range 3–6 days).

Conclusion: Oxford unicompartmental knee replacement gives excellent results, given careful patient selection, meticulous surgical technique and post-operative rehabilitation.

Introduction: It is commonly believed that there is deterioration of one grade of mobility with fracture neck of femur in elderly population. Several studies have been published in literature regarding outcome after operative management of fractures of proximal femur, but none of these focus on deterioration of mobility or its grades after the surgery.

Methods: A prospective pilot study of 50 consecutive patients with fracture neck of femur, who presented to the department were included in the study. Mobility and mortality was assessed at 6weeks and I year post operatively. We used a grading system of mobility with grades from I – VI, where grade I means fully independently mobile and grade VI stands for a bed ridden patient.

Results: Results showed that deterioration of mobility grade was much worse then conventionally thought. Out of 20 patients who were independently mobile without any aid preoperatively, only 5 patients were capable of walking with a stick. The overall mortality at 1 year post-op. was 40%. Patient’s age, residential status, MMS, ASA grade, preoperative mobility and mobility at 6weeks showed good prediction of post operative mortality in these patients.

Conclusion: Contrary to common belief much severe mobility deterioration was seen in patients following fracture neck of femur in elderly patients. Thus, deterioration of mobility becomes a very important factor to be considered in planning the management of these patients.

Introduction: Blood conservation has rapidly moved into political and medical agendas. The ongoing shortage of blood in blood banks and the discovery of vCJD pose a threat to UK blood supply with ever rising costs. The use of blood conservation techniques is increasingly being used in surgery to help reduce the need for homologous blood.

We studied the use of Autologous blood transfusion drains (Bellovac ABT) in lower limb arthroplasty compared with standard closed suction drains. We studied 123 lower limb arthroplasty (61 TKR & 62 THR) to see if there was a significant reduction in the need for homologous blood transfusion when using re-transfusion drains and its cost effectiveness.

Methods: Retrospective analysis of 123 patients undergone lower limb arthroplasty from March 2002 to Dec 2004 under one surgeon using the same technique for TKR and THR. 61 TKR (30 ABT drains v 31 standard drain) and 62 THR (30 ABT drains v 32 standard drain). Data was collected on sex, age, pre & post op Hb, volumes drained, volumes re-transfused and the number of homologous blood transfusions.

Results: 30 THR with ABT drains: 14 male, 16 female, mean age 68.7, mean pre op Hb 13.67, mean post op Hb 10.55,mean volume re-transfused 324ml, mean volume drained 466ml. 7 patients(23%) required additional homologous blood transfusion.

32 THR with standard drains: 14 male, 18 female, mean age 68.4, mean pre op Hb 12.96, mean post op Hb 9.36, mean volume drained 579.5ml. 24 patients (75%) required homologous blood transfusion.

30 TKR with ABT drains: 14 male, 16 female, mean age 69.8, mean pre-op Hb13.4, mean post-op Hb 11.03, mean volume re-transfused 415ml, mean volume drained 580ml. 4 patients (13%) required additional homologous blood transfusion.

31 TKR with Standard drains: 13 male, 18 female. Mean age72.1, mean pre-op Hb13.33, mean post-op Hb10.4, mean volume drained 711.5ml. 14 patients (45%) required homologous blood transfusion.

No re-transfusion complications occurred in the ABT group. 2 patients requiring homologous blood had increasing pyrexia and transfusion hence stopped.

Discussion: 11 out of 60 patients (18%) using ABT drains required additional homologous blood compared with 38 out of 63 patients (60%) requiring homologous blood using standard drains. Pvalue< 0.001. We show a stastically significant reduction in the need for homologous blood transfusion using an autologous blood re-transfusion drain. One unit of blood costs approximately £120 the ABT drain less than half of this amount, there is a significant cost saving in using autologous blood re-transfusion drains. We conclude that using Autologous blood Re-transfusion drains is safe, cost effective and reduces the need for homologous blood transfusion. If drains are to be used then Re-transfusion drains should be used.

From February 1992 to December 1997, 379 total hip arthroplasties in 342 patients were performed. 13 patients were lost to follow up, with 33 unrelated deaths. All arthroplasties were performed via the posterior approach in the lateral position. All patients were enrolled in an arthroplasty register at the time of surgery by the operating surgeon. Patients underwent clinical and radiological follow up. Kaplan-Meier survivorship analysis was used to determine the failure rate of the prosthesis, with revision surgery or decision to revise as the end-point.

The overall survivorship from all causes of failure at 5–10 years was 99.4%.

There were two stem revisions. One stem was revised for aseptic loosening at 4 years and one revised for recurrent dislocation. The stem aseptic loosening rate was 0.26%.

The cup aseptic loosening rate was 0%. The dislocation rate was 0.53% (2 from 379).

The superficial infection rate was 0.53% (2 from 379). There were no deep infections in this series.

At 12 months 71.2% had no pain (270 from 379), and 53.8% (204 from 379) had normal function. 94.5% said the procedure was worthwhile or very good. At 12 months radiological follow-up revealed progressive radioluceny in 7.65% (29 from 379) acetabuli, and progressive radiolucency in 2.90% (11 from 379) femora (one progressing to revision for aseptic loosening). No acetabular cups required revision.

In patients aged 65 years or younger at the time of surgery the survivorship was 100% for both components. Attention to meticulous and consistent operative technique in acetabular and femoral preparation, in particular a complete cement mantle with good zone 7 cement and osseointegrated cement bone interfaces, enables these results to be achieved.

In 2004 the Charnely Hip replacement remains the Gold Standard hip replacement.

Aims: The aim of this study was to compare the efþcacy of plastic and bone block cement restrictor as a medullary plug in total hip replacement. Methods: In this pro- spective study all patients undergoing a primary charnley total hip replacement were randomised to receive either a Hardinge cement restrictor or a Bone block. The medullary plug was inserted to a constant distance. Postoperative standardised radiographs were assessed. The length of the distal mantle was compared between the two groups. Results: 119 hips with a bone block (BB) and 85 hips with a Hardinge plastic cement restrictor (CR) were analysed over a period of 4 years. Analysis of the data by the application of the Two-sample t Ð test, ANOVA and Mann Ð Whitney test revealed a statistically signiþcant difference between the two groups (p < 0.0001). 95% CI limits for BB (a) & CR (a)(t Ð test) = (−12.9, −6.6); 95% CI (Mann-Whitney test) = (−13.002, −8.001). Results show that the plastic cement restrictor migrates distally to a greater degree than the bone plug. Conclusion: Interdigitation of cement into the cancellous endosteal bed depends on intramedullary pressure. The depth of the cement mantle is a measure of the intramedullary pressure and the function of the cement restrictor. We conclude that the bone plug is better in primary hip replacements.

The principle of the sliding hip screw is to provide a controlled collapse at the fracture site. It is during the screw insertion that clockwise rotational torque is imparted to the head and neck

In right-sided fractures the screw causes the head fragment to rotate clockwise leading to apposition or flexed position of the fracture site. In Left sided fractures the clockwise rotation leads to the head and neck fragment into extension of the fracture site leading to a potentially unstable construct.

All intertrochanteric fractures treated over a 12-month period were assessed. 75 fractures were included in the study. The fractures were classified according to Tronzo’s classification (Grades I & II – stable; Grades III & IV – unstable). Intraoperative and postoperative films were assessed for rotational abnormalities in the form of an anterior spike of the proximal fragment in left-sided fractures and a flexed position of reduction in right-sided fractures.

There were 39 Left sided fractures and 36 Right sided fractures.

A rotational abnormality was seen in 11 Left sided fractures compared with none on the right side. All 11 abnormalities were seen in Grade III and IV fractures (2 and 9 respectively). Analysis of results using the Chi-Square test revealed a significant difference (p < 0.001). 3 out the 11 fractures with rotational anterior spike had an implant cut out which needed revision surgery.

Compared to stable fractures, the accuracy of reduction determines the final stability in unstable fractures. In these fractures the rotational torque imparted to the proximal head and neck fragment can cause loss of reduction leading to potential failures of fixation. This appears to be greater in left sided fractures where the rotational torque causes the anterior spike which when not butressed inferiorly and medially can lead to a state where the implant cannot control the shear forces at the fracture site. This can then lead to failure of fixation.

In right-sided fractures the rotational torque often causes compression of the head and neck fragment into the distal fragment with the creation of an infero- medial butress.

The methods of overcoming this problem are with modifications in the technique. Untwisting the last few threads of the screw after insertion could reduce the anterior spike. The application of digital pressure along the anterior neck or the application of a reduction clamp at screw insertion provides counter rotation.

The results of this study confirm that the problem of torque at the fracture site is not of considerable importance in stable fractures but is significantly so in unstable left sided fractures. This results in a greater predisposition for potential failure of fixation

Introduction: The Gemini stem (DePuy) is a titanium femoral stem with a modular cobalt chrome femoral head. It has a roughened proximal surface finish to enhance cement bonding and a distal centraliser.

Purpose of the study: A retrospective assessment of the performance of the titanium cemented Gemini femoral component

Patients and Methods: 196 patients underwent a 204 total hip replacements using a titanium cemented Gemini stem and an uncemented cup. All the operations were performed by a lateral approach using modern cementing technique. Patients were assessed clinically (Harris hip score) and radiologically (standard AP and lateral x-rays)

Results: 11 patients with incomplete clinical and radiological follow-up were excluded from the study, leaving 185 patients (193 hips). 36 patients died with their total hip prosthesis in situ. The average age was 71 years and primary diagnosis was OA in the majority. The average follow-up was 70 months (range 35– 121). 29 of the hips have been revised. A further 11 were recognized as radiological failures. In 24, aseptic loosening or a broken stem was an indication for the revision. Mean time to revision was 3.1 years (range 1.5 to 7).

Discussion: Our results indicate that there is a high incidence of early failure associated with these titanium cemented stems, a cumulative failure of approximately 20%. The rough surface finish, titanium alloy and a fixed distal centraliser may all contribute to the early failure by increasing the stresses in the cement. Based on our experience, the continued use of this cemented stem is no longer justified.

Introduction: The main object of acetabular revisions in the presence of bone loss is to restore bone stock to provide adequate support for the cup. Allograft bone has been used to reconstruct the acetabulum with variable results.

Purpose of the study: Prospective assessment of the performance of the uncemented cups with morsellized allograft bone in revision acetabular reconstruction.

Patients and methods: A single surgeon using the lateral approach performed 98 acetabular revisions. An uncemented cup with multiple screw holes and morsellized allograft bone was used in all the patients. Acetabular defects were classified using both AAOS and Paprosky classification systems on standard AP x-rays and clinical assessment was by Harris hip scores.

Results: 93 patients had complete clinical and radiological follow-up. Mean age was 65.3 years (24–87) and majority was female. Mean number of prior operations was 1.7 (1–5). Majority of the acetabular defects belonged to group III (AAOS). The mean follow-up was 98 months (36–145). 13 patients have undergone repeat revisions, 5 for aseptic loosening and 3 each for infection, recurrent dislocation and early technical failures. Bone incorporation was complete within 3 months in all the cases

Discussion: The use of uncemented cups with screws provides the primary stability that is supplemented later by the incorporated allograft bone. The rate of re-operations for aseptic loosening of the cup in our series is low at 6% after 8 years. Even in these cases the repeat revisions were significantly easier due to restoration of the bone stock.

Introduction: Good results have been reported with curettage and cementation in the treatment of giant cell tumours of bone. There is a fear of potential degenerative changes with the long-term presence of methyl methacrylate in a weight bearing subchondral location.

Purpose of the study: To prospectively study the effectiveness of treatment of giant cell tumours by curettage, high speed burring and cementation.

Patients and methods: A single surgeon treated 37 giant cell tumours with meticulous curettage and high speed burring followed by cementation of the resulting cavity. The tumours were graded radiologically after the method of Campanacci et al. All the patients were prospectively followed up clinically by MSTS scoring system and radiologically.

Results: There were 22 women and 15 men with a mean age at operation of 34 years (range 17–72). 26 of the tumors were around the knee. 4 patients were Campanacci grade I, 22 grade II and 11 grade III. In 8 patients with pathological fractures, cementation was supplemented by internal fixation. Mean follow-up was 3.3 years (1.7–14). There were 4 recurrences. All the recurrences occurred within the first year. There have been no degenerative changes in the adjacent joint. All the patients scored either excellent or good in the MSTS scoring system.

Conclusions: Curettage, high speed burring followed by cementation is a useful method in the treatment of giant cell tumours. The advantages include relatively low recurrence rate (10% in our series), immediate stability allowing early mobilization and easier and early radiological diagnosis of recurrence.

Introduction: Osteochondral reconstruction following tumour resections has a high complication rate. We hypothesized that the vascularised fibular graft as a supplement to the allograft reconstruction following tumour resections would provide a biological solution.

Purpose of the study: A prospective study of the results of patients receiving large fragment allografts and vascularised fibular grafts following tumour resections around the hip and the knee.

Patients and methods: 18 patients underwent resection of primary malignant bone tumors followed by reconstruction with large fragment allograft and vascularised fibular graft. 8 patients underwent resection arthrodesis of the hip, six underwent resection arthrodesis of the knee and five underwent intercalary resections around the knee followed by a large fragment allograft and vascularised fibular graft reconstruction to span the gap left by resection. The patients were assessed clinically (MSTS scoring system) and radiologically at regular intervals.

Results: There were 14 males and 4 females, with a mean age of 26 years (12–70). Mean follow-up was 65 months (8–144). Five patients died of metastatic disease but without local recurrence. In six of the patients with resection arthrodesis of the hip, there was evidence of fracture of the allograft but without the failure of the construct. One fibula fractured but eventually healed uneventfully. There were no cases of non-union in cases of intercalary resections. All the patients scored good or excellent in the MSTS scoring system.

Discussion: Our experience clearly indicates that tumour resection followed by reconstruction with large fragment allograft and vascularised fibular graft is a useful limb salvage procedure providing a biological long-term solution with superior results when compared to prosthetic reconstruction.

We performed a randomised, prospective trial in 111 patients with intertrochanteric fractures of the hip comparing the use of the Gotfried percutaneous compression plate (PCCP) with that of the classic hip screw (CHS). Blood loss and transfusion requirement were less in the PCCP group but the operating time was significantly longer. The complication rate after operation was similar in both groups, and at a minimum follow-up of six months there was no difference in the rates of fracture healing or implant failure. The PCCP gives results which are similar to those obtained with a conventional device. Its suggested advantages seem to be theoretical rather than practical and, being a fixed-angle implant, it is not universally applicable.