Abstracts:
Patellar Tendon Length Following Total Knee Replacement With And Without Preservation Of The Infrapatellar Fat Pad
M. Lemon a , I. Packham, K.N. Narang, D.M. Craig
Traumatic Knee Dislocation – Outcome in ACL Deficient Knees
S I M Umarji , H Matthews, J S P Bell
Ten-year outcome of the modified Wilson's osteotomy for the treatment of Hallux Valgus
Pearse E.O. O'Neill J., Bendall S.P., Patterson M.H.
A Biomechanical Comparison Of Locking And Non-Locking Plates For The Fixation Of Calcaneal Fractures
David J. Redfern John T. Campbell, Stephen M. Belkoff PhD
Hampton Court Ice Rink, What price do we pay?
Gill K , Ormerod E, Davey P
Futura splint treatment for torus fractures of the distal radius in children under ten
T Bishop , A Khaleel
Scapholunate instability with an intact scapholunate ligament
VA Nuñez and ND Citron
Interlocking titanium alloy and HA coated stems in complex hip replacement and periprosthetic fracture
S.P. Trikha , F. Middleton, H. Matthews, O. Raynham, J. C. Lewis, D.A. Ward
Cemented femoral stem insertion, Can slowly but surely win the race?
C Steinlechner
Use of the Transverse Acetabular Ligament in assessing the correct version of the cup in Total Hip Arthroplasty
CJ Pearce , P Khirandish, A Khaleel
Hydroxyapatite coated femoral stems in revision hip surgery
S. Singh , S.P. Trikha, O. Raynham, J. Lewis, P.A. Mitchell, A. J. Edge
The effect of Total Hip Replacement on the work status of young patients
R. Mobasheri , S. Gidwani, J. W. Rosson
Bone Graft Weight in Posterolateral Lumbar Spine Instrumentation for Degenerative Spine Disorders (DSD) Affects Outcome
Ridgeway S , Tai C, Graevett-Ball C, Harrison H
Patellar Tendon Length Following Total Knee Replacement With And Without Preservation Of The Infrapatellar Fat Pad
M. Lemon * , I. Packham, K.N. Narang, D.M. Craig,
* Frimley Park Hospital, Worthing Hospital,
Introduction: Our aim was to assess whether there was any significant difference, in change in patellar tendon length following TKR, when the infrapatellar fat pad was either preserved or excised.
Methods: Data was collected prospectively for 78 consecutive primary TKR's. They were performed by six surgeons, with one of two senior surgeons scrubbed in every case. At a mean of 3 years, 7 patients were lost to follow up. Of the remaining 71 cases the infrapatellar fat pad had been completely preserved in 37 and completely excised in 34, based on the senior surgeon's practice. In all cases a medial parapatellar approach was used, the patella was not resurfaced and drains were used. There was no significant difference between the groups with regard to age, sex , component size, tourniquet time, or grade of surgeon. Postoperative rehabilitation protocol was identical. Two surgeons independently performed blinded serial measurements of patellar tendon length on the pre-operative, 1 and 3 year follow up lateral radiographs, for the 71 cases. Control measurements ruled out any effect of differing magnification.
Results: At 3 years there was a significant mean shortening of 2.3 mm (4.7%) in the fat pad excision group (p < 0.00005). There was no significant change in the length of the patellar tendon for the fat pad preservation group, which had a mean lengthening of 0.2 mm (0.5%). The difference between the two groups was significant (p<0.0005).
Discussion: Our results indicate that preservation of the infrapatellar fat pad may reduce the incidence of patellar tendon shortening following TKR.
Traumatic Knee Dislocation – Outcome in ACL Deficient Knees
S I M Umarji , H Matthews, J S P Bell
Kingston Hospital , Surrey
Background: Traumatic knee dislocation is a rare but devastating injury as it results in complex multiligament injury. Treatment remains controversial. A new approach to bicruciate rupture with posterolateral corner insufficiency is described.
Aim : We present a case series of 6 patients who sustained bicruciate rupture and posterolateral corner injury. They were treated with PCL (posterior cruciate ligament) reconstruction and posterolateral corner repair.
Methods & Materials : 6 patients (all male, mean age 29 years) with traumatic knee dislocation and resultant bicruciate and posterolateral corner injury were treated with PCL reconstruction (hamstring graft) and repair of the posterolateral corner (using autogenous or cadaveric tissue). In each case the ruptured ACL was not reconstructed leaving an ACL deficient knee.
Results: Time to surgery was on average 7 days (range 3 – 11 days). After a mean follow up of 29 months (range12 to 49) the mean flexion was 123.5 degrees and mean extension 3 degrees. The mean Lysholm score was 80 and the mean Tegner score was 6. In all cases the Lachman test was positive but none demonstrating an AP glide greater than grade 1.
Conclusion: Good results are possible following this type of surgery for traumatic knee dislocation . The ACL deficiency did not translate to clinical instability and there are no current plans to reconstruct the ACL in any patient. Another key advantage is a reduced tourniquet time compared to bicruciate reconstruction .
Ten-year outcome of the modified Wilson's osteotomy for the treatment of Hallux Valgus.
Pearse E.O. O'Neill J., Bendall S.P., Patterson M.H.
Princess Royal Hospital, Haywards Heath, West Sussex.
Purpose . To report the 10 year outcome of the modified Wilson's osteotomy.
Type of study . Case Series.
Method . Patients operated on by the same surgeon a minimum of 10 years previously were included in the study. Patients and radiographs were reviewed by two independent observers.
Results . Thirty-six of 42 feet were reviewed (four male, 32 female). Median age at the time of operation was 45 (range 28 to 63). Median follow up was 11.8 years (range 10 to 13.25). Patients were pleased or satisfied in 33 cases (92%) and disappointed in three cases (8%). Their median AOFAS score was 88 (range 52 to 100). Twenty-four (67%) had no pain, 20 (56%) were unable to wear fashionable conventional shoes, and 22 (61%) had some degree of clinical deformity. The mean physical functioning, role limitation due to physical problems, and pain dimension scores of the SF-36 were 88.75 ± 16, 87.5 ± 30, and 84.6 ± 19 respectively. There was clinical evidence of transfer loading in 23 cases (64%) but only eight (22%) were symptomatic. One patient was awaiting further foot surgery. Mean hallux valgus angle was 18.6 o ± 6.2 o , mean intermetatarsal angle was 10.5 o ± 2.2 o , and mean shortening was 6.2mm ± 3.4mm. There was no statistically significant relationship between amount of shortening and symptomatic transfer loading.
Conclusion . The modified Wilson's osteotomy has a high level of patient satisfaction at 10 years but malalignment and problems with transfer loading may be anticipated.
A Biomechanical Comparison Of Locking And Non-Locking Plates For The Fixation Of Calcaneal Fractures
David J. Redfern John T. Campbell, Stephen M. Belkoff PhD,
Department of Orthopaedics, Johns Hopkins Bayview Medical Center, Baltimore, MD
Introduction: Increasing the strength of fracture fixation is desirable to allow more aggressive rehabilitation and earlier mobilization. New locking plates have been proposed to increase the strength of fixation. The purpose of the current study was to compare calcaneal fractures stabilised with locking plates versus traditional non-locking calcaneal plates using a cadaveric model.
Methods: We simulated a Sanders type-IIB fracture in twenty paired, fresh-frozen cadaveric feet (BMD 0.304 to 0.763; age 65 to 89). One foot of each pair was fixed using a non-locking calcaneal plate (Synthes, Paoli, PA), whereas the contralateral foot was fixed using a locking calcaneal plate (calcaneal LCP, Synthes). The feet were cyclically loaded through the tibia between 0 and 700 N at 1 Hz using a materials testing machine to simulate weight bearing of a 70-kg patient. Fragment displacement was measured using 3-D kinematic analysis. After successful completion of 5000 cycles, each specimen was loaded to failure. Failure was defined as posterior facet articular step-off of 2mm or, loss of calcaneal height of 5 mm. Differences between groups were checked for significance (p<0.05) using paired t-tests.
Results: There was no significant difference in cycles to failure between the locking plate (3261 ± 2355 cycles) and the non-locking plate (2271 ± 2465), nor significant difference in mean load to failure between locking (3160 ± 1214 N) and non-locking (2811 ± 1218 N) plate fixation.
Discussion: In a cadaveric model, LCP fixation of calcaneal fractures does not appear to provide any biomechanical advantage over traditional non-locking fixation. Neither fixation appears indicated for early mobilisation.
Hampton Court Ice Rink, What price do we pay?
Gill K , Ormerod E, Davey P
Kingston Hospital, Surrey.
Introduction: Hampton Court Palace opened an ice rink between December 2003 and February 2004, they plan to make this an annual event. 73 000 people attended, an average of 1177 per day. We decided to audit the number and types of injury presenting from the ice rink with their cost implications for Kingston Hospital.
Methods: The notes were reviewed for all patients sustaining “ice rink” injuries. Information on the type of injury, operative treatment, days in hospital, X-rays performed and fracture clinic and physio outpatient consultations was collated. An estimate of total cost was made using data from finance, accounts and coding departments.
Results:Our sample contained 37 patients, 25 female and 12 male with an age range of 9 - 66 years, (mean 37). 54% of injuries (20/37) were distal radius fractures. 8 patients needed operative treatment staying a total of 30 days in hospital. There have been 68 fracture clinic consultations, 178 X-rays, 1 CT scan and 10 physio referrals at an approximate cost to Kingston Hospital of £23 293.
Conclusion :Studies have shown wrist guards to significantly reduce the incidence of distal radius fractures. 54% of injuries from the ice rink were to the distal radius. If wrist guards had been used this year our costs would have decreased by £10 264. The ice rink is willing to purchase a supply of wrist guards for hire with skates next year allowing us to perform a second audit to close the audit loop.
Futura splint treatment for torus fractures of the distal radius in children under ten.
T Bishop ,A Khaleel
St Peters Hospital Chertsey
Methods : Fifty children presenting to fracture clinic with torus fractures of the distal radius were treated with futura splint immobilisation rather than plaster backslab.
The splint was kept on for three weeks and then removed by the parents at home. Patients were then reviewed at a six week clinic appointment. They were assessed for range of movement and overall satisfaction with the futura splint treatment.X- rays were also taken to assess union and any displacement.
Results : The splint was well tolerated, 46 of 50 patients were satisfied with their treatment. Of the four dissatisfied patients only one had a significant clinical problem (pain) the other problems related to children prematurely removing their splints. None of the four dissatisfied patients had any functional deficit. At six weeks range of movement was not significantly different from the uninjured side all fractures united, there was no significant displacement in the splint.
Conclusions: We conclude that the futura splint is an acceptable and safe form of treatment for torus fractures in the under ten age group. It is easy to remove and reapply and could be safely removed at home by parents. This would allow these fractures to be treated with a single outpatient appointment saving patients the inconvenience of further appointments and reducing out patient clinics.
Scapholunate instability with an intact scapholunate ligament
VA Nuñez and ND Citron
The Hand Unit, Nelson Hospital, Kingston Road, London
Chronic dynamic scapholunate instability has traditionally been associated with complete or partial scapholunate ligament tears, confirmed at arthroscopy and/or as an operative finding. These patients usually have a positive history of falling on a dorsiflexed wrist, have tenderness over the scapholunate interval and a positive scaphoid shift test. Routine and stress radiography are normal as is the MRI.
We present a small cohort of patients which we have assessed and followed-up as part of our chronic scapholunate instability patients which have been found to have an intact scapholunate ligament. At arthroscopy the scapholunate ligament was found not to be torn although it was incompetent and of an abnormal consistency. We believe the scapholunate ligament had elongated as a result of stress across the joint, but not actually stretched to failure.
These cases with subfailure damage of the scapholunate ligament were treated with scapholunate reconstruction using a bone-retinaculum-bone autograft, as used for chronic dynamic scapholunate instability with ligament rupture. At two years, all are satisfied and back to their former work activities.
This overstretch to subfailure phenomenon has not been previously described in the scapholunate ligament, although there have been some in vitro studies for the anterior cruciate ligament showing significant alteration of the response of the overstretched ligament to stress, especially at low loads. We believe that under the dynamic in vivo loading conditions of daily living this may result in increased joint laxity, additional loads being applied to other joint structures, and, with time, to joint dysfunction.
A short break for Tea and Coffee
Interlocking titanium alloy and HA coated stems in complex hip replacement and periprosthetic fracture.
S.P. Trikha , F. Middleton*, H. Matthews, O. Raynham*,
J. C. Lewis*, D.A. Ward
Kingston NHS Trust, Surrey &
* Worthing and Southlands NHS Trust West Sussex
Introduction: We describe the early clinical and radiological results in 2 centres of 38 consecutive complex hip arthroplasties in 38 patients, comparing an interlocked long stemmed titanium alloy femoral component with or without a hydroxyapatite coating.
Methods: The mean age at the time of operation was 79 years. The average length of follow up was 2 years (range 3 months to 5.6 years). All patients receiving a Cannulok revision stem with a minimum follow up of 3 months were included regardless of their primary aetiology and number of previous surgeries. Over half were for periprosthetic fractures.
Patients were reviewed and scored using the Charnley grade preoperatively, and the Merle d'Aubigne and Postel Score, Harris Hip Score and the WOMAC index at latest review. Radiographs were assessed and femoral defects were classified according to Paprosky, and the Vancouver classification was used for periprosthetic fractures. At latest review we measured subsidence, new bone formation (including presence of callus for fractures), osteolysis, screw breakages and radiolucent lines in all areas of the stem.
Results: The mean Harris hip score was 75 at the latest post-operative review. The mean WOMAC and MDP scores were 46.5 and 13.2 respectively.
The mean pain visual analogue score was 1.7 overall and 0.5 specifically for mid-thigh pain. There has only been 1 Cannulok revision to date.
Discussion: We present encouraging early clinical and radiological results of the Cannulok stem system for periprosthetic fractures and other complex hip surgery.
Cemented femoral stem insertion, Can slowly but surely win the race?
C Steinlechner
St Peter's Hospital Chertsey
A good bone-cement interface is critical to the longevity of cemented hip arthroplasties and great efforts are made to achieve this. Once inserted however, cement is subjected to blood back pressures of up to 30 cm of water and permeation or displacement of cement by blood may occur until cement viscosity has risen sufficiently. During this period, pressure is often applied to the stem digitally, in an attempt to avert the deleterious effects of blood back pressure. Not only is this technique unreliable, it may be harmful, leading to stem sinkage and micro-motion.
Using a bench hip cementation model, we inserted femoral stems at various times and at different speeds. With early stem insertion, low cement viscosity led to poor cement pressurisation and slow stem insertion was deleterious. In contrast, later insertion, because of the rising cement viscosity, led to increased cement pressures. By inserting the stem over ninety seconds, the net effect of slower insertion combined with ever rising cement viscosity led to even higher cement pressures, particularly proximally, cement pressure also being maintained some time after stem insertion. Cement pressures were high enough to resist displacement by blood throughout the longer stem insertion procedure and at the end, cement viscosity was sufficient to resist blood back pressure.
By combining later and slower stem insertion a pressure profile was produced which we believe will lead to a more reliably good bone-cement interface.
Use of the Transverse Acetabular Ligament in assessing the correct version of the cup in Total Hip Arthroplasty
CJ Pearce , P Khirandish, A Khaleel
The Rowley Bristow Unit. St. Peters Hospital, Guilford Road, Chertsey, Surrey
We present a cadaveric study using the transverse acetabular ligament to align the cup in total hip arthroplasty.
There are many methods employed and described in the literature that can be used to facilitate the orientation of the acetabular component of a total hip replacement. None of these has been shown to be infallible.
We dissected a total of 14 cadaveric hips. All had well preserved transverse acetabular ligaments. The ligaments were identified and a wire placed along them. Furlong uncemented trial prostheses were then inserted into each acetabulum. Photographs and radiographs were taken with the trial cups aligned with the wire as well as with the cups not aligned with the wire.
The angle of planar anteversion was measured from the radiographs as described by Pradhan (JBJS Br 1999 May;81(3):431-5) to determine acceptable anteversion. Cups that were aligned with the transverse acetabular ligament were found to be within the accepted range for anteversion.
We suggest that this is another method of orientating the acetabular component in total hip arthroplasty.
Hydroxyapatite coated femoral stems in revision hip surgery.
S. Singh , S.P. Trikha, O. Raynham, J. Lewis, P.A. Mitchell*, A. J. Edge
Worthing and Southlands NHS Trust, West Sussex,
* St Georges NHS Trust, Tooting,
Aim: We describe the clinical and radiological results of 120 consecutive revision hip arthroplasties in 107 patients, using a titanium alloy femoral component fully coated with Hydroxyapatite.
Method: The mean age at the time of operation was 71 years. The average length of follow up was 7.9 years. All patients receiving a JRI Furlong HA coated femoral component with a minimum follow up of 5 years were included regardless of their primary aetiology.
Patients were independently reviewed and scored using the Merle d'Aubigne and Postel Score, Harris Hip Score and the WOMAC index. Radiographs were assessed by three reviewers (blinded to clinical details) for new bone formation, osteolysis and radiolucent lines in each Gruen Zone.
Results: The mean Harris hip score was 85.8 at the latest post-operative review. The mean WOMAC and MDP scores were 34.5 and 14.8 respectively.
The mean pain visual analogue score was 1.2 overall and 0.5 specifically for mid-thigh pain. There were no revisions of any femoral component for aseptic loosening. There were three stem re-revisions (2 cases of infection, 1 recurrent dislocation).Radiological review of all femoral components revealed stable bone ingrowth with no continuous or progressive radiolucent lines in any zone. Using revision or impending revision for aseptic loosening as the end point, at 10 years the cumulative survival for the stem was 100% (95% CI 94 to 100).
Conclusions: We present excellent medium to long term clinical, radiological and survivorship results with the use of a fully HA coated titanium stem in revision hip surgery.
The effect of Total Hip Replacement on the work status of young patients
R. Mobasheri , S. Gidwani, J. W. Rosson.
Royal Surrey County Hospital, Guildford.
Objective : To determine the proportion of patients under 60 years of age who are at work before and after total hip replacement and to examine possible influences on likelihood of patients to return to employment.
Patients and methods : A retrospective study of a consecutive cohort of 86 patients (101 hips) under the age of 60 operated on by a single orthopaedic surgeon between 1993 and 2003 at a district general hospital. Demographic and diagnostic data was collected from patients' hospital records, and a detailed questionnaire regarding occupational status was used at follow-up.
Results : Nearly all patients working prior to surgery returned to employment following surgery. Nearly half of those not working pre-operatively regained employment post-operatively; in those that did not return to work, this was for reasons unrelated to their hip. Those patients who had been out of work prior to their surgery took significantly longer to return to work.
Conclusions : THR is effective in keeping patients under the age of 60 employed. It is also effective in allowing those already off work due to hip pain to return to work, although there is a much greater delay. Patients under the age of 60 awaiting THR who are struggling to stay at work because of hip pain should therefore be prioritised on the waiting list.
Bone Graft Weight in Posterolateral Lumbar Spine Instrumentation for Degenerative Spine Disorders (DSD) Affects Outcome
Ridgeway S , Tai C, Graevett-Ball C, Harrison H
Frimley Park Hospital, Surrey.
Aims : To investigate the functional outcome with different autologous bone graft weights in posterolateral lumbar spine instrumentation for DSD's
Methods : A total of 79 patients (mean age of 47.2) with chronic lower back pain for at least 2 years, with at least 1 year of failed conservative treatment, who were undergoing posterolateral spinal fusion were admitted to the trial. Patients were randomised into three groups to receive bone graft weights of 25g (Group A=26 patients), 50g (Group B=30 patients) and 100g (Group C=23 patients) per segment. Pain, clinical characteristics, disability (Oswestry), radiographic fusion, patient satisfaction and complications were recorded at 3, 6, 12 and 24-months.
Results: At 2 years, Group B (50g) had a significantly improved Oswestry Index, pain intensity, motor and sensory changes, and overall patient satisfaction than Group C (100g), which was significantly better than Group A (25g). There was no correlation between bone graft weight and radiographic fusion; or between fusion and outcome. Complications were similar.
Conclusions: Patients had significantly better functional and clinical outcomes with bone graft weights of 50g. Bone graft weights of 25g had the worse outcomes and 100g did not seem to have any beneficial affect over 50g. We recommend autologous bone graft weights of 50g per fused spinal segments in this group of surgical patients.