The effect of total hip and hip resurfacing arthroplasty on vertical ground reaction force and impulse symmetry during a sit-to-stand task.

BACKGROUND: The aim of this study was to determine the influence of total hip arthroplasty and hip resurfacing arthroplasty on limb loading symmetry before, and after, hip reconstruction surgery during a sit-to-stand task. METHODS: Fourteen patients were recruited that were about to receive either a total hip prosthesis (n=7) or a hip resurfacing prosthesis (n=7), as well as matched controls. Patients performed a sit-to-stand movement before, 3 months after, and 12 months after surgery. Peak vertical ground reaction force and impulse were measured for each leg, from which ground reaction force and impulse symmetry ratios were calculated. FINDINGS: Before surgery, hip resurfacing patients showed a small asymmetry which was not different to normal for ground reaction force (0.88(0.28) vs. 1.00(0.11); p=0.311) or impulse (0.87(0.29) vs. 0.99(0.09); p=0.324) symmetry ratios. Total hip patients offloaded their affected hip by 30% in terms of impulse symmetry ratio (0.71(0.36) vs. 0.99(0.23); p=0.018). At 3 months following surgery asymmetries were seen that were different to normal in both hip resurfacing patients for ground reaction force (0.77(0.16); p=0.007), and total hip patients for ground reaction force (0.70(0.15); p=0.018) and impulse (0.72(0.16); p=0.011) symmetry ratios. By 12 months after surgery total hip patients regained a symmetrical loading pattern for both ground reaction force (0.95(0.06); p=0.676) and impulse (1.00(0.06); p=0.702) symmetry ratios. Hip resurfacing patients, however, performed the task by overloading their operated hip, with impulse symmetry ratio being larger than normal (1.16(0.16); p=0.035). INTERPRETATION: Physiotherapists should appreciate the need for early recovery of limb loading symmetry as well as subsequent differences in the responses observed with different prostheses.

Orthopaedic training: 'run through' or uncoupled.

The Postgraduate Medical Education and Training Board wants either 'run through' or 'uncoupled' orthopaedic training to be adopted throughout the United Kingdom but it is not willing to let both continue together as is the current situation. This annotation explores the argument for and against 'run through' training.

The mortality, morbidity and cost benefits of elective total knee arthroplasty in the nonagenarian population.

With the increasing life expectancy, a greater number of elderly patients are being referred to an orthopaedic department to have elective total knee arthroplasty (TKA). Total knee arthroplasty should be considered in the very elderly only after carefully balancing the benefits of surgery against the risks of surgery. The aim of this study was to analyse the mortality, morbidity and cost benefits of elective TKA in a cohort group of the nonagenarian population. Between 1990 and 2006, 42 patients >or=90 years of age had TKA surgery. Patient's notes were retrospectively analysed. A cost-benefit analysis was carried out by comparing the surgical costs against nursing home placement. The mean age at surgery was 90.4 years (range: 90-90.6). There was one major and 11 minor postoperative complications with no immediate or late postoperative deaths. The Knee Society Scores improved from 25 points (range: 8-44) to 81 points (range: 60-95), and the WOMAC Scores improved from 62 points (range: 54-73) to 41 points (range: 34-46) (p<0.002). The calculated cost-benefit savings for 42 patients at 5 years after TKA was estimated to be pound 2,746,839. Total knee arthroplasty in the nonagenarian population is safe, beneficial and cost-effective.

The value of magnetic resonance imaging in our current management of ACL and meniscal injuries.

Magnetic resonance imaging (MRI) is frequently used in the diagnosis of anterior cruciate ligament (ACL) and meniscal injuries. The aim of this retrospective study was to determine the reliability and value of MRI in our management of ACL and meniscal tears. 138 patients who had undergone a MRI to confirm or refute the clinical diagnosis of an ACL or meniscal tear were identified. Those who had subsequently undergone arthroscopy were selected. MRI findings and clinical diagnosis were compared with those at arthroscopy. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall accuracy of clinical diagnosis and MRI were then calculated. The overall accuracy for MRI was 91, 68 and 86% for detecting ACL, medial meniscal and lateral meniscal tears, respectively. Accuracy for clinical diagnosis was 90 and 64% for ACL and meniscal tears, respectively. In contrast to other series, our results indicate a lower accuracy of MRI in detecting pathology, especially of the ACL and medial meniscus. We noted a low sensitivity, specificity and positive predictive value but a high negative predictive value rendering MRI most useful as a negative diagnostic tool. We suggest that where symptoms and clinical findings support one of these diagnoses and arthroscopic therapeutic intervention is contemplated, that MRI scanning is not always beneficial. Our current practice of requesting scans to routinely confirm the diagnosis should be altered. Unnecessary MRI scanning increases the financial burden and delays patient treatment.

Lateralization of parathyroid adenomas by intra-operative parathormone estimation.

A simple method for intra-operative lateralization of parathyroid adenomas by venous sampling for intact parathormone (PTH [1-84] is described. After induction of anaesthesia, percutaneous right and left internal jugular and arm vein PTH [1-84] was estimated within 30 minutes by a modification of the Allegro PTH [1-84] assay. Twenty-three patients with primary hyperparathyroidism due to adenoma were explored, 21 with one adenoma and two with two adenomas. Intraoperative jugular PTH [1-84] correctly lateralized 16 (76%) of the single adenomas (P < 0.006), and the side of the neck with the greater weight of parathyroid adenoma in 18 (78%) patients (P < 0.004). Two patients with previous failed neck explorations were correctly lateralized. Thallium/technetium scanning lateralized 41%, significantly less then jugular PTH [1-84] (P < 0.02). Adenomas of 1 g or less were more likely to be lateralized by PTH [1-84] than thallium/technetium scanning (P < 0.05). Intraoperative jugular PTH [1-84] was superior to thallium/technetium scanning for parathyroid adenoma lateralization.