ABSTRACT
AIMS: The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective. METHODS: The OBC and the patellotrochlear index were used as part of the Oswestry Patellotrochlear Algorithm (OPTA) to guide the surgical treatment of patients with patellar instability. Patients were assigned to one of four treatment groups: medial patellofemoral ligament reconstruction (MPFLr); MPFLr + tibial tubercle distalization (TTD); trochleoplasty; or trochleoplasty + TTD. A prospective analysis of a longitudinal patellofemoral database was performed. Between 2012 and 2018, 202 patients (233 knees) with a mean age of 24.2 years (SD 8.1), with recurrent patellar instability were treated by two fellowship-trained consultant sports/knee surgeons at The Robert Jones and Agnes Hunt Orthopaedic Hospital. Clinical efficacy of each treatment group was assessed by Kujala, International Knee Documentation Committee (IKDC), and EuroQol five-dimension questionnaire (EQ-5D) scores at baseline, and up to 60 months postoperatively. Their safety was assessed by complication rate and requirement for further surgery. The pattern of clinical outcome over time was analyzed using mixed regression modelling. RESULTS: In all, 135 knees (mean age 24.9 years (SD 9.4)) were treated using a MPFLr. Ten knees (7.4%) required additional surgery. A total of 50 knees (mean age 24.4 years (SD 6.3)) were treated using MPFLr + TTD. Ten (20%) required additional surgery. A total of 20 knees (mean age 19.5 years (SD 3.0)) were treated using trochleoplasty + TTD. Three patients (15%) required additional surgery. In each treatment group, there was a significant improvement in Kujala, IKDC, and EQ-5D at one year postoperatively (p < 0.001) with a recognized level of overall complication rate. CONCLUSION: The OBC is a valid assessment tool to grade patients with trochlear dysplasia and, when used as part of the OPTA, helps to determine treatments that are safe and effective. This fulfils the requirements for its application in mainstream clinical practice. Cite this article: Bone Joint J 2021;103-B(10):1586-1594.
Subject(s)
Algorithms , Clinical Decision-Making/methods , Joint Instability/diagnostic imaging , Magnetic Resonance Imaging , Orthopedic Procedures/methods , Patellofemoral Joint/diagnostic imaging , Severity of Illness Index , Adolescent , Adult , Child , Female , Humans , Joint Instability/surgery , Longitudinal Studies , Male , Middle Aged , Patellofemoral Joint/surgery , Postoperative Complications/epidemiology , Reoperation/statistics & numerical data , Retrospective Studies , Treatment Outcome , Young AdultABSTRACT
The number of primary and revision total joint arthroplasty procedures is increasing exponentially with time. It is anticipated that there will be a huge expected demand for revision knee surgery over the next 2 decades. Knee revisions alone are projected to increase by 601% between 2005 and 2030 in the United States.(2) Awareness is needed by both general practitioner and physician for the signs of failure of these implants and when to refer to the surgeon. Infection remains the primary cause to exclude first. Unless the surgeon accurately identifies the mode of failure, successful treatment becomes very unlikely; an increasing physical burden on the patient and financial burden on hospital trusts ensues. In comparison with primary joint arthroplasty, complication rates after revision surgery are significantly increased, and outcome is less assured.
Subject(s)
Arthroplasty, Replacement, Hip , Arthroplasty, Replacement, Knee , Hip Prosthesis/adverse effects , Knee Prosthesis/adverse effects , Prosthesis Failure , Reoperation/adverse effects , Aged , Aged, 80 and over , Humans , Middle Aged , Postoperative Complications , Prosthesis Failure/etiology , Prosthesis-Related Infections/complications , Prosthesis-Related Infections/surgery , Risk Factors , Treatment OutcomeABSTRACT
Current research has been unable to confirm that intramedullary fixation provides greater stability for unstable fracture configurations of the proximal femur than extra-medullary devices. We present a retrospective analysis of the outcome of proximal femoral fractures treated with the Proximal Femoral Nail (PFN, Synthes) with particular reference to implant position and adequacy of reduction. Between May 2002 and October 2004, 61 patients with low-energy unstable proximal femoral fractures underwent surgery at a mean 2.4 days. Mean age was 78 years, 74% were female. Four (6.9%) implants failed secondary to proximal cut out of the hip screw. All of the failures occurred in patients who had sustained AO/OTA type 31. A3 fractures. In patients with A3 fracture patterns, there is a significant relationship between increasing Tip-Apex distance (p = 0.023), varus mal-reduction (p = 0.038) and failure; 46% patients died within 12 months of surgery. The PFN is a satisfactory implant in the management of unstable proximal femoral fractures, however accurate reduction and implant position are essential to provide the best conditions for union and to prevent implant failure.
