Component alignment and clinical outcome following total knee arthroplasty: a randomised controlled trial comparing an intramedullary alignment system with patient-specific instrumentation.

AIMS: We conducted a randomised controlled trial to assess the accuracy of positioning and alignment of the components in total knee arthroplasty (TKA), comparing those undertaken using standard intramedullary cutting jigs and those with patient-specific instruments (PSI). PATIENTS AND METHODS: There were 64 TKAs in the standard group and 69 in the PSI group. The post-operative hip-knee-ankle (HKA) angle and positioning was investigated using CT scans. Deviation of > 3° from the planned position was regarded as an outlier. The operating time, Oxford Knee Scores (OKS) and Short Form-12 (SF-12) scores were recorded. RESULTS: There were 14 HKA-angle outliers (22%) in the standard group and nine (13%) in the PSI group (p = 0.251). The mean HKA-angle was 0.5° varus in the standard group and 0.2° varus in the PSI group (p = 0.492). The accuracy of alignment in the coronal and axial planes and the proportion of outliers was not different in the two groups. The femoral component was more flexed (p = 0.035) and there were significantly more tibial slope outliers (29% versus 13%) in the PSI group (p = 0.032). Operating time and the median three-month OKS were similar (p = 0.218 and p = 0.472, respectively). Physical and mental SF-12 scores were not significantly different at three months (p = 0.418 and p = 0.267, respectively) or at one year post-operatively (p = 0.114 and p = 0.569). The median one-year Oxford knee score was two points higher in the PSI group (p = 0.049). CONCLUSION: Compared with standard intramedullary jigs, the use of PSI did not significantly reduce the number of outliers or the mean operating time, nor did it clinically improve the accuracy of alignment or the median Oxford Knee Scores. Our data do not support the routine use of PSI when undertaking TKA. Cite this article: Bone Joint J 2016;98-B:1043-9.

The surgical anatomy of the piriformis tendon, with particular reference to total hip replacement: a cadaver study.

The piriformis muscle is an important landmark in the surgical anatomy of the hip, particularly the posterior approach for total hip replacement (THR). Standard orthopaedic teaching dictates that the tendon must be cut in to allow adequate access to the superior part of the acetabulum and the femoral medullary canal. However, in our experience a routine THR can be performed through a posterior approach without sacrificing this tendon. We dissected the proximal femora of 15 cadavers in order to clarify the morphological anatomy of the piriformis tendon. We confirmed that the tendon attaches on the crest of the greater trochanter, in a position superior to the trochanteric fossa, away from the entry point for broaching the intramedullary canal during THR. The tendon attachment site encompassed the summit and medial aspect of the greater trochanter as well as a variable attachment to the fibrous capsule of the hip joint. In addition we dissected seven cadavers resecting all posterior attachments except the piriformis muscle and tendon in order to study their relations to the hip joint, as the joint was flexed. At flexion of 90° the piriformis muscle lay directly posterior to the hip joint. The piriform fossa is a term used by orthopaedic surgeons to refer the trochanteric fossa and normally has no relation to the attachment site of the piriformis tendon. In hip flexion the piriformis lies directly behind the hip joint and might reasonably be considered to contribute to the stability of the joint. We conclude that the anatomy of the piriformis muscle is often inaccurately described in the current surgical literature and terms are used and interchanged inappropriately.

A comparison of a less invasive piriformis-sparing approach versus the standard posterior approach to the hip: A randomised controlled trial.

We undertook a randomised controlled trial to compare the piriformis-sparing approach with the standard posterior approach used for total hip replacement (THR). We recruited 100 patients awaiting THR and randomly allocated them to either the piriformis-sparing approach or the standard posterior approach. Pre- and post-operative care programmes and rehabilitation regimes were identical for both groups. Observers were blinded to the allocation throughout; patients were blinded until the two-week assessment. Follow-up was at six weeks, three months, one year and two years. In all 11 patients died or were lost to follow-up. There was no significant difference between groups for any of the functional outcomes. However, for patients in the piriformis-sparing group there was a trend towards a better six-minute walk test at two weeks and greater patient satisfaction at six weeks. The acetabular components were less anteverted (p = 0.005) and had a lower mean inclination angle (p = 0.02) in the piriformis-sparing group. However, in both groups the mean component positions were within Lewinnek's safe zone. Surgeons perceived the piriformis-sparing approach to be significantly more difficult than the standard approach (p = 0.03), particularly in obese patients. In conclusion, performing THR through a shorter incision involving sparing piriformis is more difficult and only provides short-term benefits compared with the standard posterior approach.

Knee joint preservation with combined neutralising high tibial osteotomy (HTO) and Matrix-induced Autologous Chondrocyte Implantation (MACI) in younger patients with medial knee osteoarthritis: a case series with prospective clinical and MRI follow-up over 5 years.

PURPOSE: There is no ideal treatment for younger patients with medial knee osteoarthritis (OA) and varus malalignment. We have investigated the first case series of combined neutralising high tibial osteotomy (HTO) and Matrix-induced Autologous Chondrocyte Implantation (MACI) with MRI. Treatment goals were clinical improvement and delay of arthroplasty. METHODS: Between 2002 and 2005 18 patients (Mean age 47 years) underwent surgery. Exclusion criteria were lateral compartment and advanced patellofemoral OA. The Knee Injury and Osteoarthritis Outcome Score (KOOS), six minute walk test (6MWT) and a validated MRI score were outcome measures. RESULTS: There were significant improvements (p<0.05) in all five KOOS domains. Four were significantly maintained to 5 years. The domain "symptoms" and results in the 6MWT dropped off at 5 years. MRI results were first significantly improved (24/12) but declined at 60 months. Good quality infill was found in 33% patients at the study endpoint (n=5/15). Histological investigation of one knee demonstrated full-thickness hyaline-like cartilage (20/12). After 2 early failures and one graft detachment graft fixation was changed (Smart nails instead of sutures in 14 cases). Graft hypertrophy requiring a chondroplasty occurred once. There were no other major complications. Specific minor complications included patellar tendinitis (n=8). CONCLUSIONS: This combined procedure provides a safe treatment option for younger patients with medial knee OA and varus alignment with significant clinical improvement at 5 years. However, overall graft survival and cartilage infill were poor. Larger studies are needed to statistically verify predictors for longer term cartilage repair in these patients.

Effect of flexion/extension splintage post total knee arthroplasty on blood loss and range of motion -- a randomised controlled trial.

Previous published research has shown promising results with flexion splinting post total knee arthroplasty. Before instituting this practice, we conducted a randomised controlled trial to confirm any benefits over splinting in extension. Five patients were recruited into the trial. 5 were excluded. The flexion group consisted of 49 patients who had their knee placed in 70 degrees of flexion over an inactive CPM machine for 24 h post operation. The extension group consisted of 46 patients who were splinted in full extension for the first 24 h post operation. We assessed post-operative day 1 drain volume, haemoglobin and haematocrit, blood transfusions, duration of inpatient stay, range of motion and complications within 6 weeks of surgery. There was no significant difference between the two groups among any of the outcomes measured. As such, we have been unable to demonstrate any benefit with splintage in flexion post total knee arthroplasty and have not adopted it as part of our post-operative management.

Operative and non-operative treatment options for dislocation of the hip following total hip arthroplasty.

BACKGROUND: Dislocation following hip replacement is associated with significant morbidity and functional cost. The cause is usually multifactorial. A variety of treatment options are available which can broadly be classified into operative and non-operative. OBJECTIVES: To determine the best methods of treatment of recurrent dislocation following total hip replacement. SEARCH STRATEGY: The following databases were searched until August 2006: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials (CENTRAL), Health Technology Assessment database (HTA), Database of Abstracts of Reviews of Effectiveness (DARE), International Standard Randomised Controlled Trial Number Register (ISRCTN), and MetaRegister of Controlled Trials (mRCT). SELECTION CRITERIA: Randomised and quasi-randomised trials comparing operative and non-operative treatments for recurrent dislocation following total hip replacement. DATA COLLECTION AND ANALYSIS: Two independent reviewers applied the inclusion criteria to identified studies. MAIN RESULTS: Searches identified 269 studies. None fulfilled the inclusion criteria. AUTHORS' CONCLUSIONS: The authors invite researchers to perform RCTs comparing different treatment options for recurrent dislocation of the hip. The heterogeneity of the population and variety of underlying causes would favour a multi-centre study to achieve an adequate sample size.

A constrained acetabular component for recurrent dislocation.

We treated 34 patients with recurrent dislocation of the hip with a constrained acetabular component. Roentgen stereophotogrammetric analysis was performed to assess migration of the prosthesis. The mean clinical follow-up was 3.0 years (2.2 to 4.8) and the radiological follow-up was 2.7 years (2.0 to 4.8). At the latest review six patients had died and none was lost to follow-up. There were four acetabular revisions, three for aseptic loosening and one for deep infection. Another acetabular component was radiologically loose with progressive radiolucent lines in all Gruen zones and was awaiting revision. The overall rate of aseptic loosening was 11.8% (4 of 34). Roentgen stereophotogrammetric analysis in the non-revised components confirmed migration of up to 1.06 mm of translation and 2.32 degrees of rotation at 24 months. There was one case of dislocation and dissociation of the component in the same patient. Of the 34 patients, 33 (97.1%) had no further episodes of dislocation. The constrained acetabular component reported in our study was effective in all but one patient with instability of the hip, but the rate of aseptic loosening was higher than has been reported previously and requires further investigation.

A comparison of three methods of wound closure following arthroplasty: a prospective, randomised, controlled trial.

We carried out a blinded prospective randomised controlled trial comparing 2-octylcyanoacrylate (OCA), subcuticular suture (monocryl) and skin staples for skin closure following total hip and total knee arthroplasty. We included 102 hip replacements and 85 of the knee.OCA was associated with less wound discharge in the first 24 hours for both the hip and the knee. However, with total knee replacement there was a trend for a more prolonged wound discharge with OCA. With total hip replacement there was no significant difference between the groups for either early or late complications. Closure of the wound with skin staples was significantly faster than with OCA or suture. There was no significant difference in the length of stay in hospital, Hollander wound evaluation score (cosmesis) or patient satisfaction between the groups at six weeks for either hips or knees. We consider that skin staples are the skin closure of choice for both hip and knee replacements.

Interventions for treating acute Achilles tendon ruptures.

BACKGROUND: There is lack of consensus on the best management of the acute Achilles tendon (TA) rupture. Treatment can be broadly classified into operative (open or percutaneous) and non-operative (cast immobilisation or functional bracing). Post-operative splintage can be with a rigid cast (above or below the knee) or a more mobile functional brace. OBJECTIVES: To identify and summarise the evidence from randomised controlled trials of the effectiveness of different interventions in the treatment of acute Achilles tendon ruptures. SEARCH STRATEGY: We searched multiple databases including the Cochrane Musculoskeletal Injuries Group specialised register (to September 2003), reference lists of articles and contacted trialists. Keywords included Achilles Tendon, Rupture, and Tendon Injuries. SELECTION CRITERIA: All randomised and quasi-randomised trials comparing different treatment regimens for acute Achilles tendon ruptures. DATA COLLECTION AND ANALYSIS: Three reviewers extracted data and independently assessed trial quality by use of a ten-item scale. MAIN RESULTS: Fourteen trials involving 891 patients were included. Several of the studies had poor methodology and inadequate reporting of outcomes. Open operative treatment compared with non-operative treatment (4 trials, 356 patients) was associated with a lower risk of rerupture (relative risk (RR) 0.27, 95% confidence interval (CI) 0.11 to 0.64), but a higher risk of other complications including infection, adhesions and disturbed skin sensibility (RR 10.60, 95%CI 4.82 to 23.28). Percutaneous repair compared with open operative repair (2 studies, 94 patients) was associated with a shorter operation duration, and lower risk of infection (RR 10.52, 95% CI 1.37 to 80.52). These figures should be interpreted with caution because of the small numbers involved. Patients splinted with a functional brace rather than a cast post-operatively (5 studies, 273 patients) tended to have a shorter in-patient stay, less time off work and a quicker return to sporting activities. There was also a lower complication rate (excluding rerupture) in the functional brace group (RR 1.88 95%CI 1.27 to 2.76). Because of the small number of patients involved no definitive conclusions could be made regarding different operative techniques (1 study, 51 patients), different non-operative treatment regimes (2 studies, 90 patients), and different forms of post-operative cast immobilisation (1 study, 40 patients). REVIEWERS' CONCLUSIONS: Open operative treatment of acute Achilles tendon ruptures significantly reduces the risk of rerupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by performing surgery percutaneously. Post-operative splintage in a functional brace appears to reduce hospital stay, time off work and sports, and may lower the overall complication rate.

Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients.

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail.

Cemented or uncemented hemiarthroplasty for displaced intracapsular femoral neck fractures.

The aim of this study was to establish whether or not to cement the hemiarthroplasty for displaced intracapsular femoral neck fractures in the elderly. Consecutive patients treated by hemiarthroplasty in adjacent hospitals were reviewed. The same monoblock prosthesis was used; in hospital A they were uncemented (121 patients), and in hospital B they were cemented (123 patients). Notes were reviewed retrospectively. Surviving patients (50 and 56 respectively) were assessed prospectively for pain and functional ability using validated scoring systems. Follow-up was 32-36 months. Patient demographics were similar. Fewer of the cemented group had been revised or were awaiting revision ( P=0.036). There was no difference in general complication or mortality rates. There was a highly statistically significant greater deterioration in pain ( P=0.003), walking ability ( P=0.002), use of walking aids ( P=0.003) and activities of daily living ( P=0.009) in the uncemented group. Our findings support the use of cemented hemiarthroplasty in the elderly.

A survey of the treatment of displaced intracapsular femoral neck fractures in the UK.

A survey was undertaken to investigate the treatment of displaced intracapsular femoral neck fractures across the UK. The usual practice at 223 hospitals was recorded for two groups of patients, active and frail. Management of stereotyped fractures, in similar patients, varied between hospitals. There was also variation between specialists within some hospitals: two or more of the alternative methods of treatment were in routine use for active patients at 22% of hospitals and for frail patients at 27%. Overall, for active patients, bipolar hemiarthroplasty was undertaken at 41% of hospitals, internal fixation at 37%, unipolar hemiarthroplasty at 32% and total hip replacement at 16%. Cemented prostheses were used in 74% of arthroplasties for active patients. For frail patients, hemiarthroplasty with an Austin Moore or Thompson prostheses was undertaken at 94% of hospitals; bipolar prostheses were used at 8%; internal fixation was undertaken at 1%. Cement was used in 46% of hemiarthroplasties. These findings indicate a lack of consensus in aspects of the treatment of displaced intracapsular femoral neck fractures and are likely to reflect difficulties in determining "best practice."

Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip--a systematic review.

Displaced intracapsular hip fractures are often treated by hemiarthroplasty, with or without cement. The aim of this study is to perform a systematic review of the literature to establish whether this influences the outcome. A comprehensive search of the English language world literature of all studies comparing cemented with uncemented hemiarthroplasty was performed. Eighteen publications addressing this issue were identified. Three were excluded from review because of poor study design and non-comparability of groups. Of the remainder, few were suitable for statistical analysis, therefore a qualitative comparison of results was carried out. The majority of studies suggested a lower revision rate, less thigh pain and better mobility in-patients in whom the prosthesis was cemented. Cemented hemiarthroplasty may be associated with increased operative time and blood loss. There appears to be no difference in general complication, or mortality rates after 3 months, between the two groups. Radiographic differences were variable and did not correlate with clinical findings. We conclude, the literature tends to support the use of cement in hemiarthroplasty for displaced intracapsular femoral neck fractures. Further prospective randomised studies are required to resolve the issue.