Medium- and long-term results of high tibial osteotomy using Garches external fixator and gait analysis for dynamic correction in varus osteoarthritis of the knee.

In arthritis of the varus knee, a high tibial osteotomy (HTO) redistributes load from the diseased medial compartment to the unaffected lateral compartment. We report the outcome of 36 patients (33 men and three women) with 42 varus, arthritic knees who underwent HTO and dynamic correction using a Garches external fixator until they felt that normal alignment had been restored. The mean age of the patients was 54.11 years (34 to 68). Normal alignment was achieved at a mean 5.5 weeks (3 to 10) post-operatively. Radiographs, gait analysis and visual analogue scores for pain were measured pre- and post-operatively, at one year and at medium-term follow-up (mean six years; 2 to 10). Failure was defined as conversion to knee arthroplasty. Pre-operative gait analysis divided the 42 knees into two equal groups with high (17 patients) or low (19 patients) adductor moments. After correction, a statistically significant (p < 0.001, t-test,) change in adductor moment was achieved and maintained in both groups, with a rate of failure of three knees (7.1%), and 89% (95% confidence interval (CI) 84.9 to 94.7) survivorship at medium-term follow-up. At final follow-up, after a mean of 15.9 years (12 to 20), there was a survivorship of 59% (95% CI 59.6 to 68.9) irrespective of adductor moment group, with a mean time to conversion to knee arthroplasty of 9.5 years (3 to 18; 95% confidence interval ± 2.5). HTO remains a useful option in the medium-term for the treatment of medial compartment osteoarthritis of the knee but does not last in the long-term. Cite this article: Bone Joint J 2016;98-B:601-7.

A new tilt on pelvic radiographs: a pilot study.

AIM: The aim of this study was to evaluate pelvic tilt on commonly performed measurements on radiography in primary protrusio acetabuli and developmental dysplasia of the hip. MATERIALS AND METHODS: A dry assembled pelvis and spine skeleton was positioned in an isocentric skull unit and films exposed with increasing degrees of angulation of pelvic tilt. The films were then read by two independent readers for seven different measurements used to evaluate the hips and acetabular: acetabular line to ilioischial line, teardrop appearance, intercristal/intertuberous ratio, co-ordinates of femoral head, centre edge angle, acetabular depth/width ratio and acetabular angle. RESULTS: There was so much variation in the protrusio results that no formal recommendation of any standard radiographic test can be given. Only the inter tuberous distance is not effected by pelvic tilt. The acetabular angles for developmental dysplasia of the hip showed the most potential with pelvic tilt below 15 degrees. CONCLUSION: As pelvic tilt increases, measurements used in protusio become unreliable, and computed tomography/magnetic resonance imaging are probably going to be more accurate as one can directly visualise pelvic intrusion. We recommend a lateral view to assess the degree of pelvic tilt in patients with protrusion to ensure these measurements are valid.

Medium term results of reverse total shoulder replacement in patients with rotator cuff arthropathy.

BACKGROUND: The Delta III total shoulder replacement is a reversed, semi-constrained prosthesis and is recommended for the management of rotator cuff arthropathy. METHODS: We performed a retrospective mid-term review of the Delta shoulder replacements performed during 2000-2005 with a minimum 18-month follow-up. We recorded the pre-operative and post-operative constant scores. RESULTS: The Constant's score improved from a pre-operative mean of 14.8 (95% CI +8.8 to +19.8) to a post-operative mean of 60.9 (95% CI +50 to +66.2) with a P valve of <0.0001. CONCLUSION: Delta III prosthesis restores the function in shoulder affected by severe pain and dysfunction due to rotator cuff arthropathy. Inferior scapular notching in the post-operative radiographs was better visualised in abduction views compared with standard anteroposterior radiographs. Long-term follow-up is required to predict the effect of scapular notching.

Ten-year survivorship of rough-surfaced femoral stem with geometry similar to Charnley femoral stem.

The aim of this study is to review the 10-year results of 269 cemented total hip arthroplasties performed using the Harvard femoral stem with matte surface finish and Charnley stem-like geometry. This is a retrospective cross-sectional survivorship study. We retrospectively reviewed the results of 269 cemented total hip arthroplasties performed using the Harvard femoral stem in 257 patients (men/women 93:164, mean age 71.2 years) between 1990 and 1994. The median duration of follow-up for the surviving implants was 118 (range 60-129) months. Radiographs were reviewed to evaluate the type of osteoarthritis, cement mantle thickness, alignment of the components, presence of aseptic loosening, and radiolucent lines. Kaplan-Meier survival analysis and Cox proportional hazards analysis were performed to evaluate 10-year survival and the impact of various radiological parameters on the prosthesis survival respectively. Of the 248 eligible patients (260 hips), 6 patients (7 hips) were lost to follow-up, and 67 patients had died at the time of the study; 36 hips (35 patients) underwent revision surgery for aseptic failure (median duration 60 months, range 12-125 months), and 11 hips were revised for septic failure (median duration 24 months, range 10-53 months from the index procedure). The femoral component was revised in all patients, whereas the acetabular component was revised in 27 patients. Ten-year survival for the femoral and acetabular components using aseptic loosening (with and without revision surgery) as an end point was 77.5% (71.5%-83.5%) and 91.1% (87.2%-95%), respectively. Cox regression analysis did not reveal a statistically significant (P > 0.05) effect of various radiological parameters on survival rate. Our results demonstrate that the matte surface finish femoral component (with geometry similar to Charnley femoral component) has less satisfactory long-term survival rate.

Fatal haemorrhage following a low-energy fracture of the pubic ramus.

We report a case of fatal haemorrhage following a low-energy fracture of the pubic ramus in an 85-year-old woman.

Pain related to the psoas muscle after total hip replacement.

Residual pain after total hip replacement may be due to a number of causes both local to and distant from the hip. We describe pain related to the psoas muscle after total hip replacement in nine patients. All presented with characteristic symptoms. We describe the key features and management. Gratifying results were achieved with treatment. This diagnosis should be considered when assessing patients with pain after total hip replacement.

Health status in patients awaiting hip replacement for osteoarthritis.

BACKGROUND: Hip osteoarthritis is a major cause of pain and disability, especially in the elderly. As part of a study investigating factors that could be associated with advanced osteoarthritis of the hip, we compared the health status of patients awaiting arthroplasty for hip osteoarthritis with controls. We further investigated the interaction of hip osteoarthritis with other variables (age, gender, social class and concurrent pain) in relation to health status. METHODS: A case-control study was performed in two English health districts (Portsmouth and North Staffordshire) during 1993-1995. A total of 611 patients (210 men and 401 women) listed for hip replacement because of osteoarthritis over an 18-month period formed the case group and were compared with an equal number of controls selected from the general population and individually matched for age, gender and general practice. Cases and controls completed a structured interviewer-administered questionnaire, which included queries about their medical condition, occupation (from which a measure of social class was derived), and general health status using the SF36. RESULTS: Physical function (t=32.1, P<0.001), social function (t=16.8, P<0.001) and perceived general health (t=4.1, P<0.001) were worse in the case group, but energy/vitality and mental health showed little difference between cases and controls. Cases were more likely to report knee pain than controls, but case-control status was not associated with pain in the fingers or shoulders, or with social class. However, differences in physical and social function between cases and controls did vary with socio-demographic factors and concurrent knee pain status. CONCLUSION: Patients awaiting hip-replacement because of osteoarthritis were more likely to be restricted in their physical and social life than adults in the general population, but mental state and vitality appear unimpaired in this group. This contrasts with findings from other chronic pain disorders. Manual social class is not linked to being on a waiting list for osteoarthritic hip replacement but does add to the burden on health status, particularly social functioning in those with osteoarthritis of the hip.

Demonstration of cytokeratin in endothelial cells of the synovial microvasculature in situ and in vitro.

We have used a panel of anti-cytokeratin antibodies and immunofluorescence microscopy to examine synovial tissue from a variety of large and small joints in patients with various rheumatic conditions, including RA, OA, AS, pigmented villonodular synovitis (PVNS) and tenosynovitis (TS). In every case we regularly found blood vessels with endothelia which express cytokeratin. Positive staining was obtained with a guinea pig anti-keratin antibody, with monoclonal antibody 8.13 and with a monoclonal antibody specific for keratin 18. Staining of endothelial cells was confirmed by double labelling with antibodies to cytokeratin and factor VIII/von Willebrand factor. We also detected a polypeptide corresponding to cytokeratin 18 (MW 45,000) by Western blotting of synovial tissue. In addition we have isolated pure populations of synovial endothelial cells in culture and demonstrate an extensive cytokeratin intermediate filament network which co-localizes with vimentin filaments. An understanding of the role of the cytokeratin 18 network in synovial endothelium may be important for our understanding of endothelial changes in synovial disease.

Synovial sarcoma manifesting as a single joint flare in rheumatoid arthritis.

A 69-year-old female recently diagnosed as suffering from rheumatoid arthritis presented with a general flare-up of disease including a swollen left ankle. Investigation revealed the swelling to be due to a synovial sarcoma. This unusual cause should be considered in all cases of local joint flares in rheumatoid arthritis.

Carbon fibre composite bone plates. Development, evaluation and early clinical experience.

We compared the mechanical properties of carbon fibre composite bone plates with those of stainless steel and titanium. The composite plates have less stiffness with good fatigue properties. Tissue culture and small animal implantation confirmed the biocompatibility of the material. We also present a preliminary report on the use of the carbon fibre composite plates in 40 forearm fractures. All fractures united, 67% of them showing radiological remodelling within six months. There were no refractures or mechanical failures, but five fractures showed an unexpected reaction; this is discussed.

Retrospective analysis of plate fixation of diaphyseal fractures of the forearm bones.

A total of 133 fractures of the forearm bones treated by stainless steel plating have been reviewed. Technical error is the main cause of non-union. Although a union rate of 94.7 per cent was achieved, closer examination of the material shows that the stability of fixation is important in achieving early consolidation.

The shelf operation in the management of late presentation of congenital hip dysplasia.

Shelf operations performed on 24 patients (27 hips) for late presentation of congenital hip dysplasia were evaluated. The mean age at operation was 14 years 9 months and the mean follow-up 16 years 8 months. Two-thirds of the hips had good clinical results at follow-up. Patients operated on under the age of 20 years and with little or no radiological evidence of degenerative joint changes had the highest likelihood of success. The shelf operation was found to provide good cover of the femoral head and, should failure occur, also provides adequate superior support for the seating of an acetabular prosthesis.