Total hip arthroplasty using a short-stem prosthesis: restoration of hip anatomy.

PURPOSE: To evaluate hip parameters such as vertical centre of rotation (VCR), horizontal centre of rotation (HCR), femoral offset, and leg length after total hip arthroplasty (THA) using the Nanos short-stem prosthesis. METHODS: Medical records of 73 men and 74 women aged 25 to 92 (mean, 63) years who underwent THA using the Nanos short-stem prosthesis by a single surgeon were reviewed. Prior to the surgery, the optimal cup and stem size, head length, and level of the neck osteotomy were determined using radiographs. Intra-operatively, the leg length and femoral offset were checked, and the level of neck resection and head length were adjusted. VCR, HCR, femoral offset, and leg length of the operated and contralateral sides were compared. Functional outcomes were assessed using the Harris Hip Score (HHS). RESULTS: Compared with the normal contralateral hips, the operated hips had a mean increase of 0.4 mm in VCR (p=0.032), a mean decrease of 1.4 mm in HCR (p=0.027), a mean increase of 0.6 mm in femoral offset (p=0.043), and a mean increase of 0.36 mm in leg length (p=0.035). For these respective parameters, the difference between the normal contralateral side and the operated side was within 5 mm in 89%, 80%, 71%, and 96% of patients. The HHS improved from a mean of 53 to 91 at one year (p<0.001). CONCLUSION: THA using the Nanos short-stem prosthesis enabled restoration of hip anatomy (VCR, HCR, femoral offset, and leg length).

Radiographic outcome of limb-based versus knee-based patient specific guides in total knee arthroplasty.

BACKGROUND: Patient specific guides (PSG's) were developed to improve overall component alignment in total knee arthroplasty (TKA). The aim of this study was to undertake a comparative radiographic study of two commonly used PSG and determine whether the radiographic technique used to construct the PSG had a significant effect on overall alignment. METHODS: This prospective cohort study examined the accuracy of limb-based (n=112) versus knee-based (n=105) MR PSG in restoring the mechanical axis in three planes according to post-operative Perth CT scan protocol. RESULTS: Limb-based MR and knee-based MR PSG systems both restored overall hip-knee-ankle angle (HKAA), femoral coronal alignment, tibial coronal alignment, femoral sagittal alignment, tibial sagittal alignment and femoral rotation alignment to within 3° of a neutral mechanical axis with similar precision (91.1% vs. 86.7% p=0.30, 97.3% vs. 96.2% p=0.63, 97.3% vs. 97.1% p=0.94, 94.6% vs. 89.4% p=0.16, 90.2% vs. 81.0% p=0.05, 91.1% vs. 86.7% p=0.30, respectively). However, when the secondary outcome measure of alignment within 2° was assessed, limb-based MR PSG restored HKAA, femoral coronal and tibial sagittal alignment with greater precision than knee-based MR PSG (73.2% vs. 64.8% p=0.016, 93.8% vs. 80.8% p=0.004 and 82.1% vs. 62.9% p=0.001, respectively). CONCLUSIONS: The findings of this study recommend the use of limb-based MR PSG for improved precision in the restoration of neutral mechanical alignment over knee-based MR PSG in TKA. LEVEL OF EVIDENCE: Therapeutic level III.

Prospective randomized trial comparing open reduction and internal fixation with minimally invasive reduction and percutaneous fixation in managing displaced intra-articular calcaneal fractures.

PURPOSE: Managing displaced intra-articular calcaneal fractures remains controversial. A prospective randomised trial was undertaken to compare open reduction and internal fixation (ORIF) with minimally invasive reduction and percutaneous fixation (MIRPF). METHODS: Forty-five displaced intra-articular calcaneal fractures were randomised to undergo either ORIF (n = 23) or MIRPF (n = 22). Patients were followed up clinically and radiologically for a minimum of one year postoperatively. The primary outcome measure was wound-healing complication. Functional outcome was assessed using Creighton Nebraska Health Foundation (CNF) scale, and radiological outcome was assessed using plain radiographs and computed tomography (CT) scans. RESULTS: Of the 23 heels in the ORIF group, seven (30%) had wound-healing problems, compared with none in the MIRPF group (p = 0.005). There was no statistically significant difference in radiological outcomes between groups, as measured by Böhler's angle, Gissane's angle and Score Analysis of Verona (SAVE). Median time to return to work was two weeks earlier (p = 0.004), and the functional outcome score (CNF scale) at one year of follow-up was better (p = 0.013) following MIRPF compared with ORIF. CONCLUSION: MIRPF is associated with fewer wound-healing problems, better functional outcome and earlier return to work compared with ORIF.

A multi-planar CT-based comparative analysis of patient-specific cutting guides with conventional instrumentation in total knee arthroplasty.

Patient specific guides (PSGs) are postulated to improve the alignment of components in total knee arthroplasty. Three hundred consecutive total knee arthroplasties performed with either conventional (CON) (n = 185) or Visionaire PSG (n = 115) were evaluated with a CT protocol for coronal limb alignment, coronal and sagittal alignment of individual components and femoral component rotation. There was no statistically significant difference between the two groups in any of the above parameters. In addition, no difference was found in total operative time. PSGs do not offer any benefit over conventional guides in terms improving the coronal alignment of the limb or alignment of individual components.

Role of vascular endothelial growth factor as a tumour marker in osteosarcoma: a prospective study.

PURPOSE: A prospective study was undertaken to evaluate the diagnostic and prognostic significance of serum levels of vascular endothelial growth factor (VEGF) in patients with primary localised osteosarcoma. METHODS: Serum VEGF levels were measured by an enzyme-linked immunosorbent assay (ELISA) in blood samples collected prechemotherapy, postchemotherapy, and postsurgery in 40 patients with histologically proven primary osteosarcoma. Comparison was made between serum VEGF level of healthy controls (n = 10) and prechemotherapy patient sera to evaluate its diagnostic potential. Serum VEGF levels of patients with and without metastasis were compared. Immunohistochemical staining was done to establish the correlation between serum and tissue VEGF expression. The Kaplan-Meier curve was used for survival analysis RESULTS: No significant relationship was observed between serum VEGF levels and age, gender, tumour size, local recurrence or histopathological subtypes of osteosarcoma. We observed significantly raised mean serum VEGF in patient sera compared with healthy controls (p = 0.001). Significant fall in mean serum VEGF level was observed following chemotherapy (p = 0.001). Patients who developed metastases had significantly higher serum VEGF levels compared with the nonmetastatic group (P = 0.001). Serum VEGF levels correlated well with VEGF expression in tissues. CONCLUSION: Serum VEGF levels might prove to be of diagnostic, predictive and prognostic value in patients with primary osteosarcoma, although further studies with larger sample size and longer follow-up is needed to support the hypothesis.

Hip resurfacing arthroplasty in inflammatory arthritis a 3- to 5-year follow-up study.

The success of hip resurfacing in younger patients with primary osteoarthritis has paved the way for the trial of the procedure in patients with secondary osteoarthritis of the hip. We retrospectively reviewed the clinical and radiologic results in a cohort of 23 patients (32 hips) with inflammatory arthritis who were chosen for hip resurfacing after normalizing vitamin D levels and ruling out proximal femoral osteopenia using dual-energy x-ray absorptiometry. At a minimum follow-up of 3 years, there was failure in only 1 hip due to fracture of the femoral neck attributable to osteonecrosis of the remnant head. The clinical outcome was evaluated using Harris hip score and was found to be good to excellent in 30 of 31 hips. Hip resurfacing is a promising alternative in carefully chosen patients with inflammatory arthritis.

Nail patella syndrome: a rare cause of renal failure in a young adult.

Nail Patella Syndrome (NPS) is a rare hereditary disease affecting multiple systems with predominant involvement of Kidney, Bones and Nails and Eyes. We report a case of NPS which presented as renal failure in a 22 year old male. The patient was admitted with decreased urine output and features of fluid overload and was being evaluated for renal failure. Physical examination revealed associated bony deformities which raised the suspicion of NPS as a possible etiology. This was confirmed by the radiological evaluation which showed the classical features of NPS. Though NPS is a rare clinical condition, physicians should complete knowledge about the components of NPS for appropriate diagnosis and for early detection of other systems involvement.

Outcome of short proximal femoral nail antirotation and dynamic hip screw for fixation of unstable trochanteric fractures. A randomised prospective comparative trial.

A prospective, randomised, controlled trial was performed to compare the outcome of treatment of unstable trochanteric fractures with either a short proximal femoral nail antirotation (PFNA) or dynamic hip screw (DHS). Eighty one patients with unstable fracture of the proximal part of the femur were randomised, at the time of admission, for fixation with either a short PFNA (n=42) or DHS (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Clinical and radiological follow-up was undertaken for a minimum of 36 months. Any changes in the position of the implant or fixation failure were recorded. Hip range of motion, pain in the hip or thigh and return to work were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. The mean operative time was significantly less in PFNA group (25 min) than in the DHS group (38 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. Six patients in DHS group had implant failure while none experienced this in PFNA group. The PFNA group had a better functional outcome than the DHS group.

Ilizarov hip reconstruction in skeletally mature young patients with chronic unstable hip joints.

PURPOSE: Hip reconstruction with subtrochanteric valgus extension pelvic support osteotomy and distal femoral osteotomy for lengthening and varus correction is one of the options available for salvage of chronic unstable hips and is also known as Ilizarov hip reconstruction (IHR). This study evaluated the outcomes and complications associated with IHR in skeletally mature young patients. METHODS: Twelve patients (7 males, 5 females) with a mean age of 23 years underwent IHR for chronically dislocated hips due to various causes. Preoperative clinical and radiological evaluations were used to determine the site of osteotomies and the required angulations. Postoperatively the patients were followed up clinically and radiologically for a minimum of 36 months. Ilizarov fixator was removed when adequate lengthening was achieved and there was radiological evidence of union. Harris Hip Score was used to document hip function preoperatively and at final evaluation. RESULTS: Significant improvements occurred in limb length discrepancy (LLD) 5.11 cm preoperatively to 0.9 cm at final evaluation, Harris Hip Score 44.33 points preoperatively to 70.83 points (p < 0.0001) at final evaluation. Trendelenberg sign disappeared completely in nine patients and was delayed in three at final evaluation. The abduction at the hip increased from the preoperative mean of 12.08° (range 0°-25°) to 22.5° (range 15°-35°) postoperatively. The fixed flexion deformity at the hip decreased from 22° (range 10°-35°) preoperatively to 3° postoperatively (range 0°-10°). The amount of free flexion at the operated hips decreased from the preoperative mean of 88.33° (range 70°-120°) to 70.42° (range 45°-105°) at final follow up. The mean fixator interval was 7.33 months (5-12 months) and the mean follow up duration was 59.4 months (38-86 months). CONCLUSIONS: IHR is effective in improving the hip biomechanics, correcting the LLD and eliminating the Trendelenberg sign. Lengthy period of fixator wear, knee stiffness and pin tract infections, though minor are known limitations of this procedure.

Anterior cruciate ligament reconstruction using the medial third of the patellar tendon.

PURPOSE: To evaluate the mid-term outcome of anterior cruciate ligament (ACL) reconstruction using the medial third of the patellar tendon as the bone-patellar tendon-bone (BPTB) graft. METHODS: 79 men (34 right knees and 45 left knees) aged 20 to 52 (mean, 28) years underwent ACL reconstruction using the medial third of the patellar tendon with bone plugs and were followed up for a minimum of 3 years. Stability was assessed using the Lachman test and the pivot shift test. The range of motion, donor-site symptoms, Lysholm knee score, and International Knee Documentation Committee (IKDC) score were also recorded. RESULTS: In terms of stability, only 4 patients had a grade-2 laxity postoperatively, compared to all having a grade-2 or -3 laxity preoperatively. Regarding the range of motion, extension loss was <3º in 76 patients and 3º to 5º in 3, whereas flexion loss was <5º in 73 patients, 5º to 15º in 5, and 16º to 25º in one. No patient had patellar tendon rupture/shortening, patellar fracture, or patellar maltracking. The mean Lysholm knee score improved from 48 to 92 (p<0.0001); scores were excellent (>90) in 46 patients and good (83-90) in 32 patients. The overall IKDC score was grade A (normal) in 9 patients, grade B (near normal) in 66, and grade C (abnormal) in 4. Three of the latter patients had osteoarthritic changes and pain on minimal physical activity. Only one patient had a sensation of partial giving way during moderate physical activity. 20% of the patients had anterior knee pain. CONCLUSION: Outcome of ACL reconstruction using the medial third of the patellar tendon was comparable to that using the central third of the patellar tendon. In addition, there were no instances of patellar tendon rupture/shortening, patellar fracture, or patellar maltracking.

Giant lipoma: an unusual cause of carpal tunnel syndrome.

Carpal tunnel syndrome, in its idiopathic form, is an extremely common entrapment neuropathy in the clinical practice however secondary compressive causes are rare. Among secondary causes, tumors are even rarer. Although lipomas are the most common soft tissue tumor in the body, <5% of the benign tumors of the hand are lipomas. A 48-year old manual laborer man presented to us with a two-year history of numbness, tingling and burning pain in the palmar surface of the left hand and fingers along with a progressively increasing swelling in the hand and wrist. His medical history was unremarkable and no trauma episode was reported. According to the clinical examination and the result of median nerve conduction study (NCS) the diagnosis of carpal tunnel syndrome was established. Operative release of the transverse carpal ligament was subsequently performed along with excision of the lipoma using extensile open approach. Intraoperatively, median nerve and its digital branches were found to be stretched over the giant lipoma causing substantial compression to median nerve. Histopathological findings of the resected mass were consistent with lipoma. After two years the patient was pain-free without any sign of tumor recurrence. Lipomas are infrequently seen in hand and wrist, however giant lipoma as a cause of secondary carpal tunnel syndrome is even more rare, which makes this case interesting.