Fatty infiltration and muscle atrophy of the rotator cuff in stemless total shoulder arthroplasty: a prospective cohort study.

BACKGROUND: The influence of preoperative rotator cuff fatty infiltration (FI) and muscle atrophy (MA) on the postoperative outcome of total shoulder arthroplasty (TSA) has only rarely been investigated and reported in the literature. We hypothesized that more FI and MA would be associated with a worse postoperative functional outcome. METHODS: This prospective cohort study included 63 patients (31 female and 32 male patients; mean age, 71 years [range, 53-89 years; standard deviation, 7 years]) with primary osteoarthritis of the shoulder operated on with anatomic stemless TSA. Preoperatively and at 3 months and 1 year after the operation, the functional outcome (QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score) and range of motion (ROM) (goniometer) and strength (dynamometer) for abduction at the scapular plane and for external rotation were measured. The degree of preoperative FI and MA was evaluated using computed tomography scans according to the Goutallier classification and Warner classification, respectively, for the supraspinatus and infraspinatus. RESULTS: We found clinically and statistically significant improvements in functional outcome, strength, and ROM at both 3 months and 1 year of follow-up compared with those preoperatively. The Pearson correlation coefficient (r) showed significant correlations between preoperative supraspinatus and infraspinatus FI and MA and preoperative and 1-year postoperative shoulder abduction and external rotation strength but not ROM. However, we found no influence of the rotator cuff FI and MA on the functional outcome after TSA. CONCLUSION: We demonstrated a significant correlation between rotator cuff FI and MA and strength but not ROM of the shoulder joint.

Early results of Roto-glide joint arthroplasty for treatment of hallux rigidus.

BACKGROUND: Traditionally severe hallux rigidus is treated with arthrodesis. Recently arthroplasty has been used in order to retain motion at the metatarsophalangeal joint. AIM: To assess the early to mid-term functional and radiological outcomes in patients undergoing first metatarsophalangeal arthroplasty using the Rotoglide implant. MATERIALS AND METHODS: A prospective review was undertaken to assess functional and radiological outcomes of all patients undergoing an un-cemented three-component first metatarsophalangeal arthroplasty for hallux rigidus. Thirty four implants were performed in 28 patients over a 2-year period. Mean age was 60.5 years (range 45-77 years). Mean follow-up was 27.7 months (range 7-44 months). RESULTS: Mean AOFAS score improved from 41.2 pre-operatively to 89.1 at final follow-up (47.9; 95% CI=43.6-54.3; p<0.0001). The mean metatarsophalangeal (MTP) range of motion improved from 29.5° pre-operatively to 68.2° post-operatively (38.7; 95% CI=35.1-42.2; p<0.0001). The mean AOFAS pain scores improved from 8.8 preoperatively to 35.0 postoperatively (26.2; 95% CI=22.4-29.9; p<0.0001). Three patients required revision surgery. No radiological complications were observed in any other patients. CONCLUSIONS: This un-cemented prosthesis provides pain relief, while maintaining range of motion of the joint. The authors have observed clinically and statistically significant improvement in functional outcomes, with a low early complication rate and high patient satisfaction levels.

Shortening Scarf osteotomy for correction of severe hallux valgus. Does shortening affect the outcome?

BACKGROUND: Translation and shortening of Scarf osteotomy allows correction of severe hallux valgus deformity. Shortening may result in transfer metatarsalgia. AIM: To evaluate outcome of patients undergoing shortening Scarf osteotomy for severe hallux valgus deformities. MATERIALS AND METHODS: Fifteen patients (20feet, mean age 58 years) underwent shortening Scarf osteotomy for severe hallux valgus deformities. Outcomes were pre and postoperative AOFAS scores, IM and HV angles, patient satisfaction. RESULTS: Mean follow-up was 25 months (range 22-30). The IM angle improved from a median of 18.60 (range 13.4-26.20) preoperatively to 9.70 (range 8.0-13.70) postoperatively (8.9; 95% CI=7.6-10.3; p<0.001). The HV angle improved from a mean of 43.2 (range 27.4-68.2) preoperatively to 13.6 (range 3.0-37.4) postoperatively (29.6; 95% CI=26.1-33.2; p<0.001). The median AOFAS score improved from 29.2 (range 14-60) preoperatively to 82.2 (range 55-100) postoperatively (53.0; 95% CI=48.0-58.5; p<0.001). All patients rated their satisfaction as either satisfied or very satisfied. None had symptoms of transfer metatarsalgia at final follow-up. All osteotomies united. CONCLUSIONS: Shortening Scarf osteotomy is a viable option for treating severe hallux valgus deformities with no transfer metatarsalgia.

Sacroiliac joint fusion for low back pain: a systematic review and meta-analysis.

BACKGROUND CONTEXT: Although pain is generally regarded as originating in the lumbar spine, it has been estimated that in 15-30 % of patients, LBP originates from the sacroiliac joint (SIJ). PURPOSE: To determine whether sacroiliac joint fusion (SIJF) for LBP is effective in reducing pain when the SIJ is known to be the pain generator. STUDY DESIGN/SETTING: Systematic review and meta-analysis. METHODS: A systematic literature review and meta-analysis was performed of observational studies describing outcome of SIJF in patients with LBP. Outcome measures were VAS pain, ODI, SF-36 PCS/MCS and Majeed score. The following databases were searched: PubMed, Web of Science, Embase, Medline and Google scholar. The methodological quality of selected studies was assessed using the National Heart Lung and Blood Institute case series quality assessment tool. Meta-analysis was used to combine the studies for each outcome and forest plots were prepared. Outcomes were expressed as mean difference (MD). RESULTS: Six studies were included in the meta-analysis with a mean follow-up of 17.6 months. All outcomes showed statistical and clinical improvement (VAS pain MD: 54.8; 95 % CI 48.6, 61.0; n = 380; p < 0.001, ODI MD: 14.5; 95 % CI 8.4, 20.6; n = 102; p < 0.001, SF-36 PCS MD: -19.5; 95 % CI -24.7, -14.2; n = 140; p < 0.001, SF-36 MCS MD: -8.5; 95 % CI -12.9, -4.1; n = 198; p < 0.001 and Majeed score MD: -35.4; 95 % CI -48.5, -22.2; n = 140; p < 0.001). CONCLUSIONS: SIJF appears to be a satisfactory procedure for alleviating pelvic girdle pain.

Prevalence of insomnia in patients with chronic back pain.

PURPOSE: To estimate the prevalence of insomnia in patients with chronic back pain, and to correlate insomnia with severity of back pain and disability. METHODS: 63 women and 57 men aged 24 to 83 (mean, 55) years who presented with chronic back pain for >6 months were asked to complete a self-administered questionnaire to evaluate the Insomnia Severity Index (ISI), Oswestry Disability Index (ODI), and Numerical Rating Scale (NRS) for back pain. RESULTS: Of the 120 patients, 25 had no insomnia, 39 had sub-threshold insomnia, and 56 had clinically significant insomnia. According to the ODI, disability was minimal in 12 patients, moderate in 38, severe in 43, bed-binding in 26, and crippling in one. Of the 120 patients, 91 rated their NRS for back pain as 5 to 10 and 29 rated it as 1 to 4. Correlation was stronger between ISI and ODI than between ISI and NRS for back pain (r=0.59 vs. r=0.38). CONCLUSION: 47% of patients with chronic back pain had insomnia. The ODI was more reliable than the NRS for back pain to detect insomnia. Back pain should be treated early to avoid serious health problems associated with insomnia.

Effect of psychological status on outcome of posterior lumbar interbody fusion surgery.

STUDY DESIGN: Prospective longitudinal study. PURPOSE: To determine if preoperative psychological status affects outcome in spinal surgery. OVERVIEW OF LITERATURE: Low back pain is known to have a psychosomatic component. Increased bodily awareness (somatization) and depressive symptoms are two factors that may affect outcome. It is possible to measure these components using questionnaires. METHODS: Patients who underwent posterior interbody fusion (PLIF) surgery were assessed preoperatively and at follow-up using a self-administered questionnaire. The visual analogue scale (VAS) for back and leg pain severity and the Oswestry Disability Index (ODI) were used as outcome measures. The psychological status of patients was classified into one of four groups using the Distress and Risk Assessment Method (DRAM); normal, at-risk, depressed somatic and distressed depressive. RESULTS: Preoperative DRAM scores showed 14 had no psychological disturbance (normal), 39 were at-risk, 11 distressed somatic, and 10 distressed depressive. There was no significant difference between the 4 groups in the mean preoperative ODI (analysis of variance, p = 0.426). There was a statistically and clinically significant improvement in the ODI after surgery for all but distressed somatic patients (9.8; range, -5.2 to 24.8; p = 0.177). VAS scores for all groups apart from the distressed somatic showed a statistically and clinically significant improvement. Our results show that preoperative psychological state affects outcome in PLIF surgery. CONCLUSIONS: Patients who were classified as distressed somatic preoperatively had a less favorable outcome compared to other groups. This group of patients may benefit from formal psychological assessment before undergoing PLIF surgery.

A comparison of outcomes with and without a tourniquet in total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

A tourniquet is often used in total knee arthroplasty resulting in improved visualization of structures, reduced intraoperative bleeding and better cementation. The risks include deep vein thrombosis and pulmonary embolism. To quantify the case for or against tourniquet use, we carried out a systematic review and meta-analysis of selected randomized controlled trials. Ten studies were included in the meta-analysis. Of the 8 outcomes analyzed (surgery duration; total, intraoperative, and postoperative blood losses; deep vein thrombosis; pulmonary embolism; and minor/major complications), the total and intraoperative blood losses were less using a tourniquet. Minor complications were more common in the tourniquet group. The remaining outcomes showed no difference between the groups. Using a tourniquet may be beneficial, but long-term studies of outcome are needed.

Comparing the mid-vastus and medial parapatellar approaches in total knee arthroplasty: a meta-analysis of short term outcomes.

PURPOSE: Proponents of a mid-vastus (MV) approach for primary total knee arthroplasties (TKA) stress its importance in preserving function of the extensor mechanism with earlier rehabilitation and decreased prevalence of lateral release. We conducted a meta-analysis of randomised and quasi-randomised controlled trials to compare functional outcomes of the standard medial parapatellar (PP) and mid-vastus (MV) approaches in primary knee arthroplasties. METHODS: The study was conducted according to the guidelines described in the Cochrane Handbook for Systematic Reviews of Interventions. Methodological features were rated independently by two reviewers. RESULTS: We included 18 studies involving 1040 patients with mean age of 69 (SD ± 2.7) for the MV and 68.8 (SD ± 2.8) for the PP group. Using a MV approach led to significant improvement in flexion (mean difference (MD) 8.88, 95% confidence interval (CI) 4.50 to 13.25, P<0.01) and visual analogue scale score (MD -1.72 95% CI -2.08 to -1.36, P<0.01) in the first week postoperatively and reduced the number of required lateral releases (risk difference -0.16 95% CI -0.30 to -0.01, P=0.03) with no increase in complication rates. CONCLUSION: We conclude that the MV approach may provide an alternative to the standard PP approach with earlier rehabilitation and decreased lateral release rates in primary TKA and no increase in complication rates.

Space-time clustering analyses of type 1 diabetes in children from north-east England: support for an infectious aetiology?

BACKGROUND: The aetiology of type 1 diabetes in children is uncertain. A number of recent studies have suggested an infectious aetiology. It has been postulated that an infectious agent may be involved. Support for this hypothesis may be provided by a finding of space-time clustering. The aims of this study were: (i) to determine whether there was space-time clustering in cases of childhood diabetes from north-east England; and to test for differences in space-time clustering: (ii) due to age at diagnosis; (iii) between the sexes and (iv) between levels of residential population density. METHODS: We studied incidence of type 1 diabetes diagnosed in children aged 0-14 years and diagnosed during the period 1990-2007. All cases were resident in a defined geographical region of north-east England (Northumberland, Newcastle upon Tyne and North Tyneside). We applied a second-order procedure based on K-functions to test for global clustering. Locations were residential addresses at time of diagnosis. Tests were repeated using nearest neighbour thresholds to allow for variable population density, providing the primary result for each analysis. Differences between sexes and between levels of population density were assessed. RESULTS: We analysed 457 cases of type 1 diabetes. Overall, there was marginally significant evidence of global space-time clustering (P = 0.089). There was statistically significant clustering amongst pairs of cases that contained at least one female (P = 0.017), but not amongst pairs of cases that contained at least one male (P = 0.190). Furthermore, there was significant clustering amongst pairs of cases that contained at least one from a more densely populated area (P = 0.044), but not amongst pairs of cases that contained at least one from a less densely populated area (P = 0.226). CONCLUSION: Although the analyses have only found marginally significant evidence of global space-time clustering for cases of type 1 diabetes diagnosed in north-east England, there were two notable findings. First, there was evidence of clustering amongst females and secondly clustering was confined to cases from more densely populated areas. These findings are consistent with a possible aetiological involvement of an infectious agent.

Bioabsorbable fixation for Mitchell's bunionectomy osteotomy.

UNLABELLED: Although bioabsorbable pins have been used to successfully stabilize a wide range of osteotomies, to date there have been not published studies describing the results of their use for fixation of first metatarsal osteotomies in Mitchell's bunionectomy. The purpose of this retrospective investigation of 78 first metatarsal osteotomies was to evaluate the effectiveness of polydioxanone bioabsorbable pin fixation of the first metatarsal osteotomy in Mitchell's bunionectomy. The mean length of the first metatarsal preoperatively was 6.65 +/- 0.42 cm, and postoperatively it was 6.31 +/- 0.57 cm (P < .0001). The mean first IMA preoperatively was 17.59 degrees +/- 3.51 degrees , and postoperatively it was 9.91 degrees +/- 2.58 degrees (P < .0001). The mean HVA preoperatively was 29.74 degrees +/- 4.70 degrees , and postoperatively it was 12.89 degrees +/- 4.26 degrees (P < .0001). The average time to bony union was 6.01 +/- 0.61 weeks. There were 5 (6.41%) superficial wound infections that resolved with oral antibiotics, 1 (1.28%) deep-seated infection requiring surgical debridement, and 2 (2.56%) patients complained of transfer metatarsalgia. Five (6.41%) patients displayed persistent localized translucency at some portion of the osteotomy site on postoperative radiographs, and there were no cases of progressive osteolysis. In this series there were no complications related to pin fracture or failure of osteotomy fixation. Based on the results observed in this study, it appears that the use of polydioxanone bioabsorbable pins provides satisfactory stabilization of the first metatarsal osteotomy in Mitchell's bunionectomy, and was not associated with any serious complications. LEVEL OF CLINICAL EVIDENCE: 2.

Donor site morbidity following iliac crest bone harvesting for cervical fusion: a comparison between minimally invasive and open techniques.

We have studied the occurrence of donor site morbidity, cosmesis and overall satisfaction with graft procedure in 76 patients who had undergone iliac crest bone harvesting for anterior cervical discectomy and fusion (ACDF). Totally 24 patients underwent an open procedure and 52 a minimally invasive trephine harvesting method. Although our study demonstrated substantial donor site pain and its effect on ambulation in both groups, this was of limited duration. Two patients, one in each group, suffered long-term pain that was eventually resolved. Totally 8.3% of patients in the open group suffered minor complications and 11.5% in the trephine group. There were two cases of meralgia parasthetica. There were no major complications in either group. There was no statistically significant difference in morbidity between the open and trephine groups. There was a trend towards significance (P = 0.076) for pain at the donor site, with less pain reported by patients who underwent the trephine procedure for harvesting.

Incidence, etiology, classification, and management of neuralgia after posterior lumbar interbody fusion surgery in 226 patients.

BACKGROUND CONTEXT: Neurological symptoms are a well-recognized complication after posterior lumbar interbody fusion (PLIF) surgery. Concerns about this potential problem may deter surgeons from performing the procedure. PURPOSE: To determine the incidence, etiology, prevention, and management of neuralgia after PLIF surgery. STUDY DESIGN/SETTING: This study is a retrospective review of patients who underwent PLIF surgery at a university hospital in the north east of England. PATIENT SAMPLE: Two hundred sixty patients who met the inclusion criteria of degenerative disc disease, spondylolisthesis, disc herniation, and postlaminectomy/postdiscectomy syndrome underwent PLIF surgery. OUTCOME MEASURES: The outcome measure of neuralgia was assessed postoperatively by a subjective description of leg pain. Patients were considered to have post PLIF neuralgia if they complained of severe radiculopathy, which was not present before surgery. METHODS: During the study period April 1996 to April 2002, all patients who met the inclusion criteria underwent the PLIF procedure. Outcome was assessed postoperatively. In all but the first 20 cases, interbody cages were used. A subtotal superior facetectomy was performed on the first 103 patients. The subsequent 123 patients had a total removal of the superior facet. Autogenous bone and pedicle screws and plates were used in all cases. RESULTS: The study group comprised 226 patients (121 women, 105 men; mean age at surgery, 44.1 years; age range, 12-81 years). Duration of symptoms ranged from 5 to 480 months (mean, 90.6 months; median, 60.0). Overall, there were 16 cases of neuralgia in 226 patients (7.1%). In the subtotal facetectomy group, 10 of the 103 patients (9.7%) had neuralgic symptoms. In the total facetectomy group, 6 of the 123 patients (4.9%) had neuralgic symptoms. The difference in incidence was not statistically significant (p=.158). CONCLUSIONS: This study describes our experiences of post-PLIF neuralgia. It outlines strategies for prevention and management of the problem.

Cement leakage in percutaneous vertebroplasty: effect of preinjection gelfoam embolization.

STUDY DESIGN: Prospective case series. OBJECTIVES: To determine the safety and feasibility of routine preinjection of gelfoam embolization during percutaneous vertebroplasty. SUMMARY OF BACKGROUND DATA: Percutaneous vertebroplasty has been used effectively in pain relief for vertebral fractures resulting from malignancy and osteoporosis. However, cement extrusion is a common problem and can lead to complications. Gelfoam embolization of venous channels before cement injection has not been widely used as a technique to prevent leakage. METHODS: Thirty-one patients who met the inclusion-exclusion criteria for the study underwent percutaneous vertebroplasty. Venography was first performed to determine the flow pattern in the vertebrae and confirm needle placement. Next, routine gelfoam embolization of venous channels was performed. This was followed by low-pressure, minimal-volume cement injection. The outcome measure of cement leakage was assessed after surgery using radiographs and CT scans. RESULTS: There were no complications. In the 31 patients, 61 levels of vertebroplasty were performed. Overall, there were 16 leaks out of 61 levels in 12 patients (26.2%). In osteoporotic fractures, there were 11 leaks in 49 levels, giving a leakage rate of 22.5%. There was only 1 epidural leak in this group (2%), and this was asymptomatic. Seven leakages were into the adjacent disc, 2 into the body, and 1 into the paravertebral tissues. In malignant fractures, there were 5 leakages out of 12 levels (41.7%). Of these, 2 were epidural leaks (16.7%), which were asymptomatic. CONCLUSIONS: Complications resulting from leakage are the most feared side effect of the procedure. This has resulted in only limited application of vertebroplasty in the United Kingdom. Routine gelfoam embolization together with careful technique has been shown to be a safe and feasible method during vertebroplasty.