Lateral trochanteric bursa repair improves early hip function after posterior approach total hip arthroplasty: a prospective randomized control trial.

BACKGROUND: The trochanteric bursa (TB) is an anatomic structure, which is dissected during posterior/lateral hip approaches in Total Hip Arthroplasty (THA). Some surgeons prefer to simply resect the bursa as they believe that it may be responsible for postoperative lateral trochanteric pain (LTP). Others advocate that this tissue acts as a buffer minimizing friction between soft tissue and bone, and therefore its repair may prevent LTP after THA. AIM: The purpose of this prospective randomized controlled trial was to compare the clinical results of either resecting or repairing the TB during posterior approach THA. METHODS: Forty-two patients with primary hip osteoarthritis undergoing THA via a posterior hip approach were randomly assigned to two groups; Group A, or TB resection group and Group B, or TB repair group. All patients in both groups were evaluated postoperatively in terms of hip function, measured by the Harris Hip Score (HHS), at 6 weeks, 3 months, 6 months, and 12 months after surgery, as well as LTP during daily routine activities and lying on the operative side. RESULTS: Forty patients completed the study. Postoperative difference in terms of leg length and femoral offset was similar among the two groups (P = 0.467 and P = 0.39, respectively). At 6 weeks, patients in Group B had higher HHS (P = 0.052) and experienced less LTP when lying on the operative side (P = 0.046) but not during activities (P = 0.759). Thereafter, all functional parameters measured had comparable values in both groups. Subgroup analysis failed to identify any correlation between high offset stems and LTP. CONCLUSION: TB repair in posterior approach THA improves hip functional recovery as well as patients' ability to lie on the operative side during the early postoperative period.

Lateral parapatellar approach with tibial tubercle osteotomy for the treatment of non-correctable valgus knee osteoarthritis: a retrospective clinical study.

BACKGROUND: The aim of this retrospective study was to evaluate the efficacy of a lateral parapatellar approach combined with a tibial tubercle osteotomy (TTO) in patients undergoing total knee arthroplasty (TKA) with non-correctable valgus knee osteoarthritis. METHODS: We studied 53 consecutive patients (57 knees) who had a primary TKA via lateral parapatellar approach with a global step-cut "coffin" type TTO over a 10-year period. All patients had non-correctable grade II valgus deformity according to the Ranawat classification. The average age of patients was 71 years (45 to 77) and the mean follow-up was 39 months (20 to 98). RESULTS: Post-surgery, there was a significant improvement in knee extension (p=0.002), flexion (p=0.006), Knee Society Pain and Function Scores (p<0.001) and WOMAC Osteoarthritis Index (p<0.001). The tibiofemoral angle changed from a preoperative median value of 11 deg (10 to 17) to a postoperative value of 3.75 deg (0 to 9). Congruent patellar tracking was observed in all cases. All but one osteotomy united in a median period of 16.7 weeks (9 to 28) and no hardware removal was required. One knee developed infection treated with two-stage reconstruction. A proximal tibial stress fracture also occurred in a patient on long-term bisphosphonate therapy. CONCLUSION: Lateral parapatellar approach along with TTO is an effective technique for addressing non-correctable valgus knee deformity during TKA.

Ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty.

PURPOSE: To compare the use of ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty (TKA) in terms of efficacy and safety (lack of toxicity). METHODS: 14 men and 26 women aged 58 to 77 (median, 70) years who had the American Society of Anesthesiologists (ASA) grades I to III physical status were randomised to receive ropivacaine (n=20) or bupivacaine (n=20) of a concentration of 0.5% for 3-in-1 block during TKA. The dosage was 0.5 ml/kg. In addition, a sciatic nerve block (20 ml of prilocaine 1%) was used. The onset of the block, duration of postoperative analgesia, level of motor block, and any side-effects were compared. RESULTS: The median time to onset of block was significantly shorter in those receiving ropivacaine than bupivacaine (13 vs. 17.5 minutes, p<0.001), but the levels of motor blockade were not significantly different (p=0.355). Complete analgesia was achieved throughout the procedure. There was no significant difference between the ropivacaine and bupivacaine groups in terms of the mean duration of analgesia (398 vs. 367 minutes, p=0.62), the mean VAS scores at all time points, and the mean total morphine consumption. One patient in the ropivacaine group developed a joint haematoma and 2 patients in the bupivacaine group had excessive wound drainage. Both conditions resolved after antibiotic use. CONCLUSION: Ropivacaine and bupivacaine showed similar anesthetic and analgesic effects, but the former had a significantly faster onset time.

Pulsed electromagnetic fields for the treatment of tibial delayed unions and nonunions. A prospective clinical study and review of the literature.

BACKGROUND: Pulsed electromagnetic fields (PEMF) stimulation for the treatment of bone nonunion or delayed union have been in use for several years, but on a limited basis. The aim of this study was to assess the overall efficacy of the method in tibial delayed unions and nonunions and identify factors that could affect the final outcome. METHODS: We prospectively reviewed 44 patients (27 men) with a mean age of 49.6 ± 18.4 years that received PEMF therapy due to tibial shaft delayed union or nonunion. In all cases, fracture gap was less than 1 cm and infection or soft tissue defects were absent. RESULTS: Fracture union was confirmed in 34 cases (77.3%). No relationship was found between union rate and age (p = 0.819), fracture side (left or right) (p = 0.734), fracture type (simple or comminuted, open or closed) (p = 0.111), smoking (p = 0.245), diabetes (p = 0.68) and initial treatment method applied (plates, nail, plaster of paris) (p = 0.395). The time of treatment onset didn't affect the incidence of fracture healing (p = 0.841). Although statistical significance was not demonstrated, longer treatment duration showed a trend of increased probability of union (p = 0.081). CONCLUSION: PEMF stimulation is an effective non-invasive method for addressing non-infected tibial union abnormalities. Its success is not associated with specific fracture or patient related variables and it couldn't be clearly considered a time-dependent phenomenon.

The use of nanotechnology in tendon regeneration and repair.

Tendon injuries are common and due to their limited capacity for self-healing, the biomechanical and functional properties of healed tendon are usually inferior to normal tissue. Tissue engineering offers the hope of regenerating tendon tissue with the same biomechanical properties of the native undamaged tissue by augmenting the regenerative process of in vivo tissue or producing a functional tissue in vitro that can be implanted into the defective tendon site. Current research on tendon tissue engineering has focused on the role of stem cell and tendon derived cell therapy, scaffolds, chemical and physical stimulation and gene-therapeutic approaches. In this review we review the important functional anatomy and pathomechanics of tendon injury and discuss the current advances in tendon tissue engineering.

Long-term results of posterior-cruciate-retaining Genesis I total knee arthroplasty.

BACKGROUND: Long-term results of Genesis I modular total knee system are not well known. METHODS: We analyzed data from 345 patients with 393 primary total knee arthroplasties (TKA) using the Genesis I prosthesis. In all cases, the posterior cruciate ligament (PCL) was retained, and the patella was not resurfaced. The minimum follow-up was 10 (range 10-16) years. RESULTS: Preoperative range of motion improved from 89° preoperatively to 105° at the time of the most recent follow-up (p < 0.001). Mean preoperative Knee Society pain and function scores increased from 29 and 25 points to 91 and 85 points, respectively (p < 0.001). Tibiofemoral angle shifted from 2.40° of varus before to 4.8° of valgus after the operation (p < 0.001). Early postoperative complications occurred in 34 knees (8.6%). Manipulation under general anesthesia was done in six knees (1.5%). Nonprogressive radiolucent lines were seen around the femoral component in 16 knees (4%) and at the tibial bone-cement interface in 101 knees (25%). However, in only five cases (1.3%) was there significant progression leading to implant loosening and revision surgery. Eight more revisions were performed due to infection (three knees), stiffness (three knees), excessive wear and fracture of polyethylene liner (one knee), and instability (one knee). The overall survivorship of knee replacement reached 96.7%. CONCLUSIONS: In the long term (up to 16 years), PCL-retaining Genesis I total knee prosthesis is associated with good functional outcomes and low failure rates.

External fixation for stable and unstable intertrochanteric fractures in patients older than 75 years of age: a prospective comparative study.

OBJECTIVE: External fixation has been advocated as an alternative treatment method of intertrochanteric fractures in elderly and high-risk patients. However, the efficacy of the technique in all fracture types has not been clearly defined. The null hypothesis of this study was that external fixation showed equal results in either stable or unstable intertrochanteric fractures in patients older than 75 years of age. DESIGN: Prospective comparative study. SETTING: Level I trauma center. PATIENTS: Between July 2006 and June 2007, 100 patients older than 75 years of age (mean, 82.3 ± 5.2 years) and American Society of Anesthesiologists 3 or 4 who sustained an isolated intertrochanteric fracture met the inclusion criteria for the study. The patients were followed up at regular intervals until 1 year postoperatively. INTERVENTION: All fractures were stabilized with external fixation under epidural anaesthesia. The patients were divided in two groups according to the Orthopaedic Trauma Association classification system for intertrochanteric fractures. Types A1.1, A1.2, A1.3, and A2.1 fractures were considered stable (Group A) and Types A2.2, A2.3, A3.1, A.3.2, and A.3.3 unstable (Group B). Fifty patients were collected in each group. MAIN OUTCOME MEASUREMENTS: Operation and hospitalization time, union time, complication rate, Harris hip score, and patients' walking status were evaluated. RESULTS: The median operative time was 17 minutes (range, 15-50 minutes) in Group A and 21.5 minutes (range, 15-60 minutes) in Group B (P < 0.001). The median hospitalization time was 5 days (range, 2-11 days) in Group A and 7 days (range, 4-17 days) in Group B (P < 0.001). The average union time was 11.24 ± 1.66 weeks (range, 9-16 weeks) for Group A and 14.1 ± 1.63 weeks (range, 10-17 weeks) for Group B (P < 0.001). The overall complication rate was 8% for the stable fractures and 26% for the unstable fractures (P = 0.03). The rate of varus collapse in unstable fractures was 11%. The median Harris hip score was 75 points (range, 28-100) in Group A and 68 points (range, 25-99) in Group B (P = 0.006). No difference was found between groups in terms of mortality (P = 0.913) or walking status (P = 0.736). CONCLUSION: External fixation for the treatment of Orthopaedic Trauma Association Types A2.2, A2.3, A3.1, A.3.2, and A.3.3 intertrochanteric fractures in the elderly was associated with prolonged union time, increased incidence of varus position of the fracture site, and inferior functional outcome. Therefore, it should be used with caution in the geriatric population with an unstable intertrochanteric fracture.

Giant cell tumour of tendon sheath of the digits. A systematic review.

BACKGROUND: We reviewed the literature to evaluate the demographic, clinical and histological profile of giant cell tumour of tendon sheath of the digits (GCTTSD). The overall recurrence rate and the factors affecting tumour recurrence were also assessed. METHODS: We searched for published articles regarding the GCTTSD in the English literature the last 30 years using the PubMed search engine. All retrieved papers were analysed and their reference lists were also screened if relevant. Clinical studies with less than five patients and follow-up less than 2 years were excluded from further evaluation. For each report, information was gathered related to trial characteristics and study population. Location and multicentricity of lesions, kind and severity of symptoms, type of applied treatment modality and histopathological features of the excised tumours were additionally recorded. A meta-analysis for estimating the pooled recurrence rate after surgical excision was also conducted. Statistical significance was assumed for p ≤0.05. RESULTS: We found 21 studies with histological confirmation of GCTTS. However, only 10 studies including 605 patients were reviewed according to selection criteria (average follow-up 36.7 to 79 months). The male-to-female ratio was 1:1.47 (p < 0.005) and the mean age ranged from 32 to 51 years. Pain or sensory disturbances reported only in 15.7% and 4.57% of cases, respectively. A definite history of trauma recorded in 5% of lesions. The most frequent tumour location was the index finger (29.7%). In total, 14.8% of patients had tumour recurrence. Type I tumours (single lesions) were more frequently detected (78.7%) than type II tumours (two or more distinct tumours that were not joined together) (21.3%) but the latter were associated with a higher recurrence rate (p < 0.001). Study design also affected the possibility of recurrence as it was lower in prospective studies compared to retrospective studies (p = 0.003). Even though bone erosion was detected in 28.39%, recurrence was not more common in this group. In addition, recurrence was not significantly associated with a specific finger or phalanx. CONCLUSIONS: Intrinsic biology of the tumour seems to play a more fundamental role in recurrence than tumour location or local invasiveness. More prospective well-designed studies including a large number of cases are necessary to identify tumours prone to recurrence and determine the proper treatment protocol for each individual patient.

Reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. Can we expect an optimum result?

The need for reaming and the number of locking screws to be used in intramedullary (IM) tibial nailing of acute fractures as well as routine bone grafting of tibial aseptic nonunions have not been clearly defined. We describe the results of reamed interlocked IM nails in 233 patients with 247 tibial fractures (190 closed, 27 open and 30 nonunions). Ninety-six percent of the fractures were united at review after an average of 4.9 years. No correlation was found between union and nail diameter (P = 0.501) or the number of locking screws used (P = 0.287). Nail dynamization was effective in 82% of fractures. Locking screw(s) breakage was associated with nonunion in 25% of cases. Bone grafting during IM nailing was found not to increase the healing rate in tibial nonunions (P = 0.623). None of the IM nails were removed or revised due to infection. A dropped hallux and postoperative compartment syndrome were found in 0.8 and 1.6% of cases, respectively. Anterior knee pain was reported in 42% of patients but nail removal did not alleviate the symptoms in almost half. This series confirms the place of reamed intramedullary nailing for the vast majority of tibial diaphyseal fractures. It provides an optimum outcome and minimizes the need for supplementary bone grafting in aseptic nonunions.

Aspiration alone versus aspiration and bupivacaine injection in the treatment of undisplaced radial head fractures: a prospective randomized study.

HYPOTHESIS: Some physicians advocate that aspiration of elbow joint hematoma in radial head fractures is helpful not only for determining a mechanical block to motion from a fracture fragment but also for improving the elbow motion and pain. However, the supplementary role of intra-articular anaesthetic injection is unclear. MATERIALS AND METHODS: In this prospective randomized study, 40 patients with undisplaced radial head fractures (Mason I) were treated with elbow joint aspiration alone (20 patients) or aspiration plus intra-articular injection of 3 mL of bupivacaine 0.5% (20 patients). Active elbow exercises were immediately commenced. The patients were evaluated at 1 day, 1, 3, and 6 weeks, 3 and 6 months, and 1 year. RESULTS: No difference was found in terms of range of motion, pain and elbow function between the 2 groups in all the examined time points. The improvement in the above parameters achieved a plateau at 3 weeks in both groups. DISCUSSION: Intra-articular use of local anaesthetic after joint aspiration does not offer any benefit over aspiration alone in the treatment of undisplaced radial head fractures and its routine application is not supported by the clinical data.

Acute management of clavicle fractures. A long term functional outcome study.

The purpose of this study was to evaluate the long-term results after acute treatment of clavicle fractures. We reviewed 139 patients with an average age of 39.3 years (range: 18 to 74) who sustained a clavicle fracture either isolated or as part of a polytrauma. Besides demographic data, both clinical result and residual symptoms were also recorded. The average follow-up was 7.2 years (range: 4 to 13). The fracture showed a higher prevalence in young men and older women. The most frequent mechanism of injury was a fall (39.6%) and coexisting injuries were found in 12.9% of patients. Conservatively treated fractures united in 96.9% of cases and the time to union was no different with a sling or figure-of-eight bandage. Fracture location did not influence the functional outcome. One third of patients were still complaining of mild pain and discomfort during overhead activities and polytrauma patients had a lower Constant score.

One-stage shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus.

We report a case of 1-stage ipsilateral shoulder and elbow arthroplasty after comminuted fractures of both joints in a 77-year-old woman. The postoperative course was uneventful, and the patient showed prompt functional improvement and a good clinical result. Despite the higher risk of periprosthetic humeral fracture in cases of ipsilateral shoulder and elbow arthroplasty, the 1-stage procedure may be a promising and reliable solution for the treatment of complex upper limb fractures in elderly inactive patients.

Is tension band wiring technique the "gold standard" for the treatment of olecranon fractures? A long term functional outcome study.

BACKGROUND: Tension band wiring (TBW) remains the most common operative technique for the internal fixation of olecranon fractures despite the potential occurrence of subjective complaints due to subcutaneous position of the hardware. Aim of this long term retrospective study was to evaluate the elbow function and the patient-rated outcome after TBW fixation of olecranon fractures. METHODS: We reviewed 62 patients (33 men and 29 women) with an average age of 48.6 years (range, 18-85 years) who underwent TBW osteosynthesis for isolated olecranon fractures. All patients were assessed both clinically with measurement of flexion-extension and pronation-supination arcs and radiologically with elbow X-Rays. Functional outcome was estimated using the Mayo Elbow Performance Score (MEPS), Visual Analogue Scale (VAS) subjective pain score and VAS patient satisfaction score. Follow up: 6-13 years (average 8.2 years). RESULTS: There was a higher prevalence of fractures among men until the 5th decade of life and among women in elderly (p = 0.032). Slip or simple fall onto the arm was the main mechanism of injury for 38 fractures (61.3%) while high energy trauma, such as fall from a height (> 2 m) or road accident, was reported in 24 fractures (38.7%). Hardware removal performed in 51 patients (82.3%) but 34 of them (66.6% of removals) were still complaining for mild pain during daily activities. The incidence of pin migration and loosening was not statistically decreased when penetration of the anterior ulnar cortex was accomplished (p = 0.304). Supination was more often affected than pronation (p = 0.027). According to MEPS, 53 patients (85.5%) had a good to excellent result, 6 (9.7%) fair and 3 (4.8%) poor result. The average satisfaction rating was 9.3 out of 10 (range, 6-10) with 31 patients (50%) to remain completely satisfied from the final result. Degenerative changes recorded in 30 elbows (48.4%). However, no correlation could be found between radiographic findings and MEPS (p = 0.073). CONCLUSION: Tension band wiring fixation remains the "gold standard" for the treatment of displaced and minimally comminuted olecranon fractures. In long term, low levels of pain may be evident regardless of whether the metalware is removed and degenerative changes have been developed.

Has the management of shoulder dislocation changed over time?

Anterior shoulder dislocation is a disabling injury affecting all ages, young and old alike. Recently, the treatment of traumatic shoulder dislocation has included immobilisation for varying periods of time followed by physiotherapy. This study is the first in this country to address the demographic data and recurrence rates of shoulder dislocation. Three hundred and eight patients (170 men and 138 women) were followed up for an average of 5.9 years. The most frequent mechanism of injury was a fall (65.66% of cases), and in 92.1% of the patients, the shoulder was reduced in the Emergency Department without the need for sedation or general anaesthesia. The overall recurrence rate in all ages was 50%, but rose to 88.9% in the 14-20-year age group. The duration of immobilisation did not affect the rate of re-dislocation of the humeral head. We believe that conventional shoulder immobilisation in a sling offers no benefits, and it would be preferable not to immobilise the shoulder at all.