George C. Babis

An examination of the association between different morphotypes of femoroacetabular impingement in asymptomatic subjects and the development of osteoarthritis of the hip

We retrospectively examined the long-term outcome of 96 asymptomatic hips in 96 patients with a mean age of 49.3 years (16 to 65) who had radiological evidence of femoroacetabular impingement. When surveillance commenced there were 17, 34, and 45 hips with cam, pincer, and mixed impingement, respectively. Overall, 79 hips (82.3%) remained free of osteoarthritis for a mean of 18.5 years (10 to 40). In contrast, 17 hips (17.7%) developed osteoarthritis at a mean of 12 years (2 to 28). No statistically significant difference was found in the rates of development of osteoarthritis among the three groups (p = 0.43). Regression analysis showed that only the presence of idiopathic osteoarthritis of the contralateral diseased hip was predictive of development of osteoarthritis on the asymptomatic side (p = 0.039). We conclude that a substantial proportion of hips with femoroacetabular impingement may not develop osteoarthritis in the long-term. Accordingly, in the absence of symptoms, prophylactic surgical treatment is not warranted.

The Effectiveness of Isolated Tibial Insert Exchange in Revision Total Knee Arthroplasty

Background: Despite improvements in the design and manufacturing of the components used in total knee arthroplasty, wear of the polyethylene bearing remains a potential source of failure. One theoretical advantage of modular tibial implants is that, when the components are well fixed, patients with wear or instability of the tibial insert can be treated with isolated polyethylene exchange. The aim of this study was to assess the results of isolated tibial insert exchange during revision surgery in a relatively large, consecutive group of patients. Methods: From 1985 through 1997, we performed fifty-six isolated tibial insert exchanges in fifty-five patients (twenty-nine men [one man had bilateral revision] and twenty-six women; mean age, sixty-six years) primarily because of wear or instability. Patients with loosening of any of the components, a history of infection, severe stiffness of the knee, recognized malposition of any component, or problems with the extensor mechanism were excluded. Twelve knees had had one, two, or three prior revisions. The duration of follow-up averaged 8.3 years (range, 1.6 to 16.2 years) after the index arthroplasty and 4.6 years (range, two to fourteen years) after the revision. Results: The mean Knee Society knee and function scores improved from 56 and 50.9 points prior to the revision to 76 and 59 points at the time of final follopcow-up. Fourteen (25%) of the fifty-six knees subsequently required rerevision at a mean of only three years (range, 0.5 to 6.8 years) after the tibial insert exchange. The cumulative survival rate at 5.5 years was 63.5% (95% confidence interval, 14.4%, with nineteen patients remaining at risk). Of the twenty-seven knees with preoperative instability, eight were rerevised and another four were considered failures because of severe pain. Of the twenty-four knees that were treated with the index revision because of wear of the insert, five were rerevised. In addition, one extremity in this group was amputated above the knee as a result of chronic osteomyelitis of the ankle concomitant with chronic pain at the site of the total knee arthroplasty and another two inserts were considered failures because of severe pain. Conclusions: Isolated tibial insert exchange led to a surprisingly high rate of early failure. Tibial insert exchange as an isolated method of total knee revision should therefore be undertaken with caution even in circumstances for which the modular insert was designed and believed to be of greatest value.

Poor Outcomes of Isolated Tibial Insert Exchange and Arthrolysis for the Management of Stiffness Following Total Knee Arthroplasty

Background: Severe stiffness after total knee arthroplasty is a debilitating problem. In patients with securely fixed and appropriately aligned components, arthrolysis of adhesions and exchange to a thinner tibial polyethylene insert may appear to be a reasonable and logical solution. We reviewed our experience with this procedure to determine its efficacy. Methods: From 1992 through 1998, seven knees with marked stiffness after total knee arthroplasty were treated at our institution with arthrolysis of adhesions and conversion to a thinner tibial polyethylene insert. Only patients in whom the total knee prosthesis was well aligned, well fixed, and not associated with infection were included. There were five women and two men with a mean age at revision of sixty-one years (range, thirty-eight to seventy-four years). The average time to revision was twelve months, and the mean arc of motion prior to revision was 38.6° (range, 15° to 60°). The duration of follow-up after the insert exchange averaged 4.2 years (range, two to eight years). Results: Mean Knee Society pain and function scores changed from 44 and 36.4 points preoperatively to 39.6 and 46 points at the time of final follow-up. Two knees were rerevised, one because of infection and the other because of aseptic loosening of the components. The five remaining knees were painful and stiff at the time of final follow-up. Four of these five knees were severely painful, and one knee was moderately and occasionally painful. The mean arc of motion of these five knees was 58° (range, 40° to 70°) at the time of final follow-up. Conclusion: Isolated tibial insert exchange, arthrolysis, and débridement failed to provide a viable solution to the difficult and poorly understood problem of knee stiffness in a group of carefully selected patients following total knee arthroplasty. We therefore have little enthusiasm for the continued use of this strategy.

HYDATID DISEASE OF BONES AND JOINTS. 8 CASES FOLLOWED FOR 4-16 YEARS

Hydatid disease is a rare parasitic disease that seldom involves the skeleton. Treatment is difficult because of problems with the preoperative diagnosis, the invasive nature of the bony involvement and the variable anaphylactic reaction to the cyst fluid antigen. We present 8 cases with osseous hydatidosis who were treated over a period of 11 years. The spine was involved in 2 cases, the ilium in 2, the hip in 2, the tibia in 1 and the humerus in 1. We point out that diagnosis is difficult and the prognosis is often poor.

Private and public medicine: a comparison of quality perceptions

How do physicians and patients perceive the quality of medical services offered? Is this perception the same in the private and public sector? On the basis of a survey conducted in Greece on a 2 x 2 design with 20 respondents in each cell, several interesting characteristics were identified. Patients in the public sector attribute greater importance to resources of a medical and technical nature and do not seem particularly concerned about the contextual or environmental features of a hospital. Private patients are expecting a more holistic approach to their treatment and expect some attention to be directed to their emotional needs. Private surgeons are worried about the limited basic resources in private hospitals and their inability to satisfy the non-clinical needs of their patients. Important lessons may be drawn for policy makers in terms of priorities and resource allocation in.

Proximal femoral allograft-prosthesis composites in revision hip replacement: A 12-YEAR FOLLOW-UP STUDY

We report the use of an allograft prosthetic composite for reconstruction of the skeletal defect in complex revision total hip replacement for severe proximal femoral bone loss. Between 1986 and 1999, 72 patients (20 men, 52 women) with a mean age of 59.9 years (38 to 78) underwent reconstruction using this technique. At a mean follow-up of 12 years (8 to 20) 57 patients were alive, 14 had died and one was lost to follow-up. Further revision was performed in 19 hips at a mean of 44.5 months (11 to 153) post-operatively. Causes of failure were aseptic loosening in four, allograft resorption in three, allograft nonunion in two, allograft fracture in four, fracture of the stem in one, and deep infection in five. The survivorship of the allograft-prosthesis composite at ten years was 69.0% (95% confidence interval 67.7 to 70.3) with 26 patients remaining at risk. Survivorship was statistically significantly affected by the severity of the pre-operative bone loss (Paprosky type IV; p = 0.019), the number of previous hip revisions exceeding two (p = 0.047), and the length of the allograft used (p = 0.005).

Effect of Cementless Acetabular Component Orientation, Position, and Containment in Total Hip Arthroplasty for Congenital Hip Disease

We evaluated the effect of the inclination angle, position, and containment of 53 cementless cups inserted in patients with congenital hip disease (CHD), after a minimum of 10 years of follow-up. The polyethylene wear rate was significantly greater when the cup was placed in more than 45° inclination (P=.045) or if the cup was placed lateral to the teardrop position by more than 25 mm (P=.001). Aseptic loosening of the femoral component was significantly greater when the cup was placed more than 25 mm superiorly to the teardrop (P=.049). Cup placement of more than 25 mm lateral to the teardrop affected significantly periacetabular osteolysis (P=.032). In CHD cases, it is preferable to avoid excessive vertical inclination, lateral, and superior placement of cementless cups in an attempt to obtain better containment.

High energy tibial plateau fractures treated with hybrid external fixation.

Management of high energy intra-articular fractures of the proximal tibia, associated with marked soft-tissue trauma, can be challenging, requiring the combination of accurate reduction and minimal invasive techniques. The purpose of this study was to evaluate whether minimal intervention and hybrid external fixation of such fractures using the Orthofix system provide an acceptable treatment outcome with less complications. Between 2002 and 2006, 33 patients with a median ISS of 14.3 were admitted to our hospital, a level I trauma centre, with a bicondylar tibial plateau fracture. Five of them sustained an open fracture. All patients were treated with a hybrid external fixator. In 19 of them, minimal open reduction and stabilization, by means of cannulated screws, was performed. Mean follow-up was 27 months (range 24 to 36 months). Radiographic evidence of union was observed at 3.4 months (range 3 to 7 months). Time for union was different in patients with closed and grade I open fractures compared to patients with grade II and III open fractures. One non-union (septic) was observed (3.0%), requiring revision surgery. Pin track infection was observed in 3 patients (9.1%).Compared to previously reported series of conventional open reduction and internal fixation, hybrid external fixation with or without open reduction and minimal internal fixation with the Orthofix system, was associated with satisfactory clinical and radiographic results and limited complications.

The Morphologic Variations of Low and High Hip Dislocation

AbstractThree different types of congenital hip disease in adults have been distinguished based upon the position of the femoral head relative to the acetabulum and the underlying pathoanatomy of the joint: (1) dysplasia; (2) low dislocation; and (3) high dislocation. To facilitate classification of borderline or ambiguous cases, we studied the morphologic variations of low and high dislocation as observed on the radiographs of 101 hips with low and 74 hips with high dislocation. In low dislocation, 54 hips (53.5%) had extended coverage of the true acetabulum (Type B1) and 47 hips (46.5%) had limited coverage (Type B2). Among the cases with high dislocation, a false acetabulum with an adjacent femoral head occurred in 46 hips (62.2%) (Type C1), and the femoral head was floating within the gluteal muscles in 28 hips (37.8%) (Type C2). The kappa value for interobserver agreement between two raters who made radiographic measurements was 0.963, and for intraobserver agreement between the two evaluations of the same observer it was 0.946 and 0.971, respectively. The two types of low and high dislocation were associated with high intra- and interobserver agreement. Whether these distinctions have clinical utility requires further validation. Level of Evidence: Level III, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The clinical performance of a small diameter tibial nailing system with a mechanical distal aiming device

We present the clinical and radiographic results of a prospective study with the Orthofix tibial nailing system. The ease and safety of distal locking with the use of an improved targeting system was also evaluated. Sixty fresh tibial fractures in 60 patients with a mean age of 37.3 years (range 17-73 years) were treated. Eighteen of the fractures were grade I open fractures. All operations were performed in a conventional operating theatre on a simple transparent operating table, with reduction of the fracture performed under manual traction and manipulation of the fracture site. Hand reaming was then performed to ensure, where possible, the insertion of a nail of at least 9 mm in diameter. Fracture healing was observed at a mean of 17 weeks (12-28 weeks). No tibial non-unions occurred in our series, and only three fractures, two segmental and one severely comminuted, showed delayed union. No infection, either superficial or deep, was found and no cardio-pulmonary complications were recorded. Following surgery, all patients gained a full range of pain-free movement of the ankle and knee joints and only six patients (10%) complained of mild anterior knee pain. All patients returned to their previous jobs one month after fracture healing had been confirmed clinically and radiographically. Following nailing, no deviation from normal tibial alignment was detected. No mechanical failure of either the nails or the locking screws was recorded. The mean duration of operation (skin to skin) was 30 min (range 20-45 min) and the mean total theatre time was 55 min (range 40-75 min). The mean total intensification time was 5 s. In total, 120 distal locking screws were inserted using the external targeting device. All attempts at distal locking except five (4.2%) were successful with two failures in the same patient being a result of inappropriate use of the system. We conclude that this nailing system is clinically effective and that distal locking can be performed easily, without exposure to radiation.