Kevin Tetsworth

Mechanical axis deviation of the lower limbs. Preoperative planning of uniapical angular deformities of the tibia or femur.

Angular deformities of the tibia or femur in the frontal plane lead to mechanical axis deviation of the lower limb and malorientation of the joints above and below the level of deformity. Accurate correction of the malalignment and of the joint orientation is important for function and to prevent joint degeneration. An accurate yet simple method to determine the apex of deformity and the type of correction required is based on the joint reference lines of the hip, knee, and ankle, and the individual mechanical axis lines of each bone segment. If the osteotomy is performed at the level of the apex of the deformity, then the only correction needed is angulation. If the osteotomy is performed at a level proximal or distal to the apex, then translation in addition to angulation is necessary to accurately correct the deformity.

Mechanical axis deviation of the lower limbs. Preoperative planning of multiapical frontal plane angular and bowing deformities of the femur and tibia.

Multiapical deformities complicate the process of preoperative planning. It is necessary to determine the level of each apex of deformity to plan accurate correction. The basic principles of mechanical axis realignment and joint orientation need to be preserved. Using the joint reference lines and mechanical axis of each bone segment, one can accurately determine the apex of each deformity. Bowing deformities are multiapical angular deformities. There are two types of bowing deformities: compensated and noncompensated. Typical examples of compensated bowing are the anterolateral and posteromedial bows of the tibia. A noncompensated bow is typical of the deformity seen in rickets.

Osteomyelitis debridement techniques.

Debridement of chronic osteomyelitis can be technically demanding and difficult. The surgical principles that govern treatment of osteomyelitis involve an atraumatic approach and complete removal of all devitalized tissue and foreign material. Despite recent advances in medical science, the quality of surgical debridement remains the most critical factor in the successful management of chronic orthopaedic infections. Important areas discussed include thorough preoperative evaluation, the surgical philosophy, soft tissue aspects, bone considerations, and dead space management.

Accuracy of correction of complex lower-extremity deformities by the Ilizarov method

Gradual mechanical distraction with the Ilizarov external fixator was used on 28 limbs in 23 patients to correct complex lower-extremity deformities of diverse causes. To determine the accuracy of realignment and deformity correction, the charts and radiographs were reviewed retrospectively. Preoperative long-standing anteroposterior radiographs of the entire lower extremity were compared with those obtained at the most recent follow-up visit. The parameters used to assess accuracy of correction were joint alignment and joint orientation. Alignment was determined by mechanical axis deviation (MAD) and mechanical tibiofemoral angle (mTFA). The preoperative MAD averaged 48 mm and the postoperative MAD 8.6 mm. The preoperative mTFA averaged 16 degrees and the postoperative mTFA 3 degrees. The result of deformity correction from early cases was compared with the result obtained from recent cases. Residual MAD averaged 13.2 mm in the early group and 6.4 mm in the recent group. Residual mTFA averaged 4.7 degrees in the early group and 2.2 degrees in the recent group. Gradual correction by dynamic external fixation can restore alignment and correct complex deformities with great accuracy. These results suggest the accuracy of correction increases with surgical experience.

Distraction osteogenesis for nonunion after high tibial osteotomy

The purpose of this study was to determine whether distraction osteogenesis can be used to treat hypertrophic nonunion associated with angular deformity and shortening after Coventry style high tibial osteotomy. Five consecutive patients were retrospectively reviewed. In all patients the alignment had collapsed into excessive varus or valgus and leg length discrepancy was present. The leg length discrepancy, malalignment, and nonunion were treated simultaneously with distraction. Union was achieved by the time of fixator removal, which averaged 4.4 months. The Hospital for Special Surgery knee score significantly improved from 42 to 89. The mechanical axis deviation significantly improved by 5 cm. The coronal plane deformity significantly improved by 13°, and leg length discrepancy improved significantly from 2.3 to 0.5 cm. Metaphyseal bone stock increased by 43%, and the Insall-Salvati ratio increased from 1.1 to 1.2 and remained within normal limits. All patients were satisfied with the procedure, and none have had or need a total knee replacement at an average followup of 4 years. Distraction osteogenesis of nonunion after high tibial osteotomy is a minimally invasive and successful procedure. It leads to bony union with correction of deformity and leg length discrepancy and prevents the need for total knee replacement at intermediate-term followup. The increase in metaphyseal bone stock may make total knee replacement technically easier.

Does Posterior Tibial Slope Influence Knee Functionality in the Anterior Cruciate Ligament–Deficient and Anterior Cruciate Ligament–Reconstructed Knee?

PURPOSE The purpose of this study was to investigate the relation between knee functionality and posterior tibial slope in anterior cruciate ligament (ACL)-deficient and ACL-reconstructed patients. METHODS Patients with isolated ACL injuries on the surgical waiting list and patients who underwent ACL reconstruction with bone-patellar tendon-bone grafts between 18 and 24 months after surgery were recruited from the orthopaedic sports injury clinic. The study included 44 ACL-deficient patients (range 16-49) with a mean age of 26.4 years and 24 ACL-reconstructed patients with a mean age of 27.2 years (range, 25 to 49 years). Posterior tibial slope was measured on a digitalized lateral radiograph by use of the posterior tibial cortex as a reference. The Cincinnati scoring system was used to assess knee functionality. RESULTS The posterior tibial slope averaged 6.10° ± 3.57° (range, 0° to 17°) in the ACL-deficient group and 7.20° ± 4.49° (range, 0° to 17°) in the ACL-reconstructed group. An anterior tibial slope was not measured in any of the participants. The mean Cincinnati score was 62.0 ± 14.5 (range, 36 to 84) in the ACL-deficient patients and 89.3 ± 9.5 (range, 61 to 100) in the ACL-reconstructed patients. There was a moderate but nonsignificant correlation (r = 0.47) between knee functionality and slope in the ACL-deficient patients. When we divided posterior tibial slope into intervals of 0° to 4° (mean score, 58.4), 5° to 9° (mean score, 59.6), and greater than 10° (mean score, 75.4), a strong significant correlation (r = 0.91, P = .01) was observed between knee functionality and slope. There was a weak but nonsignificant correlation (r = 0.24) between knee functionality and slope in the ACL-reconstructed patients. When we divided posterior tibial slope into intervals of 0° to 4° (mean score, 78.2), 5° to 9° (mean score, 86.1), and greater than 10° (mean score, 89.4), a strong and significant correlation (r = 0.96, P = .0001) was observed between knee functionality and slope. CONCLUSIONS The results of this study suggest that ACL-deficient and ACL-reconstructed patients with higher posterior tibial slope have more functional knees. LEVEL OF EVIDENCE Level IV, therapeutic case series.

A comparison between imageless navigated and manual freehand technique acetabular cup placement in total hip arthroplasty.

The purpose of this study was to compare acetabular component positioning using an imageless system to a matched control group using conventional techniques. Thirty procedures were performed using navigation. A multislice computed tomographic scan was used to assess cup position. There was no significant difference between mean inclination (P = .11) and anteversion (P = .24) but a statistical significant difference for mean deviation from the desired position for inclination (P = .003) and anteversion (P = .007). There was a significant difference in the percentages of correctly placed cups with inclination (P = .046) and with anteversion (P = .006). Combining both anteversion and inclination, there was a significant difference (P = .01). We demonstrated a significant increase in accuracy of placement of acetabular cups within the desired position and safe zone using imageless navigation.

Hip fracture evaluation with alternatives of total hip arthroplasty versus hemiarthroplasty (HEALTH): protocol for a multicentre randomised trial

Introduction Hip fractures are a leading cause of mortality and disability worldwide, and the number of hip fractures is expected to rise to over 6 million per year by 2050. The optimal approach for the surgical management of displaced femoral neck fractures remains unknown. Current evidence suggests the use of arthroplasty; however, there is lack of evidence regarding whether patients with displaced femoral neck fractures experience better outcomes with total hip arthroplasty (THA) or hemiarthroplasty (HA). The HEALTH trial compares outcomes following THA versus HA in patients 50 years of age or older with displaced femoral neck fractures. Methods and analysis HEALTH is a multicentre, randomised controlled trial where 1434 patients, 50 years of age or older, with displaced femoral neck fractures from international sites are randomised to receive either THA or HA. Exclusion criteria include associated major injuries of the lower extremity, hip infection(s) and a history of frank dementia. The primary outcome is unplanned secondary procedures and the secondary outcomes include functional outcomes, patient quality of life, mortality and hip-related complications—both within 2 years of the initial surgery. We are using minimisation to ensure balance between intervention groups for the following factors: age, prefracture living, prefracture functional status, American Society for Anesthesiologists (ASA) Class and centre number. Data analysts and the HEALTH Steering Committee are blinded to the surgical allocation throughout the trial. Outcome analysis will be performed using a χ2 test (or Fishers exact test) and Cox proportional hazards modelling estimate. All results will be presented with 95% CIs. Ethics and dissemination The HEALTH trial has received local and McMaster University Research Ethics Board (REB) approval (REB#: 06-151). Results Outcomes from the primary manuscript will be disseminated through publications in academic journals and presentations at relevant orthopaedic conferences. We will communicate trial results to all participating sites. Participating sites will communicate results with patients who have indicated an interest in knowing the results. Trial registration number The HEALTH trial is registered with clinicaltrials.gov (NCT00556842).

The Osseointegration Group of Australia Accelerated Protocol (OGAAP-1) for two-stage osseointegrated reconstruction of amputated limbs

AIMS This study describes the Osseointegration Group of Australias Accelerated Protocol two-stage strategy (OGAAP-1) for the osseointegrated reconstruction of amputated limbs. PATIENTS AND METHODS We report clinical outcomes in 50 unilateral trans-femoral amputees with a mean age of 49.4 years (24 to 73), with a minimum one-year follow-up. Outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation, the health assessment questionnaire Short-Form-36 Health Survey, the Amputation Mobility Predictor scores presented as K-levels, 6 Minute Walk Test and timed up and go tests. Adverse events included soft-tissue problems, infection, fractures and failure of the implant. RESULTS Our results demonstrated statistically significant improvements in all five outcome measures. A total of 27 patients experienced adverse events but at the conclusion of the study, all 50 were walking on osseointegrated prostheses. CONCLUSION These results demonstrate that osseointegrated prostheses are a suitable alternative to socket-fit devices for amputees experiencing socket-related discomfort and that our strategy offers more rapid progress to walking than other similar protocols. Cite this article: Bone Joint J 2016;98-B:952-60.

Epidemiology of Traumatic Epidural Hematoma in Young Age

BACKGROUND Epidural hematoma (EDH) is a major traumatic brain injury and a potentially life-threatening condition, with the mortality rate in the young age group varying across studies. The aim of this analysis was to investigate the magnitude of traumatic EDH in young patients aged 0 year to 24 years in Queensland, Australia. METHODS Study patients presented to the emergency department of 14 public hospitals participating in the Queensland Trauma Registry during 2005 to 2007 and were diagnosed and admitted for treatment of EDH. Age group comparisons were performed for demographic, injury, treatment, operation details, and outcome-related variables. RESULTS We identified 224 young patients with traumatic EDH. The most frequent cause of injury was a fall in the 0 year to 9 years age groups and road traffic crash in those aged 10 years to 24 years. Almost 81% of the EDH cases were due to accidental injury, 17% due to assault, with the remainder due to self-harm and undetermined intent. Skull fracture was present in 75% of the study patients. Neurosurgical operations were performed on 40%. The overall Injury Severity Score adjusted in-hospital mortality rate was 4.8%. The odds of in-hospital mortality was 2.5 (95% confidence interval, 0.8-8.2) compared with older patients (25-64 years). CONCLUSIONS The results indicate that the Injury Severity Score adjusted in-hospital mortality rates for young patients with EDH were 4.8%. Given the limited information on morbidity resulting from EDH, further analysis to examine modifiable factors for better management and to evaluate survivors long-term health outcomes via a longitudinal follow-up study is warranted.