Mark Falworth

A retrospective comparative study of bilateral total knee replacement staged at a one-week interval

The clinical results of bilateral total knee replacement staged at a one-week interval during a single hospital admission were compared with bilateral total knee replacements performed under the same anaesthetic and with bilateral total knee replacements performed during two separate admissions. The data were retrospectively reviewed. All operations had been performed by the same surgeon using the same design of prosthesis at a single institution. The operative time and length of stay for the one-week staged group were comparable with those of the separate admission group but longer than for the patients treated under one anaesthetic. There was a low rate of complications and good clinical outcome in all groups at a mean follow-up of four years (1 to 7.2). The group staged at a one-week interval had the least blood loss (p = 0.004). With appropriate patient selection, bilateral total knee replacement performed under a single anaesthetic, or staged at a one-week interval, is a safe and effective method to treat bilateral arthritis of the knee.

Component Alignment in Hip Resurfacing Using Computer Navigation

The use of computer navigation during hip resurfacing has been proposed to reduce the risk of a malaligned component and notching with subsequent postoperative femoral neck fracture. Femoral component malalignment and notching have been identified as the major factors associated with femoral neck fracture after hip resurfacing. We performed 37 hip resurfacing procedures using an imageless computer navigation system. Preoperatively, we generated a patient-specific computer model of the proximal femur and planned a target angle for placement of the femoral component in the coronal plane. The mean navigation angle after implantation (135.5°) correlated with the target stem-shaft angle (135.4°). After implantation, the mean stem-shaft angle of the femoral component measured by three-dimensional computed tomography (135.1°) correlated with the navigation target stem-shaft angle (135.4°). The computer navigation system generates a reliable model of the proximal femur. It allows accurate placement of the femoral component and provides precise measurement of implant alignment during hip resurfacing, thereby reducing the risk of component malpositioning and femoral neck notching.

Clinical outcome after reconstruction for sternoclavicular joint instability using a sternocleidomastoid tendon graft.

BACKGROUND Anterior instability of the sternoclavicular joint is uncommon and usually follows a benign course, although symptomatic patients may require surgical intervention. The optimal treatment for symptomatic instability of the sternoclavicular joint remains unclear. The aim of this study was to evaluate the clinical outcome after reconstruction of the sternoclavicular joint with use of a sternocleidomastoid tendon graft to treat chronic debilitating anterior instability of the sternoclavicular joint. METHODS Thirty-two patients underwent surgical reconstruction of the sternoclavicular joint for chronic debilitating anterior instability using the tendon of the sternal head of the ipsilateral sternocleidomastoid muscle and were followed for a mean of forty-four months. The etiology of instability was posttraumatic in fourteen patients, generalized hyperlaxity in seven patients, and degenerative instability in eleven patients. Outcome measures included the Oxford instability shoulder score, subjective shoulder value, pain rating, and postoperative grading of sternoclavicular joint stability. RESULTS Clinical scores and pain rating were similar for the three groups before surgery and improved significantly in all of the groups to the same extent after the surgery. At the time of the latest follow-up, eleven of fourteen patients in the posttraumatic group, six of seven patients in the generalized hyperlaxity group, and eight of eleven patients in the degenerative group reported the sternoclavicular joint as stable with no functional limitation. Two patients reported that the joint remained unstable. No other complications occurred. CONCLUSIONS Sternoclavicular joint reconstruction using a sternocleidomastoid tendon graft is safe and offers reliable pain relief and functional improvement for patients with chronic debilitating anterior instability of the sternoclavicular joint.

Management of peri-prosthetic fracture of the humerus with severe bone loss and loosening of the humeral component after total shoulder replacement

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively. There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement.

The outcome of scapulothoracic fusion for painful winging of the scapula in dystrophic and non-dystrophic conditions

Scapulothoracic fusion (STF) for painful winging of the scapula in neuromuscular disorders can provide effective pain relief and functional improvement, but there is little information comparing outcomes between patients with dystrophic and non-dystrophic conditions. We performed a retrospective review of 42 STFs in 34 patients with dystrophic and non-dystrophic conditions using a multifilament trans-scapular, subcostal cable technique supported by a dorsal one-third semi-tubular plate. There were 16 males and 18 females with a mean age of 30 years (15 to 75) and a mean follow-up of 5.0 years (2.0 to 10.6). The mean Oxford shoulder score improved from 20 (4 to 39) to 31 (4 to 48). Patients with non-dystrophic conditions had lower overall functional scores but achieved greater improvements following STF. The mean active forward elevation increased from 59° (20° to 90°) to 97° (30° to 150°), and abduction from 51° (10° to 90°) to 83° (30° to 130°) with a greater range of movement achieved in the dystrophic group. Revision fusion for nonunion was undertaken in five patients at a mean time of 17 months (7 to 31) and two required revision for fracture. There were three pneumothoraces, two rib fractures, three pleural effusions and six nonunions. The main risk factors for nonunion were smoking, age and previous shoulder girdle surgery. STF is a salvage procedure that can provide good patient satisfaction in 82% of patients with both dystrophic and non-dystrophic pathologies, but there was a relatively high failure rate (26%) when poor outcomes were analysed. Overall function was better in patients with dystrophic conditions which correlated with better range of movement; however, patients with non-dystrophic conditions achieved greater functional improvement.

Latissimus dorsi tendon transfers for rotator cuff deficiency

Purpose: Latissimus dorsi tendon transfers are increasingly being used around the shoulder. We aim to assess any improvement in pain and function following a latissimus dorsi tendon transfer for massive, irreparable postero-superior cuff deficiency. Materials and Methods: At our institution, between 1996 and 2009, 38 latissimus dorsi tendon transfer procedures were performed. Sixteen of these were for massive irreparable rotator cuff deficiency associated with pain and impaired function. All patients were evaluated by means of interview or postal questionnaire and case note review. Pain and function were assessed using the Stanmore percentage of normal shoulder assessment (SPONSA) score, visual analogue scale and Oxford Shoulder Score. Forward elevation was also assessed and a significant improvement was thought to correlate with the success of the procedure at stabilizing the humeral head upon elevation. Results: Mean follow-up time was 70 months. There was a significant reduction in pain on the visual analogue scale from 6.4 to 3.4 (P < 0.05), an improved SPONSA score from 32.5 to 57.5 (P < 0.05), and an improved Oxford Shoulder Score from 40.75 to 29.6 (P < 0.05). Forward elevation improved from 40° preoperatively to 75° postoperatively (P < 0.05). Conclusion: Our results add to the body of evidence that latissimus dorsi tendon transfers for irreparable postero-superior cuff deficiency in selected patients reduce pain and improve shoulder function in the medium term. Level of Evidence: Level 4.

Complex shoulder arthroplasty in patients with skeletal dysplasia can decrease pain and improve function

BACKGROUND Patients with skeletal dysplasia are prone to the development of degenerative shoulder disease requiring shoulder arthroplasty at a younger age than in the general population. To date there have been no published reports on the complexities or outcome of shoulder arthroplasty in this unique patient group. METHODS This is a review of 13 shoulder arthroplasties in 10 patients with skeletal dysplasia with mean follow-up of 7 years (2-17.6 years). There were 4 men and 6 women with a mean age of 53.1 years (23-76 years), mean height of 148 cm (122-177 cm), and mean weight of 60 kg (27-80 kg). RESULTS The mean Oxford Shoulder Score increased from 13 (5-20) preoperatively to 28 (18-38) at final follow-up. Patients improved significantly in 2 of 8 Short Form 36 health-related quality of life domains: physical function (P = .04) and bodily pain (P = .04). Function was better in those who underwent nonconstrained total shoulder arthroplasty as opposed to hemiarthroplasty. Four (31%) required reoperation: 1 excision of heterotopic ossification, 1 relocation for anterior instability, and 2 revisions for periprosthetic fracture and glenoid erosion. CONCLUSION Shoulder arthroplasty is effective at relieving pain, optimizing movement, and improving function for patients with skeletal dysplasia; however, compared with the general population, there is a higher complication rate and function is not as good. Furthermore, this procedure is less effective at restoring health-related quality of life than total hip arthroplasty or total shoulder arthroplasty performed for osteoarthritis in the general population. Custom implants may be required to compensate for short stature and rotator cuff and glenoid deficiency.

A reverse shoulder arthroplasty with increased offset for the treatment of cuff-deficient shoulders with glenohumeral arthritis

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley-Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p < 0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42(°)(sd 30) and 9(°) (sd 15) respectively pre-operatively to 78(°) (sd 39) and 24(°) (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching. The Bayley-Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.

Early results of total knee arthroplasty with a low contact stress anteroposterior glide

Purpose. To present early results of 400 consecutive low contact stress (LCS) anteroposterior (AP) glide total knee arthroplasties (TKAs) performed by a single surgeon. Methods. 304 consecutive patients aged 30 to 96 (mean, 66) years underwent 400 TKAs using LCS AP glides performed by a single surgeon. Only patients with an intact posterior cruciate ligament, a fixed flexion deformity of <15°, and a valgus deformity of <15° were included. Patients were assessed pre- and post-operatively using the American Knee Society (AKS) and Hospital for Special Surgery (HSS) scores. Range of motion was measured using a goniometer. AP and lateral radiographs were assessed for radiolucencies and osteolysis. Results. The mean follow-up period was 4.2 (range, 1–8) years. The mean fixed flexion improved to 1° from 11° and the mean active flexion improved to 120° from 111°. Both AKS and HSS scores improved significantly. There were 28 anterior soft tissue impingements; 9 of them were in the first year of the study. Thereafter, the anterior lip of the bearing was modified and any offending osteophytes, soft tissue, or fat pads were excised. Of 39 (10%) knees that underwent re-operation (16 were due to anterior soft tissue impingement), 20 (5%) did not require change of the AP glide bearing and the remaining 19 were converted to a rotating platform bearing. No patellar baja was noted after fat pad excision. No patient had catastrophic wear or failure of the polyethylene bearing. The survival rate of the AP glide bearing was 95%. Conclusion. The early-to-mid-term outcomes of the LCS AP glide TKA are promising.

Increased-offset reverse shoulder arthroplasty for the treatment of failed post-traumatic humeral head replacement.

BACKGROUND Late complications after humeral head replacement (HHR) for comminuted proximal humeral fractures are common and may necessitate revision surgery. This study evaluated the outcome of revision surgery of failed post-traumatic HHR with a less medialized reverse shoulder prosthesis. METHODS Thirty-three patients with failed post-traumatic HHR due to rotator-cuff insufficiency and glenoid erosion, but with sufficient preservation of the glenoid bone stock to permit primary stability of an inverted glenoid implant, underwent revision using the Bayley-Walker reverse shoulder prosthesis (Stanmore Implants, Elstree, UK) and were monitored up for a mean of 31 months. Outcome measures included the Oxford Shoulder Score, subjective shoulder value, pain rating, active range of motion, and shoulder radiographs. RESULTS The average postrevision Oxford Shoulder Score and subjective shoulder value improved from 50 ± 6 to 29 ± 11 and from 23 ± 19 to 51 ± 23, respectively (P < .001). Pain level decreased from 6.2 ± 2.1 to 1.4 ± 2.0 (P < .001). Active forward flexion increased from 34° ± 22° to 63° ± 30° and external rotation from 11° ± 14° to 20° ± 16°(P < .01). More patients were able to use their affected arm to reach a functional triangle consisting the mouth, opposite armpit, and ipsilateral buttock after revision (24% vs 73%; P < .001). Seven patients (21%) had postrevision complications. No glenoid loosening or scapular notching occurred. CONCLUSION Revision of failed post-traumatic HHR with the Bayley-Walker shoulder offers reliable pain relief and improvement in shoulder function with a complication rate similar to other reverse prostheses. Nevertheless, revision shoulder arthroplasty remains challenging with a high rate of complications.