Mark Rickman

Advantages in Using Cemented Polished Tapered Stems When Performing Total Hip Arthroplasty in Very Young Patients

BACKGROUND The risk of revision following primary total hip arthroplasty (THA) is increased in young patients who undergo THA for pathologies other than primary osteoarthritis. We report the results of primary THA performed with cemented polished stems in patients aged 40 years and younger for pathologies other than primary osteoarthritis. METHODS We investigated 52 patients (65 hips) who underwent primary THA for secondary osteoarthritis with a cemented tapered polished stem between 1990 and 2007. Clinical and radiographic outcomes, available in 46 patients (57 hips), included the Harris Hip Scores, Societe Internationale de Chirurgie Orthopedique et de Traumatologie activity, patient satisfaction, stem survival and reoperations, and assessment of prosthesis-cement-bone radiolucencies, osteolysis, and femoral bone deficiencies. RESULTS Median patient age was 34 years (16-40) and follow-up was 14 years (mean 13, range 5-22). Stem survival to the endpoint revision for loosening was 100% and to the endpoint revision for any reason, excluding infection was 88% (95% confidence interval 78-98) at 16 years. No stem was revised for aseptic loosening. Nine stems were revised for other reasons. Radiographically, one stem was definitely loose at 16 years. The median patient Harris pain score improved from marked pain to no pain at latest follow-up. Patient activity level improved, albeit minimally, for 8 years after surgery. At latest follow-up, 98% of the patients remained satisfied with their surgery. CONCLUSION Primary THA with a cemented polished stem shows excellent results in young patients with pathology other than primary osteoarthritis. In addition, the stem design facilitates cement within cement exchange and therefore preservation of proximal femoral bone stock at revision surgery.

Postoperative weight bearing and patient reported outcomes at one year following tibial plateau fractures

Tibial plateau fractures are complex and the current evidence for postoperative rehabilitation is weak, especially related to the recommended postoperative weight bearing. The primary aim of this study was to investigate if loading in the first 12 weeks of recovery is associated with patient reported outcome measures at 26 and 52 weeks postoperative. We hypothesized that there would be no association between loading and patient reported outcome measures. Seventeen patients, with a minimum of 52-week follow-up following fragment-specific open reduction and internal fixation for tibial plateau fracture, were selected for this retrospective analysis. Postoperatively, patients were advised to load their limb to a maximum of 20kg during the first 6 weeks. Loading data were collected during walking using force platforms. A ratio of limb loading (affected to unaffected) was calculated at 2, 6 and 12 weeks postoperative. Knee Injury and Osteoarthritis Scores were collected at 6, 12, 26 and 52 weeks postoperative. The association between loading ratios and patient reported outcomes were investigated. Compliance with weight bearing recommendations and changes in the patient reported outcome measures are described. Fracture reduction and migration were assessed on plain radiographs. No fractures demonstrated any measurable postoperative migration at 52 weeks. Significant improvements were seen in all patient reported outcome measures over the first 52 weeks, despite poor adherence to postoperative weight bearing restrictions. There were no associations between weight bearing ratio and patient reported outcomes at 52 weeks postoperative. Significant associations were identified between the loading ratio at 2 weeks and knee-related quality of life at six months (R2=0.392), and between the loading ratio at 6 weeks combined with injury severity and knee-related quality of life at 26 weeks (R2=0.441). In summary, weight bearing as tolerated does not negatively affect the results of tibial plateau fracture and may therefore be safe for postoperative management. These findings should be taken in context of the sample size, which was not sufficient for sub-group analysis to investigate the role of impaction grafting.

Versatility of an Extended Posterior Approach for the Treatment of Acetabular Fractures With Reference to the Superior Gluteal Neurovascular Bundle.

Summary: The superior gluteal neurovascular bundle is at risk of injury in certain types of acetabular fractures and the associated surgery. This article describes the versatility of an extended posterior approach, previously described for complex revision total hip replacement (the Adelaide approach) and for the treatment of acetabular fractures that allows a wide exposure of the ilium through identification, protection, and mobilization of the superior gluteal neurovascular bundle.

Anterior Cruciate Ligament Reconstruction in Ehlers-Danlos Syndrome

This report details the reconstruction of the anterior cruciate ligament in an 18-year-old man with Ehlers-Danlos syndrome (EDS). The reduced mechanical properties of the tissue in EDS can pose a challenge to the orthopaedic surgeon. In this case, we describe the use of a hamstring autograft combined with a Ligament Advanced Reinforcement System (LARS). There was a good radiographical, clinical, and functional outcome after two years. This technique gave a successful outcome in the reconstruction of the ACL in a patient with EDS and therefore may help surgeons faced with the same clinical scenario.

Time dependent loss of trabecular bone in human tibial plateau fractures

We investigated if time between injury and surgery affects cancellous bone properties in patients suffering tibial plateau fractures (TPF), in terms of structural integrity and gene expression controlling bone loss. A cohort of 29 TPF, operated 1–17 days post‐injury, had biopsies from the fracture and an equivalent contralateral limb site, at surgery. Samples were assessed using micro‐computed tomography and real‐time RT‐PCR analysis for the expression of genes known to be involved in bone remodeling and fracture healing. Significant decreases in the injured vs control side were observed for bone volume fraction (BV/TV, −13.5 ± 6.0%, p = 0.011), trabecular number (Tb.N, −10.5 ± 5.9%, p = 0.041) and trabecular thickness (Tb.Th, −4.6 ± 2.5%, p = 0.033). Changes in these parameters were more evident in patients operated 5–17 days post‐injury, compared to those operated in the first 4 days post‐injury. A significant negative association was found between Tb.Th (r = −0.54, p < 0.01) and BV/TV (r = −0.39, p < 0.05) in relation to time post‐injury in the injured limb. Both BV/TV and Tb.Th were negatively associated with expression of key molecular markers of bone resorption, CTSK, ACP5, and the ratio of RANKL:OPG mRNA. These structure/gene expression relationships did not exist in the contralateral tibial plateau of these patients. This study demonstrated that there is a significant early time‐dependent bone loss in the proximal tibia after TPF. This bone loss was significantly associated with altered expression of genes typically involved in the process of osteoclastic bone resorption but possibly also bone resorption by osteocytes. The mechanism of early bone loss in such fractures should be a subject of further investigation.

Characteristics of postoperative weight bearing and management protocols for tibial plateau fractures: Findings from a scoping review

OBJECTIVE To identify and describe the characteristics of existing practices for postoperative weight bearing and management of tibial plateau fractures (TPFs), identify gaps in the literature, and inform the design of future research. METHODS Seven electronic databases and clinical trial registers were searched from inception until November 17th 2016. Studies were included if they reported on the surgical management of TPFs, had a mean follow-up time of ≥1year and provided data on postoperative management protocols. Data were extracted and synthesized according to study demographics, patient characteristics and postoperative management (weight bearing regimes, immobilisation devices, exercises and complications). RESULTS 124 studies were included involving 5156 patients with TPFs. The mean age across studies was 45.1 years (range 20.8-72; 60% male), with a mean follow-up of 34.9 months (range 12-264). The most frequent fracture types were AO/OTA classification 41-B3 (29.5%) and C3 (25%). The most commonly reported non-weight bearing time after surgery was 4-6 weeks (39% of studies), with a further 4-6 weeks of partial weight bearing (51% of studies), resulting in 9-12 weeks before full weight bearing status was recommended (55% of studies). Loading recommendations for initial weight bearing were most commonly toe-touch/<10kg (28%), 10kg-20kg (33%) and progressive (39%). Time to full weight bearing was positively correlated with the proportion of fractures of AO/OTA type C (r=0.465, p=0.029) and Schatzker type IV-VI (r=0.614, p<0.001). Similar rates of rigid (47%) and hinged braces were reported (58%), most frequently for 3-6 weeks (43% of studies). Complication rates averaged 2% of patients (range 0-26%) for abnormal varus/valgus and 1% (range 0-22%) for non-union or delayed union. CONCLUSIONS Postoperative rehabilitation for TPFs most commonly involves significant non-weight bearing time before full weight bearing is recommended at 9-12 weeks. Partial weight bearing protocols and brace use were varied. Type of rehabilitation may be an important factor influencing recovery, with future high quality prospective studies required to determine the impact of different protocols on clinical and radiological outcomes.

Complications of trans arterial embolization during the resuscitation of pelvic fractures.

INTRODUCTION Trans arterial embolization (TAE) can stem uncontrolled bleeding associated with pelvic fractures, but is associated with potential complications. This study investigated and compared the early to midterm complications in two patient cohorts: one who did and one who did not undergo TAE. METHODOLOGY The results of 14 patients who underwent TAE in the resuscitation phase, and then had their pelvic fractures managed non-operatively, the study group (Group 1), were compared with those of a control group (Group 2) of 14 patients matched for age, sex, injury and management, that did not undergo TAE. All patients were examined clinically and answered a questionnaire on bowel and urinary function, pain and limp. Gluteus medius structure and volume were assessed on MRI. The hip girdle muscle function was assessed using a hand held dynamometer, surface electromyography as well as quantitative gait analysis. RESULTS Seven patients in Group 1 (50%), but none in Group 2, had persistent urological dysfunctions, in the absence of any recognized previous pathology or urologic trauma at the time of injury. No gluteal muscle demonstrated fibrosis or fatty infiltration. The median gluteal muscle volume was not significantly decreased compared with the uninjured side in either group (P=0.421). The muscle strengths of gluteus maximus, gluteus medius, tensor fasciae latae and iliopsoas when compared to the uninjured side were significantly less in Group 1 compared to Group 2. However, no patient had a discernable limp and gait analysis showed no significant differences between the left and right sides in the study and control groups in the gluteal activation timing (p=0.171 and 0.354) and duration (p=0.622 and 0.435). There were no skin complications, and no patient reported any persistent bowel dysfunction. CONCLUSION TAE was associated with a high rate of persistent urological dysfunction. TAE could lead to decreased hip muscles strength, however this does not seem to affect gait.

Defining the Pubic Symphysis Angle with Respect to the Coronal Plane – Clinical and Biomechanical Considerations

BACKGROUND Fixation strength of constructs placed across the pubic symphysis after injury is dependent on screw length, maximisation of which requires knowledge of the bony anatomy. The aim of this study was to describe the ideal angle of drilling to achieve maximal safe screw placement within the pubic body. Furthermore, the influences of age and gender on the skeletal topography were investigated. METHODS Three hundred CT scans of patients without pelvic injury were analysed to record the angle of the pubic body (APB) with respect to the coronal plane, and the depth of the pubic body (DPB) in the sagittal plane. RESULTS Mean APB and DPB were 54.69° and 55.35mm, respectively. Females had a significantly higher mean APB than males (57.29° vs. 52.41°; p<0.001), whereas males had a significant larger mean DPB (59.13mm vs. 51.03mm; p<0.001). Age had no effect on the mean APB. Mean width of the pubic body at the base was 9.38mm. CONCLUSION The anatomy of this region is reliable in terms of angles and sizes; a drill angle of 55° with respect to the operating table will allow maximal screw length, which should be in the region of 55mm. The mean width of the pubic body should allow for placement of a 3.5 or 4.5mm diameter screw.

CORR Insights(®): Cemented Bipolar Hemiarthroplasty Provides Definitive Treatment for Femoral Neck Fractures at 20 Years and Beyond.

O steoporotic hip fractures consume substantial resources in developed healthcare systems; their prevalence continues to rise, and at the same time, overall life expectancy is increasing [3]. Many studies have found that approximately 25% of hip fracture patients will not survive beyond 1 year [2]; however, with improved awareness of the timecritical nature of this injury, as well as advances in medical care, it is likely that this figure will fall. As a result, the need for long-term studies on pain and function after treatment of these injuries is readily apparent. The paper by Roth and colleagues is unusual in that it provides 20-year outcome data for the use of cemented bipolar hemiarthroplasty for unselected patients presenting with osteoporotic hip fractures. In their study, the authors show that this type of procedure or implant will outlive the vast majority of patients in this group (as they observed a cumulative revision rate of just 3.5% at 20 years). They also show a low incidence of acetabular erosion, despite this being one of the stated problems with hemiarthroplasty in younger or more active patients [1, 5]. The implants used were of older designs, and so perhaps even better results could be expected today. The study’s ability to assess functional outcomes, however, is limited, having only a small group of patients available for analysis who remained alive at long-term (20 patients). Additionally, of the 20 surviving patients, only seven retained the original implants, suggesting that while the procedure performed may outlive most patients, those patients who survive may need a revision at some point.