Sanjeev Patil

Prospective, double blind, randomized, controlled trial of simvastatin in human fracture healing

Although statins are widely prescribed as cholesterol‐lowering drugs, a number of studies suggest that these compounds may have anabolic effects on bone. Our aim was to assess whether simvastatin affects the rate of fracture healing in humans. A prospective, double‐blind, randomized controlled trial was performed. Individuals who had sustained an undisplaced, extra‐articular fracture of the distal radial metaphysis were recruited from a trauma clinic. Patients were randomized to receive simvastatin 20 mg once daily or a placebo. Regular clinical and radiological follow‐up was undertaken for a 12 week period. Dual‐energy X‐ray absorptiometry assessment of bone mineral density was conducted at 2 and 12 weeks postinjury. Biochemical markers of bone turnover were assayed during the study period. Time to fracture union was defined as the time to cortical bridging in four cortices on plain radiographs. In addition, the rate of trabecular union was assessed. Eighty patients were recruited, of which 62 completed the study (31 in each group). Study cohorts were matched for age and gender. For patients receiving simvastatin therapy, the mean time to fracture union was 71.6 days (SD 22.2 days, SEM 3.8 days). This compared to 71.3 days (SD 21.3, SEM 4.1 days) for the control cohort (p = 0.6481). There was no significant difference between bone mineral density or bone biochemical markers between groups (p > 0.05). Despite promising results from in vivo and in vitro animal studies, simvastatin at a treatment dose of 20 mg once daily does not affect the rate of fracture healing in humans.

Circulating Cytokines after Hip and Knee Arthroplasty: A Preliminary Study

Several studies show cytokine concentrations in the peripheral blood are associated with inflammatory activity and surgical trauma. Cytokine concentrations have more rapid increase and quicker return to normal values than either C-reactive protein or erythrocyte sedimentation rate – a matter of hours rather than weeks; some studies suggest they are better predictors of postoperative infection than C-reactive protein and erythrocyte sedimentation rate. Threshold levels of interleukin-6 after joint arthroplasty have been determined, but levels of other potentially useful cytokines (tumor necrosis factor-α, interleukin-8, interleukin-10, etc) are not known. We measured the serum levels of 25 different cytokines before and after hip and knee arthroplasties and identified those associated with surgical trauma. Peripheral venous blood samples (one preoperative and three postoperative) from 49 patients undergoing hip or knee arthroplasty were analyzed by laser chromatography. Three of the 25 cytokines had a relationship with postsurgical trauma, which included one deep infection. Serum levels of these three cytokines might be useful to identify periprosthetic infections during the early postoperative period when C-reactive protein and erythrocyte sedimentation rate remain elevated.Level of Evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Fracture of an Exeter ‘cement in cement’ revision stem: a case report

The ‘cement in cement’ technique for revision hip arthroplasty has become popular in recent years, particularly in relation to polished taper stems. Since 2006 a short Exeter stem with 44mm offset has been available specifically for this purpose. We report a fracture of such a stem in the absence of trauma 5 years after the revision procedure. The patient had a BMI of 27.8 and the proximal cement mantle gave good support to the stem. The fracture initiated and propagated from the introducer hole on the shoulder of the prosthesis. Macroscopically there was no defect in this area. This may be an unusual case of fatigue failure.

Direct to Consumer Advertising via the Internet, a Study of Hip Resurfacing

Background and Aims With increased use of the internet for health information and direct to consumer advertising from medical companies, there is concern about the quality of information available to patients. The aim of this study was to examine the quality of health information on the internet for hip resurfacing. Methods An assessment tool was designed to measure quality of information. Websites were measured on credibility of source; usability; currentness of the information; content relevance; content accuracy/completeness and disclosure/bias. Each website assessed was given a total score, based on number of scores achieved from the above categories websites were further analysed on author, geographical origin and possession of an independent credibility check. Results There was positive correlation between the overall score for the website and the score of each website in each assessment category. Websites by implant companies, doctors and hospitals scored poorly. Websites with an independent credibility check such as Health on the Net (HoN) scored twice the total scores of websites without. Conclusions Like other internet health websites, the quality of information on hip resurfacing websites is variable. This study highlights methods by which to assess the quality of health information on the internet and advocates that patients should look for a statement of an “independent credibility check” when searching for information on hip resurfacing.

Knee osteoarthritis: a review of management options

Osteoarthritis of the knee is a complex peripheral joint disorder with multiple risk factors. The molecular basis of osteoarthritis has been generally accepted; however, the exact pathogenesis is still not known. Management of patients with osteoarthritis involves a comprehensive history, thorough physical examination and appropriate radiological investigation. The relative slow progress in the disease allows a stepwise algorithmic approach in treatment. Non-surgical treatment involves patient education, lifestyle modification and the use of orthotic devises. These can be achieved in the community. Surgical options include joint sparing procedures such as arthroscopyando osteotomy or joint-replacing procedures. Joint-replacing procedures can be isolated to a single compartment such as patellofemoral arthroplasty or unicompartmental knee replacement or total knee arthroplasty. The key to a successful long-term outcome is optimal patient selection, preoperative counselling and good surgical technique.

Surgical dislocation of the hip for excision of benign tumours

AIM Surgical dislocation of hip is used to treat a variety of hip conditions. We report our experience of the approach in excision of benign tumours of the hip. METHODS This is a review of the cases presenting with benign tumours to a tertiary care complex hip clinic. Data was collected prospectively. All patients were radiologically investigated before surgery for anatomical detail. Surgical dislocation was carried out by the senior surgeon in all cases. Non-Arthritic Young Hip Scores were done preoperatively and at 12 months. All patients are under annual follow-up. RESULTS There were 9 cases of benign tumours in this series including Pigmented Villonodular Synovitis (2), synovial chondromatosis (2), fibrous dysplasia (2), osteochondroma (2) and chondroblastoma (1). No recurrences, trochanteric nonunion or avascular necrosis have been seen up to a minimum of 18 months follow-up. Non-arthritic Young Hip scores improved from a mean of 45 to 89 at 12 months. CONCLUSION Surgical dislocation of the hip is a useful approach for removal of benign tumours of the hip joint.

Clinical outcome scores for arthroscopic femoral osteochondroplasty in femoroacetabular impingement: a quantitative systematic review.

Background and aims Femoroacetabular impingement is the abnormal contact of the proximal femur and acetabulum during motion. It causes hip pain and joint degeneration in young patients. This systematic review aims to clarify the clinical effect of arthroscopic femoral osteochondroplasty for cam lesions and to review the available literature for the general medical readership, including providers of primary and secondary care. Methods and results Electronic databases were searched for studies of arthroscopic femoral osteochondroplasty in primary femoroacetabular impingement. A total of 2618 article titles, 242 abstracts and 33 full text articles were considered. Ultimately nine studies with clinical outcome scores met the inclusion criteria and were included in the qualitative systematic review. Six studies were suitable for meta-analysis using an inverse variance, random effects model (RevMan software). In the nine studies, improvements were seen in Western Ontario and McMaster Universities Osteoarthritis index, Non-arthritic Hip Score and Modified Harris Hip Scores. Across the six studies suitable for meta-analysis (537 patients), a 24-point weighted mean improvement in Non-arthritic hip score was seen. This yielded a large overall effect size of 1.6. Conclusion Arthroscopic femoral osteochondroplasty appears to be a beneficial treatment for primary femoroacetabular impingement, with a large effect size seen across six eligible studies.

Noise production in ceramic-on-ceramic total hip arthroplasty is associated with lower patient satisfaction and hip scores

BACKGROUND Ceramic-on-ceramic total hip arthroplasties (THA) are commonly implanted. We investigated the incidence of noise in ceramic-on-ceramic and determined any association with patient satisfaction and hip scores. METHODS We recruited 140 THA. Questionnaires were completed to assess the incidence and frequency of noise, and satisfaction level. Hip and SF-12 scores were recorded. RESULTS Forty-two patients (30%) were aware of noise production. Patients with noise production had lower satisfaction, mean hip and SF-12 scores than those with silent hips. CONCLUSION Given the high incidence of noise in ceramic-on-ceramic THA, patients should be counselled on this risk pre-operatively.

Delays in diagnosis are associated with poorer outcomes in adult hip dysplasia

Background and Aims Developmental dysplasia of the hip is a common cause of osteoarthritis. Periacetabular osteotomy can restore femoral head coverage; however, it is reserved for patients with minimal articular degeneration. We examined the relationship between delays in diagnosis and outcomes. Methods We identified patients presenting to a hip specialist with a new diagnosis of hip dysplasia. The time taken between patients presenting to their general practitioner and attending the young adult hip clinic was established. Patients were stratified into Early, Moderate and Late Referral groups. Hip and SF-12 questionnaires were completed. Radiographs were graded according to the Tönnis classification system and the outcome following hip specialist review documented. Results Fifty-one patients were identified. Mean time from attending a general practitioner to review at the young adult hip clinic was 40.4 months. Lower hip and SF-12 scores, and higher radiological osteoarthritis grades were found in the Moderate and Late Referral groups. A higher proportion of the Moderate and Late Referral group underwent total hip arthroplasty rather than periacetabular osteotomy. Conclusion Delays in referring a patient to a hip specialist are associated with poorer outcomes. We propose pelvic radiographs are requested early by general practitioners to allow prompt diagnosis and referral to a hip specialist.

Total Hip Replacement in Developmental Dysplasia of the Hip Using Wagner Cone Prosthesis with Small Diameter Metal-On-Metal Articulation

Background Patients with developmental dysplasia of hip often undergo total hip arthroplasty (THA) at a younger age. THA in such patients are technically demanding because of deficient acetabular bone stock, abnormal femoral anatomy with increased anteversion, leg length discrepancy and soft tissue imbalance. Conical femoral stem with Metal on Metal (MoM) 28 mm bearing have been used to address the anatomical and wear issues in this young patient group. The aim of the study was to review the early midterm clinical results of this prosthesis. Material & Methods Between January 2004 and March 2009 twenty-one consecutive patients (24 hips) with osteoarthritis secondary to developmental dysplasia of the hip underwent metal-on-metal uncemented Allofit Metasul press-fit cups (Zimmer) with 28 mm-heads and tapered uncemented Wagner cone prosthesis stems (Zimmer) using posterior approach. Functional outcomes were assessed using Oxford hip score (OHS), SF12 physical and mental scores and WOMAC scores. Radiographic outcomes was carried out by two independent observers for leg length discrepancy (LLD), Crowe and Tonnis grading, lateral center -edge (CE) angle, acetabular roof-arc angle and femur neck-shaft angle heterotropic ossification, prosthesis loosening and cup inclination angle. Results There were 5 men and 16 women with mean age of 45 years (SD=9.15, 26-63). The mean follow up was four years (SD=1.7, 2-7). No patients were lost to follow up. Three patients required structural allograft, no patients required intra operative femoral shortening. Classification of DDH was Crowe type I in 14 hips, type II in 8 hips and type III in 2 hips. The mean preoperative CE angle was 10.5°, neck shaft angle was 143° and the acetabular roof arc angle was 25°. 3 hips had Tonnis Grade 2 while 21 had Grade 3 osteoarthritis. The mean cup inclination angle was 42 degrees (range 32-60 degrees). The mean preoperative limb shortening was 19.1 mm (range,-1 to -39) which improved to 2.8 mm postoperatively. The OHS improved significantly within subjects (p<0.001) from a mean of 10.6 (2-28) to 43.9 (30-48). The mean post operative scores were- WOMAC 51 (SD=7.4, 30-56), SF12 physical 51 (SD=8.5, 28-58) and SF12 mental 53 (SD=4.7, 46-59). There were two revisions for aseptic loosening, one stem and one cup; therefore giving an overall survival of 91%. No other hip had radiographic evidence of acetabular or femoral osteolysis. Three patients suffered transient femoral nerve palsy, which recovered completely. We did not observe any dislocation, deep infection or heterotopic ossification. Discussion The medium-term results of the small diameter metal-on-metal hip arthroplasty with a conical uncemented stem have been encouraging in the treatment of this difficult cohort of young patients. The inherent stability and functional outcome provided by the small femoral heads are better than the recent large metal on metal articulations. Further follow up is required to see how small MoM bearing will behave in the long term.