Warwick Bruce

Type 2 fractures of the distal clavicle: A new surgical technique

Neer type 2 fractures of the distal clavicle have a high rate of nonunion and delayed union. In this series nine cases of coracoclavicular ligament reconstruction with Dacron graft material led to union at the fracture site. All patients had no symptoms and returned to full activity. This technique allows for stable fixation with early mobilization and return to work and sports.

Custom-Fit Total Knee Arthroplasty: Our Initial Experience in 32 Knees

We share our initial experience of total knee arthroplasty (TKA) using customized cutting block technology in 32 TKAs from May 2010 to March 2011. Ten of these patients had prior TKA done on the other side using conventional or navigation-assisted TKA. Customized cutting blocks were generated for each of the knee using preoperative magnetic resonance imaging of knee and long-leg weight-bearing radiographs. At 6 weeks, long-leg radiographs were obtained to evaluate the coronal alignment. There were no adverse intraoperative events. Twenty-nine of the 32 knees had a mechanical axis restored to within 3°° of neutral. Of 10 patients with prior TKA without custom-fit technology, the mean blood loss and the mean skin-to-skin time was found to be lower in knees that had undergone custom-fit TKA. We conclude that this technology can be safely used in most of the cases of osteoarthritis.

Primary Total Hip Arthroplasty in Severe Developmental Dysplasia of the Hip. Ten-Year Results Using a Cementless Modular Stem

We report the average 10-year clinical and radiographic results of 28 hips with Crowe III or IV developmental dysplasia of the hip (DDH) and a technically difficult primary hip arthroplasty using the cementless modular S-ROM stem (DePuy Orthopedics, Warsaw, Ind). Twenty-one patients required significant autologous bone grafting, 1 had a large allograft, and 6 patients required femoral shortening at the time of their total hip arthroplasty. Three patients had an intraoperative technical complication. The average preoperative Harris hip score was 37; at 10 years, 81. The Short Form 12 was 41.64 physical/54.03 mental at 10 years, and the WOMAC average score was 23 at 10 years. None of the S-ROM stems had been revised or were loose at latest follow-up. Six hips had osteolysis in Gruen zones 1 or 7 but none around or distal to the sleeve. The 10-year results of the S-ROM stem used in patients with osteoarthritis secondary to severe DDH are excellent.

Intraoperative Assessment of Tibiofemoral Contact Stresses in Total Knee Arthroplasty

The production of polyethylene wear debris in total knee arthroplasty (TKA) is due to multiple factors. In particular, inadequate implant alignment and high bearing surface contact stresses are associated with polyethylene failure. Optimal implant placement and soft tissue balancing may contribute to reducing wear and the production of polyethylene particles. We present a case in which a quantitative technique was used to measure tibiofemoral contact stresses during implantation of a total knee prosthesis in vivo. In a knee with preoperative varus and fixed flexion deformity, medial compartment contact stresses after initial resection were reduced from 14.3 MPa to 11.3 MPa in neutral alignment by additional bone resection. Posterior cruciate release was required to reduce contact stresses further and to provide satisfactory balance between medial and lateral compartments, as determined by the operating surgeon, and was confirmed by the measurement system (3.8 MPa medially; 3.0 MPa laterally). This technique has potential to fine-tune implant positioning and ligament balancing during TKA.

Lateral hip pain: does imaging predict response to localized injection?

Lateral hip pain is a common complaint in patients with a history of lower back pain from spinal disease. These patients often are diagnosed and treated for trochanteric bursitis because of localized pain and tenderness in the lateral hip. We presumed numerous scintigraphic features could provide diagnostic criteria for diagnosing gluteus medius tendinitis and trochanteric bursitis. A study was designed to assess the scintigraphic criteria for diagnosis of trochanteric bursitis and to evaluate the relationship of trochanteric bursitis to gluteus medius tendinitis and lumbar degenerative disease in predicting relapse after injection. We evaluated 97 patients with greater trochanteric pain syndrome to find a correlation between trochanteric bursitis, gluteus medius tendinitis, and spinal degenerative disease using scintigraphy and magnetic resonance imaging. We also evaluated predictors for responding to trochanteric injection of local anesthetic/glucocorticoid injection. We found a correlation between lumbar degenerative disease, gluteus medius tendinopathy, and trochanteric bursitis. Of these, 30 of 48 patients (63%) responded to injection of local anesthetic and glucocorticoids. The major predictor of relapse of pain after injection in 18 patients was the presence of moderate to severe lumbar degenerative disease seen on scintigraphic imaging. We propose a mechanistic model of the greater trochanteric pain syndrome to explain the interrelationship and response to therapy. Scintigraphy can provide sensitive and specific diagnoses of gluteus medius tendinitis and trochanteric bursitis.Level of evidence: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Surgical management of large rotator cuff tears combined with instability in elite rugby football players

Large rotator cuff tears are extremely uncommon in young people and when they occur they may be associated with shoulder instability. This paper reports on a series of six elite rugby union and rugby league footballers who presented with shoulder instability and large rotator cuff tears. They were treated with a two stage procedure: an open rotator cuff repair followed by an open shoulder stabilisation some 10 weeks later. All had successful outcomes. The paper also highlights the risk of tearing the rotator cuff when a patient continues to play contact sport with an untreated unstable shoulder.

The influence of design parameters on cortical strain distribution of a cementless titanium femoral stem

The strain distribution imposed on a femur following a total joint replacement is an important factor, in proximal bone loss due to stress shielding, and long term clinical success. This study investigated how five different design parameters of a cementless titanium femoral prosthesis influenced cortical strains. Test loads were applied and strains were measured with and without an abductor force simulation, using six human cadaveric femora. The cementless design used demonstrated significant calcar loading proximally and a similar strain distribution to the intact femur distally. Implant gross geometry was the major factor in determining the cortical strain distributions under abductor simulation in both axial and torsional loading.

Infection or Allergy in the Painful Metal-on-Metal Total Hip Arthroplasty?

Metal-on-metal articulations are increasingly used in total hip arthroplasty. Patients can be sensitive to metal ions produced by the articulation and present with pain or early loosening. Infection must be excluded. Correct diagnosis before revision surgery is crucial to implant selection and operation planning. There is no practical guide in the literature on how to differentiate between allergy and infection in a painful total hip arthroplasty. We present the history, clinical findings and hip scores, radiology, serology, hip arthroscopy and aspirate results, labeled white cell scan, revision-hip findings, histology and clinical results of a typical patient with a hypersensitivity response to a metal-on-metal hip articulation, and how results differ from patients with an infected implant. A practical scheme to investigate patients with a possible hypersensitivity response to an implant is presented.

The accuracy of bone resections made during computer navigated total knee replacement. Do we resect what the computer plans we resect

Many studies have shown that computer navigation in total knee arthroplasty aids the surgeon to place the prosthesis in a more accurate overall alignment. Bony resection creates the flexion and extension gaps; important in balancing the knee and implant selection in TKR. The computer plans the bone cuts but has variables that it cannot control: the surgeon, the saw blade thickness and oscillation, the accuracy of the jigs, movement of the pins, and the quality of initial mapping data inputted by the surgeon. The accuracy of computer navigated bone resections are validated on cadavers, but this is the first study to compare the predicted bone cuts to that physically resected during TKR. For 89 patients undergoing primary TKR, the bone cut from the distal femur and proximal tibia was measured using Vernier callipers and compared to the computer calculation of the same. Results show that computer measurement of the physical space left by the resected bone is accurate.

Tc-99m Stannous Colloid-Labeled Leukocyte Scintigraphy in the Evaluation of the Painful Arthroplasty

The aim of this study was to evaluate the utility of scintigraphy using leukocytes labeled with Tc-99m stannous colloid in the assessment of painful arthroplasties. The results of three-phase bone scintigraphy and imaging with Tc-99m-labeled leukocytes in 40 patients with painful joint prostheses, requiring the exclusion of infection are reported. Results were compared with microbiologic culture and/or long-term clinical review. Bone scintigraphy had a sensitivity of 100%, a specificity of 64%, and a diagnostic accuracy of 73% in detecting prosthetic infection. Tc-99m-labeled leukocytes yielded a sensitivity of 70%, a specificity of 100%, and a diagnostic accuracy of 93%. Leukocyte scintigraphy improves the specificity of bone scintigraphy in the assessment of the painful prosthetic joint. A positive study is highly suggestive of infection and warrants appropriate treatment.