Centralizing the Cemented Exeter Femoral Stem Using the Direct Lateral Approach: Surgical Tips and Radiological Evaluation.

Varus malalignment in total hip arthroplasty has been associated with poor long-term outcomes and complications including abnormal load distribution, endosteal osteolysis, frank loosening, and periprosthetic fractures. Postoperative radiographic assessment was performed on 224 patients from our case series who underwent cemented Exeter total hip arthroplasty using the direct lateral approach alone. No patient had a true varus-aligned stem (ie, ≤-5° on the coronal assessment). We describe our surgical technique, with 4 easily reproducible technical tips to achieve positional consistency of the femoral stem: commencing stem insertion from the piriform fossa entry point, using a femoral stem distal centralizer, aiming the tip of the component to the center of the patella, and placing the thumb between the calcar and inferior neck of the femoral component to prevent the stem from tipping into varus.

Review of evolution of tunnel position in anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) rupture is one of the commonest knee sport injuries. The annual incidence of the ACL injury is between 100000-200000 in the United States. Worldwide around 400000 ACL reconstructions are performed in a year. The goal of ACL reconstruction is to restore the normal knee anatomy and kinesiology. The tibial and femoral tunnel placements are of primordial importance in achieving this outcome. Other factors that influence successful reconstruction are types of grafts, surgical techniques and rehabilitation programmes. A comprehensive understanding of ACL anatomy has led to the development of newer techniques supplemented by more robust biological and mechanical concepts. In this review we are mainly focussing on the evolution of tunnel placement in ACL reconstruction, focusing on three main categories, i.e., anatomical, biological and clinical outcomes. The importance of tunnel placement in the success of ACL reconstruction is well researched. Definite clinical and functional data is lacking to establish the superiority of the single or double bundle reconstruction technique. While there is a trend towards the use of anteromedial portals for femoral tunnel placement, their clinical superiority over trans-tibial tunnels is yet to be established.

Stem cell engineered bone with calcium-phosphate coated porous titanium scaffold or silicon hydroxyapatite granules for revision total joint arthroplasty.

Aseptic loosening in total joint replacements (TJRs) is mainly caused by osteolysis which leads to a reduction of the bone stock necessary for implant fixation in revision TJRs. Our aim was to develop bone tissue-engineered constructs based on scaffolds of clinical relevance in revision TJRs to reconstitute the bone stock at revision operations by using a perfusion bioreactor system (PBRS). The hypothesis was that a PBRS will enhance mesenchymal stem cells (MSCs) proliferation and osteogenic differentiation and will provide an even distribution of MSCs throughout the scaffolds when compared to static cultures. A PBRS was designed and implemented. Scaffolds, silicon substituted hydroxyapatite granules and calcium-phosphate coated porous TiAl6V4 cylinders, were seeded with MSCs and cultured either in static conditions or in the PBRS at 0.75 mL/min. Statistically significant increased cell proliferation and alkaline phosphatase activity was found in samples cultured in the PBRS. Histology revealed a more even cell distribution in the perfused constructs. SEM showed that cells arranged in sheets. Long cytoplasmic processes attached the cells to the scaffolds. We conclude that a novel tissue engineering approach to address the issue of poor bone stock at revision operations is feasible by using a PBRS.

An osteoconductive, osteoinductive, and osteogenic tissue-engineered product for trauma and orthopaedic surgery: how far are we?

The management of large bone defects due to trauma, degenerative disease, congenital deformities, and tumor resection remains a complex issue for the orthopaedic reconstructive surgeons. The requirement is for an ideal bone replacement which is osteoconductive, osteoinductive, and osteogenic. Autologous bone grafts are still considered the gold standard for reconstruction of bone defects, but donor site morbidity and size limitations are major concern. The use of bioartificial bone tissues may help to overcome these problems. The reconstruction of large volume defects remains a challenge despite the success of reconstruction of small-to-moderate-sized bone defects using engineered bone tissues. The aim of this paper is to understand the principles of tissue engineering of bone and its clinical applications in reconstructive surgery.

The use of interlocking prostheses for both temporary and definitive management of infected periprosthetic femoral fractures.

Infected periprosthetic fractures around total hip arthroplasties are an extremely challenging problem. We describe our experience of managing infected periprosthetic femoral fractures using interlocking long-stem femoral prostheses either as temporary functional spacers or as definitive implants. The Cannulock (Orthodesign, Christchurch, United Kingdom) uncoated stem was used in 12 cases, and the Kent hip prosthesis (Biomet Merck, Bridgend, United Kingdom), in 5 cases. Satisfactory outcome was noted in all cases, and in 11 cases, revision to a definitive stem has been undertaken after successful control of infection and fracture union. The use of interlocking stems offers a relatively appealing solution for a complex problem and avoids the complications that would be associated with resection of the entire femur or the use of large quantities of bone cement.

Gluteus medius tears: an under-diagnosed pathology.

Tears of the gluteus medius tendon contribute to greater trochanteric pain syndrome, but they are often overlooked as a cause of lateral hip pain and tenderness. This review presents the relevant anatomy, pathophysiology, diagnostic workup, differential diagnosis and management of these tears.

Periprosthetic femoral fractures in total hip arthroplasty - a review.

Periprosthetic femoral fractures (PFF) are among the more difficult and expensive complications of total hip arthroplasty. A rise in the elderly population and increase use of primary hip replacement has led to an escalating incidence. They can occur intra operatively and post operatively. The treatment algorithm defined by the Vancouver classification has universal acceptance. The epidemiology, etiology, classification and the management of periprosthetic femoral fractures in total hip arthroplasty are reviewed.

Common extensor origin release in recalcitrant lateral epicondylitis - role justified?

The aim of our study was to analyse the efficacy of operative management in recalcitrant lateral epicondylitis of elbow. Forty patients included in this study were referred by general practitioners with a diagnosis of tennis elbow to the orthopaedic department at a district general hospital over a five year period. All had two or more steroid injections at the tender spot, without permanent relief of pain. All subsequently underwent simple fasciotomy of the extensor origin. Of forty patients thirty five had improvement in pain and function, two had persistent symptoms and three did not perceive any improvement. Twenty five had excellent, ten had well, two had fair and three had poor outcomes (recurrent problem; pain at rest and night). Two patients underwent revision surgery. Majority of the patients had improvement in pain and function following operative treatment. In this study, an extensor fasciotomy was demonstrated to be an effective treatment for refractory chronic lateral epicondylitis; however, further studies are warranted.

Uncemented revision hip arthroplasty in B2 and B3 periprosthetic femoral fractures - A prospective analysis.

Periprosthetic femoral fractures are an increasingly common complication of total hip arthroplasty. If there is a fracture of the femur in the presence of an unstable prosthesis (Vancouver type B2 and B3), revision of the stem is imperative. We describe our experience of cementless femoral revision in management of twenty-six patients who sustained periprosthetic fractures of the Vancouver type B2 or B3, between February 1999 and March 2005. All patients were managed by revision arthroplasty, using cementless femoral stems. Cortical struts, cable plating systems, bone allograft and demineralised bone matrix were used to aid the reconstruction where indicated. All the fractures had clinical and radiological union. The outcome was graded, subjectively as satisfactory by all patients and this is substantiated objectively, by a post operative mean Harris hip score of 83.04. Uncemented revision appears to be an attractive option for periprosthetic fractures with unstable femoral stems.

Preoperative digital templating of Birmingham hip resurfacing.

The aim of our study was to determine the usefulness of preoperative digital templating of Birmingham hip resurfacing (BHR). This prospective cohort of 30 consecutive Birmingham hip resurfacings was templated digitally by two senior hip arthroplasty fellows (GM, JG) independently. A blinded observer then collated information on the actual implant sizes intraoperatively and used this to statistically analyse the correlation (Interclass correlation coefficient) between the digitally templated implant sizes and the actual implant sizes used. A significantly high rate of coincidence between digitally templated estimates and the actual implant sizes was noted for both groups of templates. The Intra class correlation coefficient (ICC) for the acetabular cup in the two groups were 0.798, p=0.013 and 0.870, p=0.0001. For the femoral component, the ICC values in the two groups were 0.888, p=0.005 and 0.784, p=0.003. Similarly a high reliability of digital templating was noted for both acetabular (0.823, 0.888) and femoral components (0.777, 0.8132). In conclusion, digital templating can reliably estimate implant sizes in Birmingham hip resurfacing.

Management of late periprosthetic femur fractures: a retrospective cohort of 72 patients.

We present our series of 72 patients with periprosthetic fractures. The Vancouver classification was used to evaluate the fractures; there was one type A, seven type B1, 42 type B2, 17 type B3 and five type C fractures. Demographics, pre and postoperative data using Charnley-D'Aubigne-Postel score for assessment of function were recorded. The mean follow-up for all patients was two years. The overall outcome of treatment was graded as excellent, good or poor. An excellent result indicated that the arthroplasty was stable with minimal deformity and no shortening. Stable subsidence of the prosthesis or when the fracture healed with moderate deformity or shortening was deemed as a good result. A loose prosthesis, nonunion, sepsis, severe deformity or shortening was considered poor. In our series 79% (n = 57) had good or excellent results following surgical intervention and 21% (n = 15) had complications; they all had undergone re-operation for various reasons such as nonunion, loosening, dislocation or infection. In B2 fractures the stem is unstable and hence revision of the prosthetic stem has been recommended with or without additional fixation. For B3 fractures an allograft prosthesis composite or tumour prosthesis is considered the treatment choice.

Odontoid metastasis: a potential lethal complication.

Nearly one third of cervical spine metastasis has a primary breast malignancy. Patients with cervical metastasis have higher mortality due to advanced stage of the malignancy. Treatment is palliative to relieve pain, prevent pathological fracture, improve mobility and function, and prolong survival. We describe a 40-year-old woman with a history of breast cancer who presented with neck and shoulder pain of 1 week duration with no neurological deficit. Following clinical examination, radiographs taken of the cervical spine was normal. Radiographs repeated 3 weeks later revealed a large lytic lesion of the odontoid occupying 70-80% of the peg. Further investigation including magnetic resonance imaging and bone scan showed no further spinal lesions. She underwent cyclical radiotherapy with complete resolution of the odontoid peg lesion and clinically was asymptomatic at 2 years. Metastatic lesions of the odontoid are atypical, and this case reinforces the necessity of early detection to evade disastrous consequences.

The role of impaction grafting: the when and how.

The challenges of acetabular revision include bone loss and poor bone biology. Favorable 10-year reports exist of uncemented acetabular revision using hemispherical uncemented sockets. In the presence of bone stock deficiency, adjunctive morsellized impaction bone grafting is a recognized means of restoring bone stock. We attempt to restore bone stock with impaction grafting beneath a cementless cup for contained defects, defects that can be rendered contained, and whenever there is capacity for rim fixation. The technique of bone graft preparation is important. We use a mixture of bone milling and bone chips of various sizes. Morsellized allograft is inserted, packed, and/or reverse reamed into any defects. The reconstruction relies on the ability to gain biological fixation of the component to the underlying host bone. This requires intimate host bone contact and rigid implant stability. The fixation is therefore augmented with screws in all cases. It is important to achieve host bone contact in a least part of the dome and posterior column. When this is possible, and particularly when there is a good rim fit, we have not found it absolutely necessary to have contact with host bone over >50% of the surface. Stability of primary fixation is a better predictor of outcome than volume of graft or percentage of host bone contact. The advantages of bone grafting in acetabular reconstruction include the ability to restore bone stock, rebuild a normal hip center and hip biomechanics, and increase bone stock for future revisions.

Do physical diagnostic tests accurately detect meniscal tears?

Numerous physical tests have been described but their diagnostic accuracy is often questioned. Karachalios et al. described the new 'Thessaly test' and concluded that it could be safely used as a first line screening test for the selection of patients who need arthroscopic meniscal surgery. Our objective was to study the role of physical diagnostic tests in screening for meniscal tears and to validate the diagnostic accuracy of the Thessaly test. We examined 109 patients (80 male, 29 female; average age: 39 years; range: 16-56) who were presented with a history suggestive of a meniscal tear. Joint line tenderness, McMurray's test, and the Thessaly test were assessed by an independent investigator blinded to any imaging data in all patients. MRI and subsequent arthroscopy results were then collated. Our study showed a much lower diagnostic accuracy for the Thessaly test (61% for medial meniscus and 80% for lateral meniscus). It is comparable to McMurray's test (57% for medial meniscus and 77% for lateral meniscus). The Joint line tenderness test has a far superior diagnostic accuracy (81% for medial meniscus and 90% for lateral meniscus). However, combining the joint line tenderness test with McMurray's test or the joint line tenderness test with Thessaly test further increased the accuracy of physical diagnosis of meniscal tears. Magnetic resonance imaging (MRI) detected 96% of meniscal tears. Physical tests may not always be diagnostic of meniscal tears. MRI and arthroscopy may be essential in dubious clinical presentations and especially where more than one pathology is suspected. Our study showed that the Thessaly test in isolation was not useful for the detection of meniscal tears but it helps to increase diagnostic certainty when combined with other standard tests.

Correction of neglected clubfoot deformity in children with Moebius syndrome.

The aim of this study was to present the functional results of treatment of neglected clubfoot in children with Moebius syndrome. A prospective analysis of seven patients with Moebius syndrome who had corrective surgery for clubfoot deformity was performed. Functional result using a modified American Orthopaedic Foot and Ankle Society (AOFAS) questionnaire at an average follow-up of 58 months was analysed. Five children were able to have their foot flat on the ground. Additional corrective surgery was required in eight feet. Our experience of treating neglected clubfoot deformity in children with Moebius syndrome shows that correction of the deformity allows them to have a reasonable independent living.