Reliability of the jones patellofemoral osteoarthritis score for radiological assessment of patellofemoral degenerative changes: comparing a physiotherapist to doctors.

PURPOSE: Radiological measurement scores are used by orthopaedic physiotherapists in triage and surveillance of patients with degenerative changes of the tibiofemoral and patellofemoral joints. The purpose of this study was to estimate the intra- and inter-observer reliability of a radiological measurement score to assess patellofemoral joint osteoarthritis, the Jones Patellofemoral Osteoarthritis Score (JPOS), with an orthopaedic physiotherapist and three grades of junior surgeons/doctors. METHODS: A total of 390 skyline X-rays of the patellofemoral joint were reviewed on 2 occasions, 4 weeks apart, by an orthopaedic physiotherapist, 2 orthopaedic surgeons, and an orthopaedic doctor. Intra- and inter-observer reliability of the JPOS was calculated using a weighted kappa analysis. RESULTS: The results indicated that while there was good overall intra-observer agreement for this measurement score for all assessors, inter-observer reliability was generally poor between the orthopaedic physiotherapist and the orthopaedic surgeons/doctor. CONCLUSION: Our findings call into question the use of the JPOS by orthopaedic physiotherapists working in triage or orthopaedic surveillance programmes with other orthopaedic clinicians.

Objectif : Les mesures radiologiques sont utilisées par les physiothérapeutes orthopédiques pour le triage et la surveillance des patients qui vivent des changements dégénératifs à l'articulation fémorotibiale et à l'articulation patellofémorale. L'objectif de cette étude était d'estimer, avec un physiothérapeute orthopédique et trois catégories de chirurgiens et médecins novices, la fiabilité intra et interobservateur d'une mesure radiologique pour l'évaluation de l'arthrose patellofémorale à l'aide de l'échelle d'arthrose patellofémorale de Jones (JPOS). Méthode : Au total, 390 incidences fémoropatellaires ont été examinées en deux occasions, à quatre semaines d'intervalle, par un physiothérapeute orthopédique, par deux chirurgiens orthopédiques et par un orthopédiste. La fiabilité intra et interobservateur de la JPOS a été calculée à l'aide du coefficient Kappa pondéré. Résultats : Les résultats ont indiqué que bien que tous les évaluateurs étaient plutôt d'accord avec cette échelle de mesure, la fiabilité interobservateur était généralement faible entre les physiothérapeutes orthopédiques et les chirurgiens orthopédiques et orthopédistes. Conclusion : Nos conclusions remettent en questions l'utilisation due la JPOS par les physiothérapeutes orthopédiques qui travaillent au triage ou dans des programmes de surveillance orthopédique avec d'autres cliniciens en orthopédie.

Assessment of radiolucent lines around the Oxford unicompartmental knee replacement: sensitivity and specificity for loosening.

The Oxford unicompartmental knee replacement gives good results in patients with symptomatic osteoarthritis of the medial compartment. Previous studies have suggested that the presence of radiolucent lines (RLLs) does not reflect a poor outcome in such patients. However, the reliability and validity of this assessment have not been determined. Our aim was to assess the intra- and interobserver reliability and the sensitivity and specificity of the assessment of RLLs around both tibial and femoral components using standard radiographs. Two reviewers assessed the radiographs of 45 patients who had loosening of the tibial or femoral component confirmed at revision surgery and compared them with those of a series of 45 asymptomatic patients matched for age and gender. The results suggested that, using standard radiographs, tibial RLLs were 63.6% sensitive and 94.4% specific and femoral RLLs 63.9% sensitive and 72.7% specific for loosening. Overall intra- and interobserver reliability was highly variable, but zonal analysis showed that lucency at the tip of the femoral peg was significantly associated with loosening of the femoral component. Fluoroscopically guided radiographs may improve the zonal reliability of the assessment of RLLs, but further independent and comparative studies are required. In the meantime, the innocence of the physiological RLLs detected by standard radiographs should be viewed with caution.

Pre-operative patellofemoral degenerative changes do not affect the outcome after medial Oxford unicompartmental knee replacement: a report from an independent centre.

There has been debate about the role of unicompartmental knee replacement in the presence of radiologically identifiable degenerative changes of the patellofemoral joint. We studied 195 knees in 163 patients in whom an Oxford unicompartmental knee replacement had been performed for medial osteoarthritis between January 2004 and July 2007. The mean age of the patients was 66 years (51 to 93). The degree of degenerative change of the patellofemoral joint was assessed using Jones' criteria. Functional outcome was assessed at a mean of 3.4 years (2 to 7) post-operatively, using the Oxford knee score and the Short-form 12 score. Degenerative changes of the patellofemoral joint were seen pre-operatively in 125 knees (64%) on the skyline radiographs. There was no statistically significant difference in the Oxford knee or Short-form 12 scores between those patients who had patellofemoral osteoarthritis pre-operatively and those who did not (p = 0.22 and 0.54, respectively). These results support the opinion expressed at the designer's hospital that degenerative changes of the patellofemoral joint in isolation should not be considered to be a contraindication to medial Oxford unicompartmental knee replacement.

One-stage versus two-stage bilateral unicompartmental knee replacement: a comparison of immediate post-operative complications.

We retrospectively studied the major complications occurring after one- and two-stage bilateral unicompartmental knee replacements (UKR). Between 1999 and 2008, 911 patients underwent 1150 UKRs through a minimally invasive approach in our unit. Of these, 159 patients (318 UKRs) had one-stage and 80 patients (160 UKRs) had two-stage bilateral UKRs. The bilateral UKR groups were comparable in age and American Society of Anaesthesiology grade, but more women were in the two-stage group (p = 0.019). Mechanical thromboprophylaxis was used in all cases. Major complications were recorded as death, pulmonary embolus, proximal deep-vein thrombosis and adverse cardiac events within 30 days of surgery. No statistical differences between the groups were found regarding the operating surgeon, the tourniquet time or minor complications except for distal deep-vein thrombosis. The anaesthetic times were longer for the two-stage group (p = 0.0001). Major complications were seen in 13 patients (8.2%) with one-stage operations but none were encountered in the two-stage group (p = 0.005). Distal deep-vein thrombosis was more frequent in the two-stage group (p = 0.036). Because of the significantly higher risk of major complications associated with one-stage bilateral UKR we advocate caution before undertaking such a procedure.

The continued value of clinical and radiological surveillance: the Charnley Elite Plus hip replacement system at 12 years.

We report the follow-up at 12 years of the use of the Elite Plus total hip replacement (THR). We have previously reported the results at a mean of 6.4 years. Of the 217 patients (234 THRs), 83 had died and nine had been lost to follow-up. The patients were reviewed radiologically and clinically using the Oxford hip score. Of the 234 THRs, 19 (8.1%) had required a revision by the final follow-up in all but one for aseptic loosening. Survivorship analysis for revision showed a survival of 93.9% (95% confidence interval (CI) 89.2 to 96.5) at ten years, and of 88.0% (95% CI 81.8 to 92.3) at 12 years. At the final follow-up survival analysis showed that 37% (95% CI 37.3 to 44.7) of the prostheses had either failed radiologically or had been revised. Patients with a radiologically loose femoral component had a significantly poorer Oxford hip score than those with a well-fixed component (p = 0.03). Radiological loosening at 6.4 years was predictive of failure at 12 years. Medium-term radiographs and clinical scores should be included in the surveillance of THR to give an early indication of the performance of specific implants.

Pseudoaneurysm of a branch of the profunda femoris artery following distal locking of an intramedullary hip nail: an unusual anatomical location.

Vascular complications following internal fixation of trochanteric femoral fractures are extremely rare. Iatrogenic injury to the profunda femoris artery or one of its branches and resultant pseudoaneurysm formation has been documented, most commonly following sliding hip screw fixation and typically arises on the posteromedial aspect of the femur. We report an unusual variation, following proximal femoral nailing of an intertrochanteric femoral neck fracture, where the pseudoaneurysm presented four weeks following surgery on the posterolateral aspect of the femur. The mechanism of injury, clinical presentation and potential preventative measures are discussed.

Outcome of traumatic subtrochanteric femoral fractures fixed using cephalo-medullary nails.

We performed a retrospective review of 101 patients sustaining 102 traumatic, non-pathological subtrochanteric fractures treated with cephalo-medullary nailing over a period of 6 years from 1999 to 2005. Mean follow up was 24 weeks (range: 6-96). Twenty patients were lost to follow up and 21 died, whilst 57 of 60 fractures were followed to union. There were 19 fractures fixed in varus, as defined as a varus angulation of greater than 10 degrees at the fracture site. Implant failure, 9 of the 10 malunions and all 3 of the non-unions occurred in the varus group whilst only 1 malunion occurred in the satisfactory reduction group. This difference in outcome is statistically significant (p<0.0001). Twenty four of the 60 patients had undergone open reduction at the time of fixation. There were three malunions and one non-union in the open reduction group compared with six and two, respectively in the closed group (p>0.05). Post-operative recovery rates, infection rates and other complications were similar for both groups. We therefore advocate the use of open reduction where necessary to avoid varus malreduction to avoid such complications, particularly as open reduction was not associated with a higher complication rate in this series. The study supports the use of cephalo-medullary nailing for subtrochanteric fractures with a union rate of 95%.

Femoral neck-shaft angle in extra-capsular proximal femoral fracture fixation; does it make a TAD of difference?

The effect of femoral neck-shaft angle and implant type on the accuracy of lag screw placement in extra-capsular proximal femoral fracture fixation was investigated. Radiographs of all extra-capsular proximal femoral fractures seen in one unit over 18 months were reviewed. Of 399 cases, 307 (237 female, 70 male) were included in the study as they had no contra-lateral proximal femoral metal work. Femoral neck-shaft angle (NSA) of the uninjured hip and magnification adjusted tip-apex distance (TAD) of femoral head lag screw were measured. Type of fixation implant was 135 degrees classic hip screw (CHS) (n=144) or 130 degrees intra-medullary hip screw (IMHS) (n=163). Mean contra-lateral NSA was 130.2 degrees (112.9--148 degrees ) and 64 patients (58 female, 6 male) had a NSA <125 degrees . Mean adjusted TAD was 18.7 mm (5.8--43.8mm) and 88.9% of cases had a TAD of less than 25 mm. TAD values were significantly greater using an IMHS if NSA was <125 degrees than if NSA was >125 degrees (p=0.028). This was not the case with the CHS. The use of the 130 degrees -IMHS in patients with a NSA <125 degrees leads to poorer lag screw placement than if NSA >125 degrees and caution is advocated when using this device in such cases.

Arthrofibrosis following total knee replacement; does therapeutic warfarin make a difference?

Arthrofibrosis following total knee replacement (TKR) is a relatively common complication which results in a reduction in knee range of movement and patient dissatisfaction. A retrospective study examined the relationship between anticoagulation with therapeutic warfarin and rates of arthrofibrosis following TKR. Arthrofibrosis was defined as less than 80 degrees of knee flexion 6-8 weeks post-TKR. Patients were warfarinised if they had a history of thrombophilic tendencies or medical conditions necessitating anti-coagulation, rather than as routine thromboprophylaxis. All other patients received thromboprophylaxis using low molecular weight heparin. A total of 728 patients underwent 874 primary TKR between 1993 and 2002 in one centre, performed by four surgeons. Mean age was 68 years (range 48-89 years) and there were 483 female and 391 male knees. Eighty cases were warfarinised post-operatively (53 female, 27 male). Overall, 83 of 874 TKRs (9%) had arthrofibrosis (57 female, 26 male) requiring manipulation under anaesthetic (MUA). In the warfarinised group, 21 knees (26%) had an MUA (15 female, 6 male). This compared to 62 cases (8%) requiring MUA in the non-warfarinised group (42 female, 20 male). There was a statistically significant difference on Fisher's exact testing (P<0.0001) between groups. Following MUA, knee flexion improved in 95% cases to a minimum 95 degrees but 8 cases had a fixed flexion deformity of 5-10 degrees . In conclusion, therapeutic warfarinisation post-TKR leads to a statistically greater chance of the patient developing arthrofibrosis compared to prophylactic low molecular weight heparin and that patients should be counseled appropriately.

The Elite Plus total hip arthroplasty: the need for radiological surveillance.

We prospectively studied 217 patients who underwent 234 Elite Plus total hip arthroplasties. At a mean of 6.4 (SD 0.7) years post-operatively, 39 patients had died and 22 were either lost to follow-up or had no radiographs available. Clinical (Oxford hip score) and radiological assessments were performed on 156 patients (168 hip arthroplasties) who had a mean age of 67.7 (SD 9.7) years at operation. In the assessed group, 26 of 159 (16.4%) of femoral stems which had not already been revised and 19 of 159 (11.9%) of acetabular cups were definitely loose. In total, 52 of 168 (31%) of hips had either been revised or had definite evidence of loosening of a component. We could not establish any relationship between clinical and radiological outcomes. Despite the fact that the clinical outcome and rate of revision for the Elite Plus appeared to meet international standards, our findings give us cause for concern. We believe that joint registries should include radiological surveillance in order to provide reliable information about medium-term outcomes for hip prostheses.

Chondral degeneration and therapeutic hip arthroscopy.

Therapeutic hip arthroscopy for the treatment of chondral degeneration remains controversial. A retrospective cohort study examined 70 patients of mean age 47 (range 22-87) years who had undergone hip arthroscopy and assessed them for evidence of chondral degeneration using radiological and arthroscopic means. Clinical outcome was assessed using a modified Farjo and Glick classification. Thirty-nine patients had evidence of chondral degeneration on arthroscopy with or without radiological diagnosis, and 31 had alternative pathology. If patients were found to have chondral degeneration at arthroscopy, they were significantly more likely to have a poor clinical result than if an alternative diagnosis such as a loose body or labral tear was made (p<0.0001). Patients with evidence of degenerative changes on plain hip radiographs were significantly more likely to have a poor clinical result following hip arthroscopy than patients with unremarkable hip radiographs (p<0.0001). Therapeutic hip arthroscopy for osteoarthritis should be used with caution, as a poor clinical result is significantly more likely compared to other pathologies such as a labral tear or loose body.

Patient-perceived outcome measures following unicompartmental knee arthroplasty with mini-incision.

We reviewed 150 patients (183 knees) who underwent mini-incision unicompartmental knee arthroplasty (Oxford). Mean age was 71.5 (36-92) years. Review was conducted at least 12 months following surgery. To assess results, we used the Oxford knee questionnaire, modified Grimby score, return to sport and work, knee "normality" and patient general health. The mean Oxford knee score was 22.17 (range 12-54). Kneeling scored worse than other activities. No significant age or gender difference was found. Mean modified Grimby score was 3.89, equating to moderate exercise less than 2 h a week. Patients with "artificial-feeling" knees had significantly worse scores than patients with normal/near-normal-feeling knees. Patients who returned to/increased sporting activity had better Oxford scores than those who did not. Ninety-four percent of patients working pre-operatively returned to work. Sixty-seven percent continued at the same level of or increased sporting activity. Oxford knee scores and return to sport compared well to published data. Results regarding modified Grimby score, return to work and pain relief were encouraging. The best results were achieved in active patients who felt their health was good and their knee felt normal or near normal following surgery.

Screening time for extra-capsular proximal femoral fracture fixation; the difference between extra-medullary and intra-medullary implant usage.

The aim of this study was to compare the fluoroscopic screening time used for treatment of fractures of the trochanteric region of the femur using two different implant systems. Data were collected from 277 proximal femoral fracture fixations. A dynamic hip screw (DHS) was used in 145, and an intra-medullary hip screw (IMHS) was used in 132. There was no difference between the two groups with respect to age, gender or side. Altogether, there were 42% two parts, 35% were three parts and 23% were four parts extra-capsular neck fractures. There was no statistical difference in ionising radiation exposure in closed reduction of these fractures regardless of the fracture configuration or surgical experience of the surgeon. The mean screening time to implant a DHS in two part fractures was 0.48 min, for three part fractures it was 0.45 min and for four part fractures it was 0.46 min. The mean screening time to implant IMHS was 1.02 min for two part fractures, 0.96 min for three part fractures and 1.03 min for four part fractures. These differences were statistically significant (P < or = 0.05).

AO or Schatzker? How reliable is classification of tibial plateau fractures?

INTRODUCTION: We compare the intra- and interobserver reproducibility of classifications of tibial plateau fractures most commonly used in our clinical practice. These were the AO and Schatzker classifications. PATIENTS AND METHODS: Agreement was measured using kappa coefficients on the data obtained from three observers reviewing 30 fractures and these values were interpreted according to Landis and Koch. RESULTS: It was found that both classifications were substantially reliable with regards to intraobserver reliability but that the Schatzker system was only fairly reliable and the AO classification moderately reliable with regards to interobserver reliability. Breaking down the AO classification, with regards to intraobserver reliability, the AO group was substantially reliable and the type excellently reliable. For interobserver reliability, the AO group was moderately reliable while the AO type was substantially reliable. CONCLUSION: For tibial plateau fractures seen on plain x-ray, the AO classification is more reliable between observers than the Schatzker classification.

Idiopathic radial artery aneurysm in the anatomical snuff box.

An otherwise fit and well 40-year-old left-handed male computer operator presented with a minimally symptomatic lump of 2 years duration in his non-dominant anatomical snuffbox. There was no history of trauma. This was pulsatile and did not transilluminate despite being referred as a ganglion. MRI scan confirmed the presence of a 1.5 cm radial artery aneurysm fed by the radial artery and draining to the second digital artery. In view of his lack of symptoms the patient declined surgical intervention. Literature review reveals radial artery aneurysms to be very rare and usually traumatic in origin. Iatrogenic pseudoaneurysms are widely reported following cannulation. We are unaware of previous descriptions of an idiopathic, isolated radial artery aneurysm.

Treatment of unstable distal radial fractures by intrafocal, intramedullary K-wires.

Displaced distal radial fractures with extensive dorsal comminution and plastic cancellous deformation are unstable and frequently cause treatment problems since there is no single, reliable method of treatment, notably in osteoporotic bone. We present a method of holding unstable distal radial fractures with blunt ended K-wires via intrafocal and intramedullary insertion, so modifying the Kapandji technique. Wires were placed dorsally, radially and when necessary from the volar direction depending on fracture configuration. Over a 7-year period (1992-1999) we treated 102 patients with unstable distal radial fractures in this way. Of these, 80 were followed up for 6-42 weeks according to clinical need and scored radiologically and functionally using modified Lidstrom scoring system. Results showed that 92 and 95% of these patients achieved good or excellent results in these scoring systems, respectively. We present this as a useful and reliable method of treating these common fractures, particularly in osteoporotic bone.

The musculoskeletal manifestations of Werner's syndrome.

Werner's syndrome is a rare condition usually presenting as premature ageing in adults. Over a period of 30 years we have followed two siblings with extensive musculoskeletal manifestations including a soft-tissue tumour, insufficiency fractures, nonunion and tendonitis, with associated problems of management. The literature is reviewed.