International Orthopaedics

Published by Springer Verlag
Online ISSN: 1432-5195
Publications
Article
We regret that the value of serum CRP was reported incorrectly. Serum CRP levels were reported incorrectly to be 10 times higher than their true value. The value of serum CRP in osteoarthritis patients following total knee arthroplasty should have been reported in milligrams per litre (mg/l), instead ofmilligrams per decilitre (mg/dl) for the whole article. The authors apologise for this error.
 
Article
This is an analysis from one hospital of the first 1043 operations where pure self-reinforced poly-L-lactide (SR-PLLA) implants have been used alone. The operations were performed between 1988 and 1999 and included 407 orthopaedic patients and 636 trauma patients. There was a total of 107 complications. There were 21 infections but no sinus formation. Failure of fixation was seen in 46 patients. In 936 operations the healing was uneventful. C'est une analyse, au sein d'un même hôpital des 1043 premières opérations où des implants de poly-L-lactide auto-renforcé pur (SR-PLLA) ont été utilisés de façon isolée. Les opérations ont été faites entre 1988 et 1999 et ont inclus 407 malades orthopédiques et 636 malades traumatisés. Il y avait un total de 107 complications. Il y avait 21 infections mais aucune fistulisation. L'échec de fixation a été noté chez 46 malades. Dans 936 opérations la guérison était obtenue sans incident.
 
Article
When HEBP (1-hydroxyethylidene-1, 1-biphosphonic acid) was administered to young rats in large doses over a short period rickets was consistently produced. When HEBP was administered concomitantly with 1,25 (OH)2D3 or calcitonin (CT), calcification appeared in the growth-plate cartilage where there had been an increase in thickness due to the inhibition of calcification. This experiment was done in an attempt to clarify differences in the calcification-promoting mechanisms of 1,25 (OH)2D3 and CT. The serum alkaline phosphatase level was reduced in rats with an accelerated calcification following the administration of 1,25 (OH)2D3, but there was no reduction in the serum alkaline phosphatase level in rats in which the calcification was accelerated by the administration of CT. The mode of appearance of calcification in the growth-plate cartilage by 1,25 (OH)2D3 or CT differed, depending on the time of administration. These results suggest that mechanisms involved in the enhancement of calcification by 1,25 (OH)2D3 and CT differ in cases where rickets are induced by HEBP.
 
Type of fracture according to the AO/OTA classification 
Demographic data and fracture type according to the osteosynthesis method 
Comparison between principle osteosynthesis method and functional outcomes 
Article
Distal tibia fractures are complex injuries with a high complication rate. In this retrospective and multicentre study we attempted to detail complications and outcomes of this type of injury in order to determine predictive factors of poor results. Between 2002 and 2004, 104 patients were admitted for 105 distal tibia fractures. One hundred patients (101 fractures) were reviewed with an average follow-up of 19 months (range, 12-46). Internal fixation, external fixation, limited internal fixation (K-wires or screws), intramedullary nailing and conservative treatment were used. Outcome parameters included occurrence of complications, radiographic analysis, evaluation of the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and measures of the ankle range of motion. The average functional score was 76 points (range, 30-100 points), and complications occurred in 30 patients. Predictive factors of poor results were fracture severity, complications, malunion and the use of external fixation. We believe that external fixation must be reserved for trauma with severe skin injury, as a temporary solution in a two-staged protocol. For other cases, we recommend ORIF with early mobilisation.
 
The planning application of the SurgiGATE hip prosthetics module can simulate the positioning of a new cup. By placing the virtual cup onto the real implant, the spatial orientation can be calculated. Calculation according the anterior pelvic plane is recommended 
Article
We studied 105 patients who received a total hip arthroplasty between June 1985 and August 2001 using freehand positioning of the acetabular cup. Using pelvic CT scan and the hip-plan module of SurgiGATE-System (Medivision, Oberdorf, Switzerland), we measured the angles of inclination and anteversion of the cup. Mean inclination angle was 45.8 degrees +/-10.1 degrees (range: 23.0-71.5 degrees ) and mean anteversion angle was 27.3 degrees +/-15.0 degrees (range: -23.5 degrees to 59.0 degrees ). We compared the results to the "safe" position as defined by Lewinnek et al. and found that only 27/105 cups were implanted within the limits of the safe position. We conclude that a safe position as defined by Lewinnek et al. [13] was only achieved in a minority of the cups that were implanted freehand.
 
Article
This paper investigates the incidence of infection following Kuntscher intramedullary nailing of 1059 open or closed fractures treated between January 1967 and December 1980. The fractures comprised 503 of the tibia 440 of the femur and 116 of the humerus. The literature over the past 10 years demonstrates that infection following plating or nailing with open reduction is more frequent than after closed intramedullary nailing. This paper confirms that nailing with open reduction for tibial and femoral fractures increases the infection rate to 5.7% and 3.5% respectively. Closed intramedullary nailing by Kuntscher's method is considered to be sound treatment in a university service for the treatment of fractures of the shaft of the tibia, femur and humerus with an infection rate of less than 1% in closed fractures.
 
Article
The authors have studied a series of 1059 compound and closed fractures of the diaphysis of long bones treated by intramedullary nailing according to the technique of Kuntscher, to assess the incidence of non-union. Between January 1st 1967 and December 31st 1980, 503 fractures of the tibia, 440 of the femur and 116 of the humerus were so treated in both adolescents and adults. The fractures were mostly sustained in road traffic accidents. The risk of aseptic non-union was small, but occurred more readily when the skin was damaged and when the site of the fracture was at the junction of the lower two quarters of the tibia; the incidence was highest when the technique of nailing was incorrect or when the going was undertaken too late. The incidence of non-union and infection are compared with those of other series using the same closed technique and with reports describing insertion of the nail of the plate by opening the fracture. It is concluded that intramedullary nailing using the Kuntscher technique is the most reliable treatment for this type of injury for routine use in an acute fracture service. In this series the incidence of aseptic non-union was approximately 1%, of infection with non-union less than 0.5% and of early infection with eventual union less than 1.5%.
 
Survival rate of 141 knees after 10–16 years with any kind of revision surgery as the endpoint  
Septic revisions
Survival rate of 141 knees after 10–16 years, not including septic complications or insert exchanges  
Aseptic revisions
Knee scores dependent on age and activity level
Article
To present representative data of long-term survivorship and clinical outcome for the PFC total knee arthroplasty (PFC-TKA). A consecutive series of 141 TKA was followed for a mean of 13 years (range, 11-16 years). Sixty-five knees were evaluated, 30 of these clinically and radiographically. Twenty-eight knees could only be assessed with the use of a questionnaire. Six patients were living in nursing homes. Fifty-four patients (65 knees) had died. Eleven had undergone a revision. One patient was considered lost to follow-up. With re-operation for any reason as the endpoint, the 10-year survival rate was 92% (n = 91 patients at risk), and the 14-year survival rate was 91% (n = 12). With aseptic loosening of the implant as the endpoint, the 10- and 14-year survival rates were 97%. The mean Knee Society and function scores were 76 and 48 points, respectively. In this multi-surgeon series modular fixed-bearing TKA had good clinical and radiographic results with excellent long-term survivorship.
 
Survivorship of loosened stems as the end point
Serum titanium levels in the unilateral hip replacement group
Serum titanium levels in the group with failed stems
Article
This study prospectively assessed the outcome of 134 cemented titanium stems and serum ion levels. The stems were polished (0.1 microm Ra) with circular cross section. At the end point, only one stem revision was performed for aseptic loosening, and two were planned due to subsidence greater than 5 mm. Non-progressive radiolucencies in zones 1 and 7 were observed in 16 hips at the cement-bone interface without osteolysis. Median serum titanium concentrations were below the detection limit (30 nmol/l) except in patients with failed stems. The overall stem survival rate was 97.7% at nine years, which is comparable to other series of cemented stems. The protective layer of titanium oxide coating the stem and a thick cement mantle may help resist aseptic loosening. In addition, satisfactory monitoring of the stem was reached using titanium serum level determination.
 
Article
We describe the clinical and radiological long-term outcomes of 77 primary total hip replacements in 69 patients using the fully hydroxyapatite-coated JRI (Furlong) total hip replacement. The total cases followed up were 77 hips, performed at a mean duration of 11 years and 2 months. Twelve hips could not be followed up for various reasons, which are discussed in the results section. The mean Harris hip score was 89. Seventeen acetabular cups were revised for aseptic loosening. Only one femoral stem was revised, for fracture. By Engh's criteria there were a further two unstable cups with no symptoms, and all femoral stems were stable. Kaplan-Meier survivorship analysis revealed a survival of 98.8% for the femoral stem, 78.7% for the acetabular cup, and a combined survival of 77.8% for both components. Our findings suggest that the JRI (Furlong) hip gives a durable femoral stem implant fixation, whereas the prosthesis-bone interface achieved with the acetabular component is questionable.
 
Article
The long-term results are reported of the treatment of bone cysts by means of the injection of methylprednisolone acetate (MPA) into the bony cavity using Scaglietti's technique. Eighteen patients were reviewed at a follow-up of 9-11 years from the beginning of the treatment. The results confirm the value of this technique and show a high percentage of recovery. During the growth period, a recurrence of osteolytic activity in the lesion may be observed after complete healing, though this does not happen frequently. In these cases further prompt treatment with MPA injected into the small osteolytic areas brings about their complete resolution. These observations lead us to conclude that a bone cyst can never be considered completely healed before complete skeletal maturity is reached. Regular radiological reviews must be carried out in order to recognise and treat promptly the first signs of a recurrence of cystic activity.
 
Pre-op and five year post-op radiographs of a patient with rheumatoid arthritis managed with hip resurfacing 
Article
Total hip replacement has shown good outcomes for patients with rheumatoid arthritis. Can hip resurfacing give similar results for patients with rheumatoid arthritis? Using an international hip resurfacing register, 47 patients with rheumatoid arthritis were identified and age and gender matched to a group of 131 randomly selected patients with osteoarthritis of the hip joint. Patients completed a questionnaire to record function and implant revision. Hierarchical regression, Cox regression and Kaplan-Meier method were used for analysis. There was a significant increase in post operative hip score in both groups (p < 0.001) with rheumatoid group scoring higher as compared to the osteoarthritis group (p = 0.23). The post operative score was not significantly influenced by pre-operative score and age (p = 0.15 and 0.84, respectively) but the pre-operative score was a predictor of implant failure (p = 0.02). Patient mobility was affected by age with younger patients scoring high on mobility as compared to older patients (p = 0.01). The Kaplan-Meier analysis showed a survival rate of 96.3% in the rheumatoid group and 97.8% in the osteoarthritis group. This difference was not significant (Log rank test, p = 0.45). Our results from an independent and international register show that hip resurfacing provides good post-operative hip function and excellent implant survival for patients with rheumatoid arthritis of the hip joint. This procedure can be considered as a viable option for management of rheumatoid arthritis of the hip joint.
 
Article
Eleven cases of extra-articular tuberculous osteomyelitis are presented. Eight of the patients were children. Ten were treated by curettage and chemotherapy and the diagnosis proved by histology or positive culture of the tubercle bacillus. One case was diagnosed because she also had tuberculous salpingitis, and she was treated by chemotherapy alone. A high index of suspicion is needed for early diagnosis. Treatment gave satisfactory results.
 
Patient characteristics according to fixation method
Article
Purpose: Adverse events associated with the use of bone cement for fixation of prostheses is a known complication. Due to inconclusive results in studies of hip fracture patients treated with cemented and uncemented hemiprostheses, this study was initiated. Methods: Our study is based on data reported to the Norwegian Hip Fracture Register on 11,210 cervical hip fractures treated with hemiprostheses (8,674 cemented and 2,536 uncemented). Results: Significantly increased mortality within the first day of surgery was found in the cemented group (relative risk 2.9, 95 % confidence interval 1.6-5.1, p=0.001). The finding was robust giving the same results after adjusting for independent risk factors such as age, sex, cognitive impairment and comorbidity [American Society of Anesthesiologists (ASA) score]. For the first post-operative day the number needed to harm was 116 (one death for every 116 cemented prosthesis). However, in the most comorbid group (ASA worse than 3), the number needed to harm was only 33. Conclusions: We found increased mortality for the cemented hemiprosthesis the first post-operative day compared to uncemented procedures. This increased risk is closely related to patient comorbidity estimated by the patient's ASA score.
 
Article
Operation was carried out on 110 fractures of the tibial plateau. Fractures of a single condyle were the most common. Associated ligamentous injury was present in 12.7% of the patients and a meniscal lesion was seen in 15.5%. The meniscus was preserved if possible. Satisfactory results were obtained in 79% of cases, with good correlation between the clinical result and the radiological appearance at review. The late complications and technical difficulties are discussed and the difference in prognosis between simple and complex fractures is emphasised.
 
Article
A prospective scintigraphic study using Gallium 67 and granulocytes labelled with Indium 111 was carried out in 60 patients who were thought to have infection following orthopaedic operations. Both investigations gave positive results in 11 of the 16 infections observed. The Indium 111 labelled leucocyte scan was more accurate than the Gallium 67 studies in delineating patients who did not have an infection, and appears to be more reliable in the diagnosis of post-operative sepsis.
 
Article
Purpose: The aim of the study was to control the in vivo localisation of implanted cells in cell-based therapies. Labelling cells with (111)indium-oxine is one of the most interesting methods proposed. We evaluated this method in the setting of autologous osteoblast implantation in nonunion fractures. Methods: An in vitro study of osteoblasts was conducted after (111)indium-oxine labelling. Radioactivity retention and viability, proliferation and the ability to produce alkaline phosphatase were evaluated in a seven-day culture. In vivo labelling of implanted osteoblastic cells was conducted during a therapeutic trial of atrophic nonunion fractures, with the leakage outside the nonunion site and local uptake evolution at four, 24 and 48 hour being studied. Results: The mean labelling efficiency for osteoprogenitors was 78.8 ± 4.6 %. The intracellular retention was 89.4 ± 2.1 % at three hours and 67.3 ± 4.7 % at 18 hours. The viability assessed at three hours was 93.7 ± 0.6 %. After seven days of culture, morphology and alkaline phosphatase staining were similar for both labelled and unlabelled control cells, although the proliferation rate was decreased in the labelled cells. Some local intraosseous leakage was observed in four of 17 cases. All patients showed uptake at the injection site, with four having no other uptake. Four patients showed additional uptake in the bladder, liver and spleen, while 11 patients had additional uptake in the lungs in addition to the bladder, liver and spleen. The activity ratios (injection site/body) were 48 ± 28 % at four hours, 40 ± 25 % at 24 hours and 35 ± 25 % at 48 hours. After correcting for decay, the activity within the injection site was 82 ± 15 % at 24 hours and 69 ± 11 % at 48 hours compared with the activity measured at four hours. No relationship was found between uptake and radiological bone repair. Conclusions: The (111)indium-oxine labelling appears to be a good method for monitoring the behaviour of the osteoblastic cells after their implantation in atrophic nonunion fractures.
 
Article
Between January 1982 and December 1987 we used 112 threaded acetabular cups in 102 patients undergoing total hip replacement. The clinical and radiographic results of 107 implants are reported in this survey. Using the functional grading of the hip advocated by Merle d'Aubigné and Postel, 62% can be classified as excellent, very good or good. On x-ray only 35% of the cups show neither radiolucency at the bone-implant interface nor migration of the component. There is a statistically significant correlation between a radiolucency in 2 of the 3 areas at the bone-implant interface and the clinical result. The revision rate for failure of the cup is 11.6% (13 implants). The actuarial survival of the threaded cup decreased from 0.95 in the 1st year to 0.75 in the 5th year after implantation. Analysis of our failures and of published data suggest that the problem lies in the lack of primary bone integration. We describe our difficulties in assessing risk factors, in interpreting the radiographs and in the intraoperative determination of component instability. The disappointing short term results have prompted us to abandon the use of threaded cups.
 
Article
Changes occurring in the fixation of 113 porous-coated PCA uncemented femoral stems were studied in 90 patients who were operated on between 1984 and 1988. The average follow up was 5 years. Fixation was classified in radiographs as osteointegration, stable fibrous fixation or unstable. Four femoral components were revised. Metaphyseal osteoporosis was associated with those with a stem diameter greater than 13 mm. After 2 years, osteointegration was present in 73% and instability in 24% which was not related to the position of the stem. At the end of the follow up period, 20% of the stems showing osteointegration had changed and become unstable.
 
Article
We read with interest the article by Markmiller et al. [1] that discussed an important issue regarding time of weight bearing after cementless total hip arthroplasty. Although we agree with the conclusion drawn from their observations, we ask clarification on several points in their methods. The authors mention that they used radiographs to measure subsidence and migration postoperatively, but as radiographs are prone to errors due to patient positioning and radiograph centring [2], were any specific steps taken to ensure minimal errors, and how was radiograph uniformity ensured during follow-up? Furthermore, all measurements were done manually by an orthopaedic surgeon. Were these measurements made on radiographs or digital images? Was any specific software used for making these measurements? There are several software packages available, such as Ein-Bild-Roentgen-Analyse (EBRA) that have been validated previously [2, 3]. These are available free and are easy to use. Although Roentgen stereophotogrammetric analysis (RSA) provides the best method for making these measurements, its availability might be an issue at several centres. We would further like to know the impact of femoral anatomy (according to Dorr types) in choice of patients for cementless femoral stem and any possible difference in prosthesis migration amongst different femoral canal morphologies [4]. In our opinion, although this study makes important and valid inferences regarding the relation between weight bearing and subsidence or migration in THR, better methods could have been used to provide firmer conclusions.
 
A patient from group A demonstrating the ability to perform pre-operative full-range (heel-to-buttock) knee flexion 
Demographic data and follow-up & clinical variables
A patient sitting in Thai polite style. Patients who underwent unilateral TKA ( white arrow ) typically preferred placing the foot of the operated limb underneath the unaffected knee 
Comparing clinical outcomes and knee flexion among studies on high-flexion TKA
Article
We prospectively evaluated outcomes of high-flexion total knee arthroplasty in 165 patients who had advanced arthritis with a minimum 120-degree pre-operative knee flexion, with a mean follow-up of 77 months. Patients were divided into two groups according to their ability to perform full-range (heel-to-buttock) pre-operative knee flexion (group A) and the inability to do so (group B). The overall clinical rating was "excellent" in 96% of patients and "good" in 4% of patients. Mean maximum knee flexion decreased from 137.9° to 134.8°, with no statistical difference between pre- and post-operative knee flexion. However, patients in group A had significantly decreased knee flexion (146.2° vs. 135.0°, p < 0.001), whereas patients in group B exhibited no change in knee flexion (133.7° vs. 134.7°, p = 0.14). We found that 14.7%, 36.5% and 43.0% of the studied patients could engage in kneeling, Thai polite style sitting and cross-legged sitting, respectively, with no significant differences between groups A and B. The survival rates for any reoperation and prosthesis-related problem (such as early loosening) at six years were 98.3% and 100%, respectively. At six-year follow-up in patients with well preserved pre-operative knee flexion, the high-flexion knee prosthesis provided a favourable outcome without improving knee flexion.
 
Article
The postoperative flexion angle reportedly shows a positive correlation with the preoperative flexion angle, but in some cases, the postoperative flexion angle decreases in patients with a large preoperative flexion angle. The purpose of this study was to investigate factors affecting the range of motion after total knee arthroplasty (TKA) in patients with a large preoperative flexion angle. The study evaluated 120 knees with more than 120 degrees of preoperative flexion angle that underwent NexGen LPS-Flex mobile bearing. The groups with and without a reduction in the postoperative flexion angle were compared. Also, a logistic regression analysis was performed, where the presence or absence of a reduction in the postoperative flexion angle was the dependent variable and age, sex, body mass index (BMI), preoperative femorotibial angle (FTA), γ angle, δ angle, pre/postoperative change amount in posterior condylar offset (PCO), pre/postoperative change amount in joint line, and pre/postoperative change amount in patellar thickness were independent variables. Those with preoperative FTA of 186° or larger did not have a reduction in the postoperative flexion angle, compared with the angle of 185° or smaller. Those with δ angle of 83° or smaller also did not have a reduction in the postoperative flexion angle, compared with the angle of 84° or larger. Our results showed that preoperative FTA and δ angle had an impact on a reduction in the postoperative flexion angle. The installation angle of the tibial component in the sagittal plane is important.
 
Article
Two-hundred fractures of the upper femur were treated with the Bousquet nail-plate system between July 1977 and June 1981. One-hundred and twenty of these patients--37 males and 83 females, aged 26-96 years, constitute the material of the present study. Ninety-eight fractures were trochanteric, nineteen sub-trochanteric, and three of the basal type. The follow-up time ranged from two to four years. The Bousquet nail and plate was found adequately to fulfil the mechanical needs of fractures of the trochanteric region. The operation is simple, safe and fast, and an appropriate angle between the nail and the plate can be easily selected. All fractures satisfactorily united in good position and no pseudarthrosis was observed. Mortality and rate of complications was comparatively low.
 
Article
We have reviewed 109 out of 122 operations performed for malunion of the distal radius. An excellent or good result was achieved in 80%, with 3% poor and 7% mediocre. Complications occurred in 12.6%. Accurate assessment of the frontal and sagittal angles of the articular surface of the distal radius was necessary in planning the operation, and correct realignment was required to achieve a proper result. Some cases in which an excellent correction was achieved did not produce a satisfactory outcome because of residual problems with soft tissue or ligaments. No patient with carpal instability had a good result. The morphology of the fracture and the sex or activity level of the patient did not influence the result.
 
Article
Between 1968 and 1987 the authors treated 122 cases of chronic haematogenous osteomyelitis of the tibia by operation. The procedures used were drilling, sequestrectomy, and saucerisation, with bone resection in 2 cases. Operation was combined with chemotherapy for between 10 and 60 days. Eleven patients, thought to be healed, were lost to follow-up after 4 months. The remainder were reviewed for between 4 and 288 months, 97 for more than one year. After the first operation 102 patients healed completely, while 20 relapsed. Of these, 12 were treated by further operation and 8 by drainage of the abscess. Two patients relapsed twice and another 4 times. When last seen 110 patients were healed, 6 had an intermittent discharge and 6 had a permanent sinus. Special features of chronic osteomyelitis of the tibia are discussed, including destructive lesions of the knee and tibio-tarsal joints, a high incidence of axial deformity, indications for particular surgical approaches, the use of cancellous grafts and arguments against bone resection. The lesions carry a relatively good prognosis.
 
Total knee arthroplasty (TKA) after failure of OWHTO using Biosorb® 
Article
The objective of this work was firstly to evaluate the long-term results of medial opening wedge high tibial osteotomy (HTO) and secondly to evaluate the tolerance and integration of a Biosorb® wedge (β Tricalcium Phosphate, SBM Company, Lourdes, France). The series consisted of 124 knees in 110 patients, 74 men and 36 women, with mean age of 53.23±10.68 years (range 32-74) and treated between June 1995 and November 2000 for medial compartment knee osteoarthritis by the senior author. The mean preoperative Lysholm and Tegner functional score was 65.44±13.32 (range 27-80) and the preoperative HKA angle was 172.51°±3.8° (range 162-179°). According to the modified Ahlbäck classification there were 27 stage I, 42 stage II, 44 stage III and 11 stage IV knees. All patients were reviewed clinically and radiologically with a mean follow-up of 10.39±1.98 years (range 8-14 years). Immediate postoperative complications consisted of nine undisplaced lateral tibial plateau fractures of no clinical significance, two deep vein thromboses and three pulmonary emboli which resolved with appropriate treatment. At a later stage, there were seven delayed unions without development of pseudarthrosis, and three screw breakages when the AO T-plate was used, leading to a secondary angulation in one case, requiring revision by femoral osteotomy. Postoperative mean weightbearing HKA angle was 182°±1.8° (range 178-186°) and 73.4% of axes were 184°±2°. Fifteen knees (12.1%) underwent total knee arthroplasty (TKA) after a mean delay of 8.87±3.04 years and were excluded from the final analysis. Concerning the long-term results (n = 107 knees), the mean Lysholm-Tegner score was 88±12.7 points (51-100) and the KOOS score was 86±14.6 points (25-100) with 94 patients satisfied or very satisfied (87.85%). In terms of the HTO survivorship curve, with failure consisting of revision to TKA or another operation, survival was 88.8% at five years and 74% at ten years. Concerning Biosorb®, this was completely integrated in 100% of cases and there was complete resorption in 12.1% of cases and greater than 50% resorption in 52.3% of cases.
 
Article
One hundred and twenty-five cases of tuberculous osteomyelitis have been observed by the authors since 1968. The site of the lesion and the clinical and radiological findings have been analysed. The importance of accurate diagnosis by bacteriological and histological investigation is emphasized. Pitfalls in the differential diagnosis with chronic haematogenous osteomyelitis are described. Treatment is by chemotherapy, and immobilization is useless. Operation was limited to the drainage of three large abscesses. A favourable response to chemotherapy was obtained in 92% of the 105 cases which were followed up. The role of a super-added pyogenic bone infection in 8 cases of persisting sinus after chemotherapy is discussed. Finally, the authors stress the importance of preventing the development of tuberculous arthritis by the correct diagnosis and treatment of juxta-articular tuberculous osteomyelitis.
 
Patient demographics 
Patient outcomes 
Article
Tibial plateau fractures occur due to a combination of axial loading and varus/valgus applied forces leading to articular depression, malalignment and an increased risk of posttraumatic osteoarthritis (OA) [14, 19]. When treating intra-articular fractures, the goal is to obtain a stable joint permitting early range of motion for cartilage nourishment and preservation [19]. Various treatment modalities have been used over the years, with mixed results. These include traction [3] or closed treatment with cast bracing [9, 16]. Surgical procedures including circular frames [1, 2, 18], percutaneous screw fixation [17], open reduction/internal fixation (ORIF) [1, 5, 6, 10, 28] and arthroplasty have also been advocated. More recent techniques such as the use of fixed angle devices [12, 20], arthroscopically-assisted reduction [8], calcium based cement augmentation [26, 29] and the use of novel grafting methods to address articular depression [4], constantly gain popularity amongst orthopaedic surgeons. Protection from weight bearing and length of immobilisation receive varied emphasis among authors [2, 11, 27]. Despite anatomical joint reconstruction, development of osteoarthritis may still occur secondary to the initial articular cartilage and meniscal injury [14, 21]. In young patients this could be detrimental as it can lead to total knee replacement (TKR) at an early age. In addition, these fractures may have significant socio-economic influence, mainly due to time taken off work. In order to assess the effect of these injuries on functional outcome and development of OA, we retrospectively reviewed a series of tibial plateau fractures treated in our institution.
 
Amputation rates for each endoprosthetic replacement site 
Article
Endoprosthetic replacements are commonly used for limb salvage following surgical excision of bone tumours. Advantages include initial reliability, rapid restoration of function and their ready availability. Potential long-term problems include loosening, infection and mechanical failure. Increasing problems may lead to the necessity for amputation; this paper assesses that risk. A total of 1,261 patients have undergone endoprosthetic replacements in our centre in the past 34 years, with a total of 6,507 patient years of follow up. A total of 112 patients have had subsequent amputation. The reasons for amputation were local recurrence in 71, infection in 38, mechanical failure in two and chronic pain in one. The proximal tibia had the greatest risk of amputation (n=38/245). The time to amputation varied from 2 days to 16 years, with a mean of 31 months. The risk of amputation decreased with time, although 10% took place after more than 5 years.
 
Article
The purpose of this study was to investigate the mechanism of expression of matrix metalloproteinase-13 (MMP-13) induced by nitric oxide (NO). Human chondrocytes (HCs) were stimulated with a NO donor (MAHMA-NONOate), then mitogen-activated protein kinases' (MAPKs) and nuclear factor κB' (NF-κB) activations and MMP-13' expression were assayed by Western blot analysis. Additionally, the intracellular signalling of NO was investigated using the inhibitors of MAPKs and NF-κB. NO-induced MMP-13 expression was not suppressed by extracellular signal-regulated kinase (ERK) inhibitor (PD98059) or inhibitors of p38 kinase (SB203580), but was inhibited by a c-jun terminal kinase (JNK) inhibitor (SP600125) and inhibitors of NF-κB (SN-50). Additionally, SP600125 treatment reduced NF-κB activation, but SN-50 treatment did not significantly affect JNK activation. These results suggest that NO induces MMP-13 expression by JNK and NF-κB activation in HCs.
 
Article
A series of total hip replacements was performed using a proximally porous coated, tapered femoral stem system. At a mean follow-up of 8.1 (5-13) years, 80 out of 107 hips were available for clinical and radiological examination. The mean age at the index procedure was 58.6 years. The mean Harris Hip Score at final follow-up was 91.7. Radiological ingrowth was observed in 77 femoral stems, 2 stems were fibrous stable and 1 stem was loose.
 
Article
Dear Editor, We would like to thank Dr. Aditya N. Aggarwal and Dr. Anil Agarwal for their interest in our recently published article [1], and we thank you for the opportunity to reply. As evident from our article, the patients selected for valgus osteotomy in recent femoral neck fractures are those with vertical fractures. Their preoperative fracture angle ranged from 55 to 75º (average 64º). We appreciate the concerns raised by Dr. Aditya N. Aggarwal and Dr. Anil Agarwal about the use of angled blade plates in fixation of recent fractures. We described in our article the technique of valgus osteotomy and the advantages of fixation using a single-angled 130° plate. We think that reclining of the vertical fracture plane, after fracture reduction, will convert the shear forces into compression forces and this will enhance fracture union. The resultant of the compressive forces at the hip subtends an angle of 25° with the anatomical axis of the femur. If the fracture plane is reclined to subtend this angle with the perpendicular to the anatomical axis of the femur, it is under pure compression [2, 3]. Introduction of the blade into the head by hammering helps in initial compression of the fracture. Addition of a lag screw proximal to the blade was optional in our patients with recent fractures and was not mandatory in all patients. References 1. Said GZ, Farouk O, Said HGZ (2009) Valgus intertrochanteric osteotomy with single-angled 130° plate fixation for fractures and non-unions of the femoral neck. Int Orthop.
 
Article
Postoperative infection is a regular complication in coccygectomy. The authors propose the use of a topical skin adhesive on the postoperative wound as a contribution to the prevention of this complication. It was used on the first 56 patients in this study. The rate of infection was 3.6% compared with the 14% rate of infection in a previous study. The 80 following patients had, in addition to the skin adhesive, two prophylactic antibiotics for 48 hours (cefamandole and ornidazole), a preoperative rectal enema, and closure of the incision in two layers. The rate of infection dropped to 0.0%. Topical skin adhesive constitutes a significant contribution in the prevention of infection after coccygectomy.
 
Article
We assessed the clinical and radiographic results of 40 porous-coated acetabular cups with an Acetabular Cup System polyethylene liner over a minimum 14-year follow-up. Femoral head penetration was estimated using a software package. Fifteen cups were revised, 11 due to polyethylene liner rupture. All cups but two were radiographically stable, and 11 hips showed acetabular osteolysis. The overall femoral head penetration rate in hips without liner fracture with reference to the early penetration point was 0.1188+/-0.070 mm per year. Polyethylene liner fractures were associated with higher early femoral head penetration (P<0.0001) and a vertical cup position (P=0.0016). The 14-year survival without cup revision for any reason was 63.9%, 71.8% with no ACS polyethylene liner fracture and 65.3% with no acetabular osteolysis. Most cups showed a good clinical outcome in general, but major Acetabular Cup System liner failure and osteolysis were frequent. Patients with the ACS cups still in place should be monitored closely.
 
Article
Fourteen wrists in 11 girls, mean age 13.3 years (range 9-16) at surgery, were treated for Madelung's deformity. The presenting complaint was incapacitating pain. All were treated by radial closing wedge osteotomy and ulnar shortening osteotomy. The dorsal retinaculum was also surgically repaired in six cases. At a mean follow-up of 5.1 years (range 4-8.75), we observed improved range of motion in both flexion/extension and pronation/supination and absence of pain during daily activity. Radiographically, positioning of the distal radial articular surface and lunate subsidence were improved. Union was obtained after all osteotomies without secondary procedures. Posterior displacement of the ulnar head persisted in two wrists. Combined radioulnar osteotomy restored the anatomy to as near normal as possible. This technique provides satisfactory and encouraging results and does not compromise the surgical future of the wrist. However, longer follow-up is required to assess recurrence or possible long-term degenerative consequences.
 
Article
The aim of the study was to analyse the survivorship of 60 total hip arthroplasties using the cementless Lord prosthesis in 51 patients with inflammatory joint disease. Patients were operated on between the years 1985 and 1988. The mean follow-up time was 13.8 (4.0-18.6) years. During the follow-up, one deep infection was encountered, and seven patients died of causes unrelated to the hip replacement. Revision surgery or death of the patient was used as an end point. The overall survival was 88.1% [95% confidence interval (CI) 76.6-94.1] for the stem, and 64.3% (95% CI 50.6-75.1) for the cup at 15 years. Causes for revision surgery were loosening of the cup in 17 hips, loosening of both components in five hips, and one deep infection.
 
Article
We read with deep interest the article by Singh et al. [1]. We thank the authors for sharing with us such experience with these rare injuries. Since the capitellum injury is an uncommon fracture, the described technique left certain queries unanswered for the less experienced user. Do the authors routinely recommend CT in all capitellum fractures as assessment of fracture comminution by plain radiographs is particularly deceptive in this region [2]? Again, how long did the fractures take to unite and how was the union assessed radiologically? Singh et al. recommend very early mobilisation (e.g. illustrative case 2) of elbow joint even in bone grafted cases, which is not a common clinical practice, unless the graft itself is stabilised. Moreover, the fracture fragments are often osteoporotic in old fractures, precluding stable fixation, and the risk of implant cutting through remains high with such early mobilisation. Singh et al. also managed three capitellum fractures which were more than six months old. An older epiphyseal fracture usually presents with hypertrophy of articular cartilage, rounding of margins and sometimes it is practically impossible to make out the proximal fractured surface of the fragment. Despite a meticulous surgical technique, restoration of joint congruity is difficult. Did Singh et al. face such difficulties in their series?
 
Giant cell tumour of the left distal humerus in a 30-year-old female patient 
Article
From 1975 to 1997, 649 cases of benign giant cell tumours of the bone were treated at the Istituto Rizzoli. Fourteen patients (2.1%) experienced lung metastases after a mean of 35.2 months. The time interval between the diagnosis and the appearance of the lung metastases ranged from 3 months to 11.9 years. Metastasectomy was performed in all patients. Histologically, the metastases were identical to the primary bone lesions. Two patients with unresectable multiple metastases received additional chemotherapy. After a follow-up of 70 months (range: 8.2 to 185 months), all patients are alive. Ten patients showed no evidence of disease, one of these after a second resection of metastases, and four patients presented stable disease with multiple lung metastases. Local recurrence of the bone lesion occurred in seven patients before or simultaneously to the metastases. In contrast to previous reports, we could not detect a predominance of the distal radius, but all of the patients had a stage III tumour according to the Enneking criteria of benign lesions. We conclude that even metastatic benign giant cell tumours have an excellent prognosis after adequate resection. No prognostic factors despite high-grade lesions were detectable.
 
Comparison of associated injuries among groups 
Article
We have retrospectively reviewed 14 patients with bilateral femoral shaft fractures who attended our institution between January 1993 and March 1999. The mean age of the patients was 38 years (19-75) and the median injury severity score (ISS) was 16 (interquartile range 10-20). Thirteen patients were treated with intramedullary nailing and 1 with plating and nailing within 24 h of admission to hospital. The mean resuscitation requirements were 10.6 (6-16) litres of colloid and crystalloid and 8.6 (4-30) units of blood. The mean intensive care unit/high dependency unit (ICU/HDU) stay was 4 days (1-14) and the mean hospital stay was 36.3 days (3-210). There were 6 cases of adult respiratory distress syndrome (ARDS), 1 compartment syndrome, 1 case of osteomyelitis, 1 above-knee amputation and 2 deaths (14.2%). The mean time to union was 24.5 weeks (12-37). Comparison to patients with unilateral injuries revealed a higher ISS, resuscitation requirements, ARDS, hospital stay and mortality.
 
Article
A case report of 14-year old female with an acetabular fracture involving the anterior column and posterior column-posterior wall is presented here and the findings on 20-year follow-up are described.
 
Article
Fourteen patients with displaced fractures of the humeral capitellum were treated by open reduction and internal fixation of the capitellar fragments with Herbert screws. As per Bryan and Morrey classification, there were seven type I fractures, one type II fracture, three type III fractures, and three non-unions. Patient outcomes were evaluated using the Mayo elbow performance score. The follow-up period ranged from three to seven years (mean 4.8 years). All patients had a stable, pain-free elbow with good range of motion at follow-up. There was no evidence of avascular necrosis or degenerative change.
 
a Control animal with predominantly fibrous cartilage (H&E stain). The edges are clearly visible (red arrows) and there are still remnants of scaffold (black arrows) in the subchondral bone in the control animal. b Study animal with regeneration of cartilage and subchondral bone (H&E stain). The edge of the study animal is well integrated (red arrows) and there are few remnants of scaffold (black arrows) in the subchondral bone in the study animal  
a Control animal with poor matrix staining (Safranin O stain). b Study animal with uniform and normal matrix staining and appearing similar to adjacent normal cartilage (Safranin O stain)  
a Control animal with negative immunohistochemistry for type II collagen. b Study animal with positive immunohistochemistry for type II collagen  
Article
This study aimed to determine the efficacy of PEMF (pulsed electromagnetic field) treatment in experimental osteochondral defect healing in a rabbit model. The study was conducted on 12 New Zealand white rabbits. Six rabbits formed the study group and six rabbits the control group. The right knee joints of all 12 animals were exposed and a 3.5-mm diameter osteochondral defect was created in the trochlear groove. The defect was filled with calcium phosphate scaffold. Six animals from the study group were given PEMF of one hour duration once a day for six weeks with set parameters for frequency of 1 Hz, voltage 20 V, sine wave and current ±30 mA. At six weeks the animals were sacrificed and histological evaluation was done using H&E, Safranin O, Maissons trichrome staining and immunohistochemistry for type 2 collagen. The quality of the repair tissue was graded and compared between groups with the Wakitani histological grading scale and a statistical analysis was done. The total histological score was significantly better in the study group (p = 0.002) with regeneration similar to adjacent normal hyaline cartilage. Immunohistochemistry for collagen type II was positive in the study group. PEMF stimulation of osteochondral defects with calcium phosphate scaffold is effective in hyaline cartilage formation. PEMF is a non-invasive and cost effective adjuvant treatment with salvage procedures such as abrasion chondroplasty and subchondral drilling.
 
Clinical outcome with regard to mental function  
Total costs after internal fixation and THR dichotomised by mental function (€)
Total hospital costs with regard to surgical method  
Types of living before the fracture, after discharge from hospital and at 1 year. Deaths ( †) and changes in types of living during the first year are shown. At one year, 76/113 (67%) lived independently  
Article
We randomised 143 patients--age 75 years or older--with displaced femoral neck fracture to either internal fixation or total hip replacement (THR) and compared the socio-economic consequences. In the internal fixation group, 34 of 78 hips underwent secondary surgery. In the THR group, 12 of 68 hips dislocated, the majority in mentally impaired patients. We calculated the total hospital costs for two years after operation. When secondary surgery was included, there was no difference in costs between the internal fixation and THR groups, or between the mentally impaired and lucid subgroups. The costs to the community were calculated comparing the baseline cost before surgery with the average cost per month during the first postoperative year. No difference was found between the treatment groups. The Harris hip scores were higher in the THR group, and pain was more common in the internal fixation group. In lucid patients, THR gives a better clinical result at the same cost.
 
Article
Massive bone allografts from cadavers have been sterilised by gamma-radiation from radioactive cobalt at a dose of 25,000 gray (Gy). The biological effects of radiation are discussed. Human cortical bone showed an acceptable 20% decrease in strength on bending tests after 27,000 Gy irradiation, but higher doses are more damaging and should be avoided. The procurement protocol used at the Cochin Hospital is described, and the importance of dosimetry and record-keeping emphasised. The clinical results of 150 massive bone allografts are reported. The infection rate was low. The evolution of the graft in each type of reconstruction is analysed and appears to be comparable to nonirradiated allografts. Very few complications occurred after composite reconstructions in the lower limb. Pelvic reconstructions had the highest complication rate, but most were not related to the use of the allograft.
 
Article
The results of classical treatment (suture plus immobilisation) and of Kleinert's technique (suture under magnification with early semipassive movement), were compared in 290 primary flexor tendon repairs. The site of injury and the nature of associated injuries were the major prognostic factors. Kleinert's rehabilitation program was of particular value when a large range of movement was needed in simple lesions of zones III and IV. When tendon rupture must be avoided and preservation of strength is more important than achieving a full range of movement, immobilisation after an atraumatic suture is preferred.
 
Article
We have reviewed the history of 154 primary, traumatic dislocations of the shoulder in order to determine the risk of recurrence. We found a recurrence rate of 68% in patients under the age of 20, after a follow-up period of 1-9 years (average 4.5 years). There was a highly significant difference (p < 0.0001) in the recurrence rate of patients under, and above, 30 years of age. Twenty per cent of the patients had a concurrent minor fracture at the shoulder with 2 out of 39 of the recurrent cases (5%) and 29 of the 115 non-recurrent cases (25%); this is also a significant difference (p < 0.01). Neither the need for general anaesthesia at primary injury nor the occupation of the patient was a relevant factor in the final outcome of the dislocation. Four nerve injuries were encountered (3%), with no severe sequelae at follow-up. The young patient with no concurrent fracture at the time of the primary shoulder dislocation has a high risk of recurrence.
 
Kaplan-Meier survival curve including 95% confidence interval with time and probability of survivorship regarding the CFP (collum femoris preserving) stem
Occurrence of osteosclerotic femoral bone transformation distributed along Gruen zones
Distribution of the Harris hip score (HHS) according to categories excellent (≥90 points), good (89-80), fair (79-70), and poor (<70)
Article
Short stem prostheses that preserve the femoral neck are becoming more and more popular. The CFP (collum femoris preserving) has been introduced especially for the treatment of younger patients. However, information about remodelling, complications and learning curve are thus far rare. We present a retrospective study of 155 patients (average age 59.3 ± 9.9 years) who underwent total hip replacement with the CFP prosthesis. Follow-up was obtained 74.3 ± 9.4 months postoperatively. The Harris hip score revealed excellent and good results in 96%. One stem had to be exchanged due to aseptic loosening revealing a survival rate of 99% and 100% for stem and cup, respectively. Radiological analysis showed typical patterns of remodelling with appearance of cortical thickening predominantly in the distal part of the prosthesis. Implant related revision rate was <1%, with further complication rate independent of the surgeon's individual experience. With regard to outcome, survivorship and complication rate, the medium-term results of the CFP prosthesis are promising.
 
Article
We reviewed 157 knees in 118 patients who underwent posteriorly stabilised (Insall-Burstein) knee replacement arthroplasty. Their mean age at operation was 69 years (range 47 to 85 years) and the average follow-up was 3.5 years (range 2 to 7 years). The "BASK" knee function assessment chart was utilised to evaluate the functional and clinical results. One hundred and thirty-five knees (86%) had excellent or good results, 16 knees (10%) had fair results and six (4%) had poor results. The mean postoperative BASK score was 79 points and the average postoperative knee flexion was 95 degrees (range 65 degrees to 130 degrees). Two patients had a superficial infection, one deep sepsis requiring revision arthroplasty and two mechanical loosening. Patellar impingement symptoms were present in 8% of the knees, although they were troublesome in less than half. Varus alignment of the knee and a varus tilt of the tibial component of more than 2 degrees correlated with the incidence of radiolucent lines around the tibial prosthesis. 90% of the patients were pleased or satisfied with the functional result. The total condylar knee is a safe, reliable and versatile prosthesis.
 
Top-cited authors
Peter Giannoudis
  • University of Leeds
Philippe Hernigou
  • University of Paris-Est
Masahiro Kurosaka
  • Kobe Kaisei Hospital
Michael A Mont
  • Lenox Hill Hospital
Pierre Hoffmeyer
  • University of Geneva