Journal of Orthopaedic Surgery and Research - Latest Articles

Major limb amputations: A tertiary hospital experience in northwestern Tanzania

Phillipo Chalya — 2012-05-11T00:00:00Z

Background: Major limb amputation is reported to be a major but preventable public health problem that is associated with profound economic, social and psychological effects on the patient and family especially in developing countries where the prosthetic services are poor. The purpose of this study was to outline the patterns, indications and short term complications of major limb amputations and to compare our experience with that of other published data. Methods: This was a descriptive cross-sectional study that was conducted at Bugando Medical Centre between March 2008 and February 2010. All patients who underwent major limb amputation were, after informed consent for the study, enrolled into the study. Data were collected using a pre-tested, coded questionnaire and analyzed using SPSS version 11.5 computer software. Results: A total of 162 patients were entered into the study. Their ages ranged between 2-78 years (mean 28.30 +/- 13.72 days). Males outnumbered females by a ratio of 2:1. The majority of patients (76.5 %) had primary or no formal education. One hundred and twelve (69.1 %) patients were unemployed. The most common indication for major limb amputation was diabetic foot complications in 41.9 %, followed by trauma in 38.4 % and vascular disease in8.6 % respectively. Lower limbs were involved in 86.4 % of cases and upper limbs in 13.6 % of cases giving a lower limb to upper limb ratio of 6.4:1 Below knee amputation was the most common procedure performed in 46.3 %. There was no bilateral limb amputation. The most common additional procedures performed were wound debridement, secondary suture and skin grafting in 42.3 %, 34.5 % and 23.2 % respectively. Two-stage operation was required in 45.4 % of patients. Revision amputation rate was 29.6 %. Post-operative complication rate was 33.3 % and surgical site infection was the most common complication accounting for 21.0 %. The mean length of hospital stay was 22.4 days and mortality rate was 16.7 %. Conclusion: Complications of diabetic foot ulcers and trauma resulting from road traffic crashes were the most common indications for major limb amputation in our environment. The majority of these amputations are preventable by provision of health education, early presentation and appropriate management of the common indications.

The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty

Ola Hallert — 2012-04-25T00:00:00Z

Background: Less invasive approaches for hip arthroplasty have been developed in order to decreasetraumatisation of soft tissue and shorten hospital stay. However, the benefits with a newtechnique can be at the expense of a new panorama of problems. This manuscript describes,with emphasis on postoperative complications, our experience from the first 200 cases ofunilateral hip replacement using the direct anterior minimally invasive (MIS) approach. Methods: A straight incision in front of the greater trochanter was used and the tensor muscle wasapproached subfascially and retracted laterally. The joint was opened and the femoral headwas removed. Usually excellent acetabular exposure was obtained. In order to get access tothe proximal femur, the hip capsule was released posterolaterally so that the femur could belifted using a special retractor behind the tip of the trochanter. After insertion of theprostheses, the wound was closed using running sutures in the fascia overlying the tensor,sub- and intracutaneously. Results: There was a small influence of BMI on the duration of surgery, and obese patients tended tohave the cup positioned at a higher degree of deviation. There were in total 17 complicationsof which 5 necessitated revision surgery; 3 peroperative femoral fractures and 2 dislocations.Another 4 dislocations were treated with closed reduction and did not recur. 3 cases of nerveinjury were noted, all resolved within 12 months. Three cases of DVT were diagnosed as wellas 2 cases of postoperative infection; none of these led to chronic disability. Conclusions: The technique is perhaps more technically demanding than the lateral approaches used todaydue to the somewhat limited surgical exposure. Morbidly obese or very muscular patients aswell as patients with a short femoral neck or acetabular protrusion can represent particularproblems. Our results indicate that there are certain risks when adopting this procedure butthe complications noted are avoidable.

Obesity and long term functional outcomes following elective total hip replacement

Heather Vincent — 2012-04-25T00:00:00Z

IntroductionObesity rates continue to rise and more total hip arthroplasty procedures are being performedin progressively younger, obese patients. Hence, maintenance of long term physical functionwill become very important for quality of life, functional independence and hip prosthesissurvival. Presently, there are no reviews of the long term efficacy of total hip arthroplasty onphysical function. This review: 1) synopsized available data regarding obesity effects on longterm functional outcomes after total hip arthroplasty, and 2) suggested future directions forresearch. Methods: A literature search was conducted from 1965 to January of 2011 for studies that evaluatedlong term functional outcomes at one year or longer after THA in obese (body mass indexvalues [greater than or equal to]30 kg/m2) and non-obese patients (body mass index <30 kg/m2). Results: Five retrospective studies and 18 prospective studies were identified as those that assessedphysical function before surgery out to [greater than or equal to] one year after total hip arthroplasty. Study samplesizes ranged from 108-18,968 and followed patients from one to twenty years. Total hiparthroplasty confers significant pain reduction and improvement in quality of life irrespectiveof body mass index. Functional improvement occurred after total hip arthroplasty among allstudies, but obese patients generally did not attain the same level of physical function by thefollow-up time point.DiscussionUncontrolled obesity after total hip arthroplasty is related to worsening of comorbidities andexcessive health care costs over the long term. Aggressive and sustainable rehabilitationstrategies that include physical exercise, psychosocial components and behavior modificationmay be highly useful in maximizing and maintaining weight loss after total hip arthroplasty.

The benefits and barriers to physical activity and lifestyle interventions for osteoarthritis affecting the adult knee

Jonathan Stevenson — 2012-03-31T00:00:00Z

Osteoarthritis prevalence is increasing, placing greater demands on healthcare and future socioeconomic costing models. Exercise and non-pharmacological methods should be employed to manage this common and disabling disease. Expectations at all stages of disease are increasing with a desire to remain active and independent. Three key areas have been reviewed; the evidence for physical activity, lifestyle changes and motivational techniques concerning knee osteoarthritis and the barriers to instituting such changes. Promotion of activity in primary care is discussed and evidence for compliance has been reviewed. This article reviews a subject that is integral to all professionals involved with osteoarthritis care.

Thromboprophylaxis in spinal surgery: a survey

David Bryson — 2012-03-29T00:00:00Z

Background: Venous Thromboembolism (VTE) is the most common complication following major joint surgery. While attention has been focused upon the incidence of thromboembolic disease following total hip or knee arthroplasty or emergency surgery for hip fracture, there exists a gap in the medical literature examining the incidence of VTE in spinal surgery. Evidence suggests that the prevalence of DVT after spinal surgery is higher than generally recognized but with a shortage of epidemiological data, guidelines for optimal prophylaxis are limited. This survey, of individuals attending the 2009 British Association of Spinal Surgeons Annual Meeting, sought to examine prevailing trends in VTE thromboprophylaxis in spinal surgery, adherence to guideline outlined by the National Institute for Health and Clinical Excellence (NICE) and to compare selections made by orthopaedic and neurosurgeons. Methods: We developed a questionnaire with eight clinical scenarios. Participants were asked to supply details on their specialty and to select which method(s) of thromboprophylaxis they would employ for each scenario. Chi squared analysis was used for statistical comparison of the questionnaire responses. Results: 73% of neurosurgical respondents' and 31% of orthopaedic surgeons employed low molecular weight heparin (p < 0.001). Neurosurgeons also selected anti-embolism stockings more frequently (79% v 50%) while orthopaedic surgeons preferred mechanical prophylaxis (26% v 9%). There was no significant difference between trauma and non-trauma scenarios (p = 0.05). Conclusion: There is no clear consensus in thromboprophylaxis in spinal surgery. There was a significant difference in selections across surgical disciplines with neurosurgeons more closely adhering to national guidelines. Further research examining the epidemiology of venous thromboembolism in spinal surgery and the risks-benefit relationship of thromboprophylaxis is warranted.

Predictors of excellent early outcome after total hip arthroplasty

George Smith — 2012-03-25T00:00:00Z

Background: Not all patients gain the same degree of improvement from total hip replacement and the reasons for this are not clear. Many investigators have assessed predictors of general outcome after hip surgery. This study is unique in its quest for the predictors of the best possible early outcome. Methods: We prospectively collected data on 1318 total hip replacements. Prior to surgery patient characteristics, demographics and co-morbidities were documented. Hip function and general health was assessed using the Harris Hip score (HHS) and the Short-Form 36 respectively. The HHS was repeated at three years. We took a maximal HHS of 100 to represent an excellent outcome (102 patients). Multiple logistic regression analysis was used to identify independent predictors of excellent outcome. Results: The two strongest predictive factors in achieving an excellent result were young age and a high pre-operative HHS (p = 0.001). Conclusions: It was the young and those less disabled from their arthritis that excelled at three years. When making a decision about the timing of hip arthroplasty surgery it is important to take into account the age and pre-operative function of the patient. Whether these patients continue to excel however will be the basis of future research.

Sagittal plane articulation of the contralateral knee of subjects with posterior cruciate ligament deficiency: an observational study

Sivashankar Chandrasekaran — 2012-03-20T00:00:00Z

Background: The aim of the present study was to compare the in vivo articulation of the healthy knee to the contralateral knee of subjects with acute and chronic PCL injuries. Methods: Magnetic resonance was used to generate sagittal images of 10 healthy knees and 10 knees with isolated PCL injuries (5 acute and 5 chronic). The subjects performed a supine leg press against a 150 N load. Images were generated at 15 degree intervals as the knee flexed from 0 to 90 degrees. The tibiofemoral contact (TFC), and the centre of the femoral condyle (as defined by the flexion facet centre (FFC)), were measured from the posterior tibial cortex. Results: There was no significant difference in the TFC and FFC between the healthy knee and contralateral knee of subjects with acute and chronic PCL injuries in the medial and lateral compartments of the knee. Conclusions: The findings of this study suggest there is no predisposing articulation abnormality to PCL injury, in the setting of chronic injury the contralateral knee does not modify its articulation profile and the contralateral knee can be used as a valid control when evaluating the articulation of the PCL deficient knee.

Extracorporeal shockwave therapy in musculoskeletal disorders

Ching-Jen Wang — 2012-03-20T00:00:00Z

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

Chondrogenic differentiation of human subchondral progenitor cells is affected by synovial fluid from donors with osteoarthritis or rheumatoid arthritis

Jan Philipp Kruger — 2012-03-13T00:00:00Z

Background: Microfracture is a first-line treatment option for cartilage repair. In microfracture, subchondral mesenchymal cortico-spongious progenitor cells (CSP) enter the defect and form cartilage repair tissue. The aim of our study was to investigate the effects of joint disease conditions on the in vitro chondrogenesis of human CSP. Methods: CSP were harvested from the subchondral bone marrow. CSP characterization was performed by analysis of cell surface antigen pattern and by assessing the chondrogenic, osteogenic and adipogenic differentiation potential, histologically. To assess the effect of synovial fluid (SF) on chondrogenesis of CSP, micro-masses were stimulated with SF from healthy (ND), osteoarthritis (OA) and rheumatoid arthritis donors (RA) without transforming growth factor beta 3. Results: CSP showed the typical cell surface antigen pattern known from mesenchymal stem cells and were capable of osteogenic, adipogenic and chondrogenic differentiation. In micro-masses stimulated with SF, histological staining as well as gene expression analysis of typical chondrogenic marker genes showed that SF from ND and OA induced the chondrogenic marker genes aggrecan, types II and IX collagen, cartilage oligomeric matrix protein (COMP) and link protein, compared to controls not treated with SF. In contrast, the supplementation with SF from RA donors decreased the expression of aggrecan, type II collagen, COMP and link protein, compared to CSP treated with SF from ND or OA. Conclusion: These results suggest that in RA, SF may impair cartilage repair by subchondral mesenchymal progenitor cells in microfracture, while in OA, SF may has no negative, but a delaying effect on the cartilage matrix formation.

Clinical results of Hi-tech Knee II total knee arthroplasty in patients with rheumatoid athritis: 5- to 12-year follow-up

Hajime Yamanaka — 2012-02-22T00:00:00Z

Background: Total knee arthroplasty (TKA) is a common form of treatment to relieve pain and improve function in cases of rheumatoid arthritis (RA). Good clinical outcomes have been reported with a variety of TKA prostheses. The cementless Hi-Tech Knee II cruciate-retaining (CR)-type prosthesis, which has 6 fins at the anterior of the femoral component, posterior cruciate ligament (PCL) retention, flat-on-flat surface component geometry, all-polyethylene patella, strong initial fixation by the center screw of the tibial base plate, 10 layers of titanium alloy fiber mesh, and direct compression molded ultra high molecular weight polyethylene (UHMWPE), is appropriate for TKA in the Japanese knee.The present study was performed to evaluate the clinical results of primary TKA in RA using the cementless Hi-Tech Knee II CR-type prosthesis.Materials and methodsWe performed 32 consecutive primary TKAs using cementless Hi-Tech Knee II CR-type prosthesis in 31 RA patients. The average follow-up period was 8 years 3 months. Clinical evaluations were performed according to the American Knee Society (KS) system, knee score, function score, radiographic evaluation, and complications. Results: The mean postoperative maximum flexion angle was 115.6°, and the KS knee score and function score improved to 88 and 70 after surgery, respectively. Complications, such as infection, occurred in 1 patient and revision surgery was performed. There were no cases of loosening in this cohort, and prosthesis survival rate was 96.9% at 12 years postoperatively. Conclusion: These results suggest that TKA using the cementless Hi-Tech Knee II CR-type prosthesis is a very effective form of treatment in RA patients at 5 to 12 years postoperatively. Further long-term follow-up studies are required to determine the ultimate utility of this type of prosthesis.