There has been an in increase in the availability of effective biological agents for the treatment of rheumatoid arthritis as well as a shift towards early diagnosis and management of the inflammatory process. This article explores the impact this may have on the place of orthopaedic surgery in the management of patients with rheumatoid arthritis.

Cite this article: Bone Joint J 2014;96-B:1287–9

Osteoarthritis results in changes in the dimensions of the glenoid. This study aimed to assess the size and radius of curvature of arthritic glenoids. A total of 145 CT scans were analysed, performed as part of routine pre-operative assessment before total shoulder replacement in 91 women and 54 men. Only patients with primary osteoarthritis and a concentric glenoid were included in the study. The CT scans underwent three-dimensional (3D) reconstruction and were analysed using dedicated computer software. The measurements consisted of maximum superoinferior height, anteroposterior width and a best-fit sphere radius of curvature of the glenoid.

The mean height was 40.2 mm (sd 4.9), the mean width was 29 mm (sd 4.3) and the mean radius of curvature was 35.4 mm (sd 7.8). The measurements were statistically different in men and women and had a Gaussian distribution with marked variation. All measurements were greater than the known values in normal subjects.

With current shoulder replacement systems using a unique backside radius of curvature for the glenoid component, there is a risk of undertaking excessive reaming to adapt the bone to the component resulting in sacrifice of subchondral bone or under-reaming and instability of the component due to a ’rocking horse‘ phenomenon.

Cite this article: Bone Joint J 2013;95-B:1377–82.

Enhanced recovery pathways (ERPs) utilise multimodal rehabilitation techniques to reduce post-operative pain and accelerate the rehabilitation process following surgery. Originally described following elective colonic surgery enhanced recovery pathways have gained increasing use following elective hip and knee joint replacement in recent years. Early studies have indicated that enhanced recovery pathways can reduce length of hospital stay, reduce complications and improve cost-effectiveness of joint replacement surgery. Despite this growing evidence base uptake has been slow in certain centres and many surgeons are yet to utilise enhanced recovery pathways in their practice. We look at the process and effects of implementing an enhanced recovery pathway following total hip replacement surgery at a district general hospital in the United Kingdom.

A retrospective study was initially undertaken over a four-month period to assess patient demographics, length of stay, time to physiotherapy and complication rates including re-admission within 28 days.

Based on national recommendations an enhanced recovery pathway protocol was then implemented for an elective total hip replacement list. Inclusion criteria were elective patients undergoing primary total hip replacement (THR) surgery. The pathway included pre-operative nutrition optimisation, 4mg ondansetron, 8mg dexamethasone and 1g tranexamic acid at induction and 150mL ropivacaine HCL 0.2%, 30mg ketorolac and adrenaline (RKA) mix infiltration to joint capsule, external rotators, gluteus tendon, iliotibial band, soft-tissues and skin around the hip joint. The patient was mobilised four-hours after surgery where possible and aimed to be discharged once mobile and pain was under control.

Following implementation a prospective study was undertaken to compare patient demographics, length of stay and complication rates including re-admission within 28 days.

34 patients met the inclusion criteria and were included in each group pre and post-enhanced recovery pathway. Following implementation of an enhanced recovery pathway mean length of stay decreased from 5.4 days to 3.5 days (CI 1.94, p < 0.0001). Sub-group analysis based on ASA grade revealed that this reduction in length of stay was most pronounced in ASA 1 patients with mean length of stay reduced from 5.0 days to 3.2 days (CI 1.83, p < 0.0001). There was no significant change in the number of complications or re-admission rates following enhanced recovery pathway.

The enhanced recovery pathway was quick and easy to implement with co-ordination between surgeons, anaesthetist, nursing staff and patients. This observational study of consecutive primary total hip replacement patients shows a substantial reduction in length of stay with no change in complication rates after the introduction of a multimodal enhanced recovery protocol. Both of these factors reduce hospital costs for elective THR patients and may improve patient experiences.

This study was undertaken to assess for equivalence or superiority in tendon reconstruction techniques. This is an in vitro analysis of several, different, reconstruction techniques for chronic Achilles tendon ruptures. The surgical techniques have been borne out of surgical preference rather than biomechanical principles with little published research into their comparability. Surgical preferences are a result of the supposed benefits of reduced operative time, single operative incision and decreased morbidity. An animal model, after human cadaveric tissue dissection to guide the specimen construction, was used to compare the different techniques using bovine bone and tendon and tested using a material testing machine. Ultimate load to failure was recorded for all specimens and statistical analysis of the results was undertaken.

A statistically significant difference was shown between all the techniques by analysis of variance. This will guide clinical application of these techniques. The use of bone tunnels, through which the flexor hallucis longus tendon can be passed, were found to be biomechanically superior, with regard to ultimate load to failure, to either bone anchors or end-to-end tendon suture techniques. Interference screws were found to have a large range in their ultimate load suggesting a lack of consistency in the results. The mean of the bone tunnel group (482.8N, SD 83.6N) is significantly (p < 0.01) higher than the mean of the bone anchor group (180.2N, SD 19.3N), which is, in turn, significantly (p < 0.01) higher than the mean of the Bunnell group (73.7N, SD 20.9N). This study is larger than any previous study found in the literature with regard to number of study groups and allows the techniques to be compared side by side.

Purpose

to analyze the survivorship of the RSA with a minimum 10 years follow up.

Aim

To identify a means to reduce the duration and radiation dose coupled with fluoroscopic guided nerve root blocks (NRB).

We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening (sd) as endpoints. The Constant score was found to improve from a mean of 26.8 (sd 10.3) pre-operatively to 57.6 (sd 20.0) post-operatively (p < 0.001). Active forward flexion improved from a mean of 85.3° (sd 27.4) pre-operatively to 125° (sd 37.3) postoperatively (p < 0.001). External rotation improved from a mean of 7° (sd 6.5) pre-operatively to 30.3° (sd 21.8°) post-operatively (p < 0.001). Survivorship with revision of the glenoid component as the endpoint was 99.1% at five years, 94.5% at ten years and 79.4% at 15 years. Survivorship with radiological loosening as the endpoint was 99.1% at five years, 80.3% at ten years and 33.6% at 15 years.

Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years.

Thirty patients underwent tibio-talo-calcaneal fusion using an interlocking arthrodesis intramedullary nail device with locking screws. Although the nail is described as being stiffer in flexion, rotation and cantilever bending it was noted that the placement of the locking screw holes were not sufficiently in-tune with the variations found in nature. The placement of the holes and locking screws with relation to the heights of the talus and calcaneum were measured on post operative xrays and conclusions drawn from the variations found. It was felt that the intramedullary nail is a good device when used for tibio-talo-calcaneal fusion but that the design could be improved in order to improve patient outcome.

Purpose: Radiographic signs of osseointegration have been well established for cementless femoral components, but not for cementless acetabular components. At our institution using principles similar to those applied to cementless femoral components, we have observed apparent radiographic signs of osseointegration of porous-coated cups. We then hypothesized that these signs could be used to predict bone ingrowth of porous-coated acetabular components

Methods: In a series of 119 total hip arthroplasties with porous-coated cementless cups, we reviewed post-primary and prerevision serial radiographs and proposed five radiographic signs for detecting osseointegration of a porous-coated acetabular component: absence of radiolucent lines, presence of a superolateral buttress, medial stress shielding, radial trabeculae, and an infero-medial buttress. We compared the predictability of each sign to intraoperative findings of cup stability and measured the sensitivity, specificity, and intra-observer agreement of each sign

Results: . In our population, ninety-eight cups had three to five radiographic signs of osseointegration; of these, ninety-five cups (97%) were found to be bone-ingrown at the revision operation. Conversely, twelve cups had only one or no sign; of these, ten (83%) were clinically unstable at the revision operation.

Conclusions: We concluded these five, readily detectable signs of acetabular osseointegration are very useful in predicting acetabular component stability found at surgery.

Introduction and Aims: Assessment of the metabolic state of articular cartilage (AC) is important in understanding the initiation and progression of osteoarthritis (OA). The purpose of this study was to evaluate changes in gene expression of the major AC extracellular matrix (ECM) components, in addition to a number of molecules involved in OA, including the novel glycoprotein lubricin, following lateral meniscectomy in a sheep model of OA.

Method: AC tissue from both medial (MTP) and lateral (LTP) tibial plateaux were collected from six non-operated control (NOC) and six lateral meniscectomised (MEN) pure-bred Merino sheep six months post-surgery for semi-quantitative RT-PCR to assess patterns of mRNA expression (relative to GAPDH). Histological evaluation using a modified Mankin score was undertaken in the same sheep to grade the AC and immunohistochemical localisation of gene products was performed.

Results: Cartilage degeneration was evident both macroscopically and histologically in the LTP following MEN, with less marked changes appearing in the MTP. The mean total tissue RNA increased greater than five-fold in the LTP following MEN (p< 0.01). Expression of aggrecan (p< 0.01) and collagen type II (p< 0.01) were found to be significantly elevated in LTP AC following MEN. Increased expression of biglycan (p< 0.01) was observed in LTP AC following MEN, whereas conversely, there was a decreased expression of decorin (p< 0.01), the other fibril associated small leucine rich proteoglycan. Expression of both lubricin (p< 0.01) and connective tissue growth factor (CTGF) (p< 0.05) were also found to decrease following MEN in LTP AC. TGFβ demonstrated no change in expression following MEN. Significant changes in gene expression were generally not seen in the MTP following MEN; however trends were observed reflecting similar gene profile changes to those occurring in the LTP.

Conclusion: Strong up-regulation in gene expression of the major cartilage ECM components was found, reflecting an anabolic response and attempted tissue repair. Significant changes were also observed for other ECM macromolecules thought to be involved in degenerative joint disease, contributing to alterations in the gene expression profile associated with OA.

Introduction and Aims: This study was designed to assess the impact of lower limb arthroplasty on performance and other outcome measures in active golfers. The aim was to obtain justification data prior to proceeding with a much larger prospective study.

Method: Subjects were selected for inclusion in the study on the basis of having undergone lower limb arthroplasty surgery and actively playing golf at a social or competitive level at least fortnightly. Data was collected retrospectively by the use of a self-administered, patient-orientated questionnaire. Pre- and post-joint replacement data was obtained for: Australian Golf Union (AGU) handicap; driving and longest iron distances; frequency and duration of golf rounds played; use of motorised assistance; and pain, stiffness, swelling and subjective performance scores. Demographics, length of time to return to playing golf post-operatively and post-operative complications were also recorded.

Results: Results were obtained from 25 subjects with 33 joints in total replaced, 24 male and one female, mean age 70.6 years (range 53–81 years) and average time to survey post-arthroplasty was five years and 10 months. The right knee was replaced in 30.3% of subjects, left knee 27.3%, right hip 24.2% and left hip 18.2%. Eight of the 25 subjects reported complications with three requiring further surgery. There were no reports of dislocation. The average time taken to resume golfing activity post-arthroplasty was 15.4 weeks (range 5–52 weeks). Subjects demonstrated a mean increase in their AGU handicap of 1.6 strokes (p< 0.05). Average drive distance off the tee shortened by 8.6 metres (p< 0.05), with a similar change for average longest iron length, in the magnitude of 7.4 metres (p< 0.05). There was no significant change in the numbers of rounds played per month, with a mean of 8.9 pre-joint replacement and 8.3 after surgery. Wilcoxon signed-ranks test values were significant (p < 0.05) for comparison of pre to post-joint replacement, showing a decrease in reported symptoms of pain, stiffness and swelling following joint replacement. A highly significant (p< 0.001) finding was a reduction in the subjective impact of joint symptoms on golf performance post-arthroplasty.

Conclusion: Although subjects seem to be more satisfied with their golf by playing with less joint pain, stiffness and swelling, they appear to do so with an actual decrease in objective performance. These significant findings support conducting a much larger prospective study looking at the impact of arthroplasty on golf activity, and vice versa.

The British Orthopaedic Association assessment questionnaire for knee replacements was adapted to allow comparison of the severity of underlying polyarthritis with the benefits of geometric knee replacement in a retrospective study of 150 knees between six months and six years after operation. Total or partial relief of pain was achieved in 81 per cent of the operation, and changes in mobility occurred in fewer patients. Late sepsis remained a serious complication of nine per cent of the operations and one patient died from septicaemia. Late sepsis was associated with previous synovectomy or osteotomy. Retropatellar pain rarely interfered with the mobility of the patient. There was no association of operations that failed with a high erythrocyte sedimentation rate, a high platelet count, a low haemoglobin level or with a strongly positive rheumatoid factor but pain in the contralateral knee was associated with a diminished functional capacity.

Thirteen patients suffering from rheumatoid arthritis had 19 stress fractures of the tibia or fibula. These patients characteristically presented with sudden, severe, unexplained pain with localised tenderness just below the knee or above the ankle. In seven patients examination of the adjacent joint indicated a flare-up of disease activity or a pyogenic arthritis. In six patients the diagnosis was delayed by the late appearance of callus in minute fractures. All patients had rheumatoid deformities of the ipsilateral lower limb: valgus deformities of the knee and subtalar joints occurred most frequently. All patients had osteoporosis; all except two had received steroid treatment and five had abnormalities of calcium metabolism. We suggest that deformities of the knee and ankle predispose patients with rheumatoid arthritis and osteoporosis to stress fractures of the tibia and fibula.