Aims

The aims of this study were to report the efficacy of revision surgery for patients with co-infective bacterial and fungal prosthetic joint infections (PJIs) presenting to a single institution, and to identify prognostic factors that would guide management.

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The aim of this study was to evaluate health-related quality of life (HRQoL) and joint function in tenosynovial giant cell tumour (TGCT) patients before and after surgical treatment.

Aims. The aim of this study was to evaluate the outcome of spinal instrumentation in haemodialyzed patients with native pyogenic spondylodiscitis. Spinal instrumentation in these patients can be dangerous due to rates of complications and mortality, and biofilm formation on the instrumentation. Patients and Methods. A total of 134 haemodialyzed patients aged more than 50 years who underwent surgical treatment for pyogenic spondylodiscitis were included in the study. Their mean age was 66.4 years (50 to 83); 66 were male (49.3%) and 68 were female (50.7%). They were divided into two groups according to whether spinal instrumentation was used or not. Propensity score matching was used to attenuate the potential selection bias. The outcome of treatment was compared between these two groups. Results. A total of 89 patients (66.4%) underwent non-instrumented surgery and 45 (33.5%) underwent instrumented surgery. There were no significant differences in the rates of postoperative complications, except for an increased rate of wound problems in the instrumented group, which was found in the unmatched cohorts (p = 0.034). There were no significant differences in the rate of recurrent infections (p = 0.328 for the unmatched cohort; p = 0.269 for the matched cohort) and mortality rate, including in-hospital (p = 0.713 for the unmatched cohort; p = 0.738 for the matched cohort) and one-year rates (p = 0.363 for the unmatched cohort; p = 0.787 for the matched cohort), between the groups. However, the interval between the initial diagnosis and the first recurrence was significantly longer in the instrumented group (p = 0.008 for the unmatched cohort; p = 0.032 for the matched cohort). Conclusion. Instrumented surgery for haemodialyzed patients with pyogenic spondylodiscitis showed similar outcomes, including recurrence and mortality, to non-instrumented surgery, despite the instrumented group having more severe neurological deficit, a larger number of involved levels, and increased kyphotic angle

Aims

Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called ’combined hip procedure’ (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone.

We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs. In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intra-operatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years). There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029). We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support. Cite this article: Bone Joint J 2015;97-B:192–6

Aims

The aim of this study was to determine the influence of developmental spinal stenosis (DSS) on the risk of re-operation at an adjacent level.

The Unified Classification System (UCS) emphasises the key principles in the assessment and management of peri-prosthetic fractures complicating partial or total joint replacement. We tested the inter- and intra-observer agreement for the UCS as applied to the pelvis and femur using 20 examples of peri-prosthetic fracture in 17 patients. Each subtype of the UCS was represented by at least one case. Specialist orthopaedic surgeons (experts) and orthopaedic residents (pre-experts) assessed reliability on two separate occasions. For the pelvis, the UCS showed inter-observer agreement of 0.837 (95% confidence intervals (CI) 0.798 to 0.876) for the experts and 0.728 (95% CI 0.689 to 0.767) for the pre-experts. The intra-observer agreement for the experts was 0.861 (95% CI 0.760 to 0.963) and 0.803 (95% 0.688 to 0.918) for the pre-experts. For the femur, the UCS showed an inter-observer kappa value of 0.805 (95% CI 0.765 to 0.845) for the experts and a value of 0.732 (95% CI 0.690 to 0.773) for the pre-experts. The intra-observer agreement was 0.920 (95% CI 0.867 to 0.973) for the experts, and 0.772 (95% CI 0.652 to 0.892) for the pre-experts. This corresponds to a substantial and ‘almost perfect’ inter- and intra-observer agreement for the UCS for peri-prosthetic fractures of the pelvis and femur. We hope that unifying the terminology of these injuries will assist in their assessment, treatment and outcome. Cite this article: Bone Joint J 2014;96-B:1472–7

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The purpose of this study was to identify prognostic indicators of outcome at presentation to the orthopaedic surgeon, in patients with metastatic prostate cancer. Our aim was to use this information in a pragmatic, clinic-based approach so that surgical decision making could be optimized to benefit the patient in their remaining lifetime.

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The aim of this study was to evaluate the surgical management and outcome of patients with an acral soft-tissue sarcoma of the hand or foot.

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This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.

Popliteal artery injury (PAI) is a feared complication during knee replacement. Our aim was to investigate those injuries that occurred in association with knee replacement in terms of the type of injury, treatment and outcomes. From our national vascular registry (Swedvasc) and the Swedish Patient Insurance databases a total of 32 cases were identified. Prospective data from the registries was supplemented with case-records, including long-term follow-up. We estimated the incidence during 1998 to 2010 to be 0.017%. In our series of 32 patients with PAI occurring between 1987 and 2011, 25 (78%) were due to penetrating trauma and seven were caused by blunt trauma. The patients presented in three ways: bleeding (14), ischaemia (7) and false aneurysm formation (11), and five occurred during revision surgery. A total of 12 injuries were detected intra-operatively, eight within 24 hours (3 to 24) and 12 at more than 24 hours post-operatively (2 to 90 days). Treatment comprised open surgery in 28 patients. Patency of the vascular repair at 30 days was 97% (31 of 32, one amputation). At the time of follow-up (median 546 days, mean 677 days (24 to 1251)), 25 patients had residual symptoms. Of seven patients with a complete recovery, six had had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital. PAI is a rare adverse event during knee replacement surgery. The outcome following such events is often adversely affected by diagnostic and therapeutic delay. Bleeding and false aneurysm were the most common clinical presentations. Cite this article: Bone Joint J 2013;95-B:1645–9

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Recurrent infection following two-stage revision total hip arthroplasty (THA) for prosthetic joint infection (PJI) is a devastating complication. The purpose of this study was to report the survival of repeat two-stage revision hip arthroplasty, describe complications, and identify risk factors for failure.

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High-quality clinical research in children’s orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children’s orthopaedics.

The sternoclavicular joint (SCJ) is a pivotal articulation in the linked system of the upper limb girdle, providing load-bearing in compression while resisting displacement in tension or distraction at the manubrium sterni. The SCJ and acromioclavicular joint (ACJ) both have a small surface area of contact protected by an intra-articular fibrocartilaginous disc and are supported by strong extrinsic and intrinsic capsular ligaments. The function of load-sharing in the upper limb by bulky periscapular and thoracobrachial muscles is extremely important to the longevity of both joints. Ligamentous and capsular laxity changes with age, exposing both joints to greater strain, which may explain the rising incidence of arthritis in both with age. The incidence of arthritis in the SCJ is less than that in the ACJ, suggesting that the extrinsic ligaments of the SCJ provide greater stability than the coracoclavicular ligaments of the ACJ. Instability of the SCJ is rare and can be difficult to distinguish from medial clavicular physeal or metaphyseal fracture-separation: cross-sectional imaging is often required. The distinction is important because the treatment options and outcomes of treatment are dissimilar, whereas the treatment and outcomes of ACJ separation and fracture of the lateral clavicle can be similar. Proper recognition and treatment of traumatic instability is vital as these injuries may be life-threatening. Instability of the SCJ does not always require surgical intervention. An accurate diagnosis is required before surgery can be considered, and we recommend the use of the Stanmore instability triangle. Most poor outcomes result from a failure to recognise the underlying pathology. There is a natural reluctance for orthopaedic surgeons to operate in this area owing to unfamiliarity with, and the close proximity of, the related vascular structures, but the interposed sternohyoid and sternothyroid muscles are rarely injured and provide a clear boundary to the medial retroclavicular space, as well as an anatomical barrier to unsafe intervention. This review presents current concepts of instability of the SCJ, describes the relevant surgical anatomy, provides a framework for diagnosis and management, including physiotherapy, and discusses the technical challenges of operative intervention. Cite this article: Bone Joint J 2013;95-B:721–31

The aim of this study was to identify whether there was any difference in patient, tumour, treatment or outcome characteristics between patients with skeletal or extra-skeletal Ewing’s sarcoma. We identified 300 patients with new primary Ewing’s sarcoma diagnosed between 1980 and 2005 from the centres’ local database. There were 253 (84%) with skeletal and 47 (16%) with extra-skeletal Ewing’s sarcomas. Although patients with skeletal Ewing’s were younger (mean age 16.8 years) than those with extra-skeletal Ewing’s sarcoma (mean age 27.5 years), there was little difference between the groups in terms of tumour stage or treatment. Nearly all the patients were treated with chemotherapy and most had surgery. There was no difference in the overall survival of patients with skeletal (64%) and extra-skeletal Ewing’s sarcoma (61%) (p = 0.85), and this was also the case when both groups were split by whether they had metastases or not. This large series has shown that the oncological outcomes of Ewing’s sarcoma are related to tumour characteristics and patient age, and not determined by whether they arise in bone or soft tissue

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This study aimed to investigate the role of quantitative histological analysis in the diagnosis of fracture-related infection (FRI).

Coccydynia is a painful disorder characterised by coccygeal pain which is typically exaggerated by pressure. It remains an unsolved mystery because of the perceived unpredictability of the origin of the pain, some psychological traits that may be associated with the disorder, the presence of diverse treatment options, and varied outcomes. A more detailed classification based on the aetiology and pathoanatomy of coccydynia helps to identify patients who may benefit from conservative and surgical management. This review focuses on the pathoanatomy, aetiology, clinical features, radiology, treatment and outcome of coccydynia