The purpose of this study was to evaluate the long-term outcome of patients with a sacral chordoma and the surgical management of locally recurrent disease.

Between October 1990 and August 2013 we operated on 54 consecutive patients with a sacral chordoma. There were 34 men and 20 women with a mean age of 60 years (25 to 86). The mean maximum diameter of the tumour was 9.3 cm (3 to 20).

The mean follow-up was 7.8 years (2 months to 23.4 years). The disease-specific survival was 82% at five years, 57% at ten years and 45% at 15 years. The local recurrence-free survival was 49% at five years, 37% at ten years and 20% at 15 years. Local recurrence occurred in 30 patients (56%) at a mean of 3.8 years (3 months to 13 years) post-operatively.

Survival after the treatment of recurrence was 89% at two years, 56% at five years and 19% at ten years. Of nine patients who had complete resection of a recurrence, one died after 72 months and eight remain disease-free. Incomplete resection of recurrent disease resulted in a survival of 54% at two years and 36% at five years.

For 12 patients with a local recurrence who were treated palliatively, survival was 81% at two years and 31% at five years.

A wide margin of resection gave the best chance of long-term survival and complete resection of local recurrence the best chance of control of disease.

Cite this article: Bone Joint J 2015;97-B:711–15.

Data on early morbidity and complications after revision total hip replacement (THR) are limited. The aim of this nationwide study was to describe and quantify early morbidity after aseptic revision THR and relate the morbidity to the extent of the revision surgical procedure. We analysed all aseptic revision THRs from 1st October 2009 to 30th September 2011 using the Danish National Patient Registry, with additional information from the Danish Hip Arthroplasty Registry. There were 1553 procedures (1490 patients) performed in 40 centres and we divided them into total revisions, acetabular component revisions, femoral stem revisions and partial revisions. The mean age of the patients was 70.4 years (25 to 98) and the median hospital stay was five days (interquartile range 3 to 7). Within 90 days of surgery, the readmission rate was 18.3%, mortality rate 1.4%, re-operation rate 6.1%, dislocation rate 7.0% and infection rate 3.0%. There were no differences in these outcomes between high- and low-volume centres. Of all readmissions, 255 (63.9%) were due to ‘surgical’ complications versus 144 (36.1%) ‘medical’ complications. Importantly, we found no differences in early morbidity across the surgical subgroups, despite major differences in the extent and complexity of operations. However, dislocations and the resulting morbidity represent the major challenge for improvement in aseptic revision THR.

Cite this article: Bone Joint J 2014; 96-B:1464–71.

The December 2014 Research Roundup³⁶⁰ looks at: demineralised bone matrix not as good as we thought?; trunk control following ACL reconstruction; subclinical thyroid dysfunction: not quite subclinical?; establishing musculoskeletal function in mucopolysaccharidosis; starting out: a first year in consultant practice under the spotlight; stroke and elective surgery; sepsis and clots; hip geometry and arthritis incidence; and theatre discipline and infection.

Knee arthrodesis is a potential salvage procedure for limb preservation after failure of total knee arthroplasty (TKA) due to infection. In this study, we evaluated the outcome of single-stage knee arthrodesis using an intramedullary cemented coupled nail without bone-on-bone fusion after failed and infected TKA with extensor mechanism deficiency. Between 2002 and 2012, 27 patients (ten female, 17 male; mean age 68.8 years; 52 to 87) were treated with septic single-stage exchange. Mean follow-up duration was 67.1months (24 to 143, n = 27) (minimum follow-up 24 months) and for patients with a minimum follow-up of five years 104.9 (65 to 143,; n = 13). A subjective patient evaluation (Short Form (SF)-36) was obtained, in addition to the Visual Analogue Scale (VAS). The mean VAS score was 1.44 (SD 1.48). At final follow-up, four patients had recurrent infections after arthrodesis (14.8%). Of these, three patients were treated with a one-stage arthrodesis nail exchange; one of the three patients had an aseptic loosening with a third single-stage exchange, and one patient underwent knee amputation for uncontrolled sepsis at 108 months. All patients, including the amputee, indicated that they would choose arthrodesis again. Data indicate that a single-stage knee arthrodesis offers an acceptable salvage procedure after failed and infected TKA.

Cite this article: Bone Joint J 2015;97-B:649–53.

The aims of this retrospective study were to compare the mid-term outcomes following revision total knee replacement (TKR) in 76 patients (81 knees) < 55 years of age with those of a matched group of primary TKRs based on age, BMI, gender and comorbid conditions. We report the activity levels, functional scores, rates of revision and complications. Compared with patients undergoing primary TKR, those undergoing revision TKR had less improvement in the mean Knee Society function scores (8.14 (–55 to +60) vs 23.3 points (–40 to +80), p < 0.001), a similar improvement in UCLA activity level (p = 0.52), and similar minor complication rates (16% vs 13%, p = 0.83) at a mean follow-up of 4.6 years (2 to 13.4). Further revision surgery was more common among revised TKRs (17% vs 5%, p = 0.02), with deep infection and instability being the most common reasons for failure. As many as one-third of patients aged < 55 years in the revision group had a complication or failure requiring further surgery.

Young patients undergoing revision TKR should be counselled that they can expect somewhat less improvement and a higher risk of complications than occur after primary TKR.

Cite this article: Bone Joint J 2014; 96-B:1657–62

Aims

Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head–neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis.

The “Universal Protocol” (UP) was launched as a regulatory compliance standard by the Joint Commission on 1st July 1 2004, with the primary intent of reducing the occurrence of wrong-site and wrong-patient surgery. As we’re heading into the tenth year of the UP implementation in the United States, it is time for critical assessment of the protocol’s impact on patient safety related to the incidence of preventable never-events. This article opens the debate on the potential shortcomings and pitfalls of the UP, and provides recommendations on how to circumvent specific inherent vulnerabilities of this widely established patient safety protocol.

The August 2014 Hip & Pelvis Roundup³⁶⁰ looks at: Serial MRIs best for pseudotumour surveillance; Is ultrasound good enough for MOM follow-up?; Does weight loss in obese patients help?; Measuring acetabular anteversion on plain films; Two-stage one-stage too many in fungal hip revisions? and 35 is the magic number in arthroplasty.

The August 2014 Wrist & Hand Roundup360 looks at: Trapeziectomy superior to arthrodesis;Tamoxifen beneficial in the short term; Semi-occlusive dressing “the bee’s knees” even with exposed bone; “Open” a relative concept in the hand and wrist; Editorial decisions pushing up standards of reporting; Ulnar variance revisited; Traditionalists are traditional; Diabetes not so bad with carpal tunnel

Haematomas, drainage, and other non-infectious wound complications following total knee replacement (TKR) have been associated with long-term sequelae, in particular, deep infection. However, the impact of these wound complications on clinical outcome is unknown. This study compares results in 15 patients re-admitted for wound complications within 90 days of TKR to 30 matched patients who underwent uncomplicated total knee replacements. Patients with wound complications had a mean age of 66 years (49 to 83) and mean body mass index (BMI) of 37 (21 to 54), both similar to that of patients without complications (mean age 65 years and mean BMI 35). Those with complications had lower mean Knee Society function scores (46 (0 to 100 vs 66 (20 to 100), p = 0.047) and a higher incidence of mild or greater pain (73% vs 33%, p = 0.01) after two years compared with the non re-admitted group. Expectations in patients with wound complications following TKR should be tempered, even in those who do not develop an infection.

Cite this article: Bone Joint J 2014;96-B:619–21.

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail.

The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open.

The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture.

A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices.

Cite this article: Bone Joint J 2014; 96-B:817–22.

Peri-acetabular tumour resections and their subsequent reconstruction are among the most challenging procedures in orthopaedic oncology. Despite the fact that a number of different pelvic endoprostheses have been introduced, rates of complication remain high and long-term results are mostly lacking.

In this retrospective study, we aimed to evaluate the outcome of reconstructing a peri-acetabular defect with a pedestal cup endoprosthesis after a type 2 or type 2/3 internal hemipelvectomy.

A total of 19 patients (11M:8F) with a mean age of 48 years (14 to 72) were included, most of whom had been treated for a primary bone tumour (n = 16) between 2003 and 2009. After a mean follow-up of 39 months (28 days to 8.7 years) seven patients had died. After a mean follow-up of 7.9 years (4.3 to 10.5), 12 patients were alive, of whom 11 were disease-free. Complications occurred in 15 patients. Three had recurrent dislocations and three experienced aseptic loosening. There were no mechanical failures. Infection occurred in nine patients, six of whom required removal of the prosthesis. Two patients underwent hindquarter amputation for local recurrence.

The implant survival rate at five years was 50% for all reasons, and 61% for non-oncological reasons. The mean Musculoskeletal Tumor Society score at final follow-up was 49% (13 to 87).

Based on these poor results, we advise caution if using the pedestal cup for reconstruction of a peri-acetabular tumour resection.

Cite this article: Bone Joint J 2014;96-B:1706–12.

This protocol describes a pragmatic multicentre randomised controlled trial (RCT) to assess the clinical and cost effectiveness of arthroscopic and open surgery in the management of rotator cuff tears. This trial began in 2007 and was modified in 2010, with the removal of a non-operative arm due to high rates of early crossover to surgery.

Cite this article: Bone Joint Res 2014;3:155–60.

The February 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: flexible plasters; dual 8-plate or ablation for knee epiphysiodesis; ultrasounds for pulled elbow; leg length without the radiation; Boyd amputation in limb deficiencies; gold standard club foot treatment; quadrupled semitendinosis graft effective in paediatric ACL reconstruction; and predicting complications following cerebral palsy hip reconstruction

Objectives

To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care.

Patient-centred medicine is an approach to medical care that emphasises the patient experience. Treatment outcome measures reflect this experience, and outcomes are measured by obtaining patient feedback. Central to this type of care is the patient-physician relationship. Communication, physician empathy, and shared decision making are key components of this relationship. Patient-centred care is correlated with better patient outcomes across medical specialties and higher patient perceived quality of care. Payors are now using patient-centred quality measures in their physician reimbursement schedules.

We compared the clinical, radiological and quality-of-life outcomes between hybrid and total pedicle screw instrumentation in patients undergoing surgery for neuromuscular scoliosis. A matched comparison using prospectively collected data was undertaken. A total of 66 patients underwent posterior or anteroposterior correction and fusion with hybrid (n = 33, mean age at surgery 15.8 years (9.10 to 19.6)) or total pedicle screw instrumentation (n = 33, mean age 14.7 years (7.0 to 20.7)) with a minimum follow-up of two years. The major curve pre-operatively was a mean of 87° (sd 29, 25° to 141°) and 81° (sd 18, 47° to 116°) in the hybrid and total pedicle screw groups, respectively (p = 0.29) and at a minimum of two years it was 33° (sd 20; 2° to 87°) and 20° (sd 12; 1° to 55°), respectively (p = 0.0016). The mean correction of the major curve was 59% (41% to 88%) in the hybrid and 75% (43% to 99%) in the total pedicle screw groups at two-year follow-up (p = 0.0011). The mean operating time was 7.45 hours (sd 2.18) and 6.04 hours (sd 1.71) in the hybrid and total pedicle screw groups, respectively (p = 0.001), and the mean intra-operative blood loss was 3760 ml (sd 2790) and 1785 ml (sd 1110), respectively (p = 0.001).

Total pedicle screw instrumentation provided shorter operating times, less blood loss and better correction of the major curve compared with hybrid constructs in patients undergoing surgery for neuromuscular scoliosis.

The National Institute for Health and Clinical Excellence (NICE) has thus far relied on historical data and predominantly industry-sponsored trials to provide evidence for venous thromboembolic (VTE) prophylaxis in joint replacement patients. We argue that the NICE guidelines may be reliant on assumptions that are in need of revision. Following the publication of large scale, independent observational studies showing little difference between low-molecular-weight heparins and aspirin, and recent changes to the guidance provided by other international bodies, should NICE reconsider their recommendations?

Cite this article: Bone Joint Res 2014;3:146–9.

We evaluated the clinical results and complications after extra-articular resection of the distal femur and/or proximal tibia and reconstruction with a tumour endoprosthesis (MUTARS) in 59 patients (mean age 33 years (11 to 74)) with malignant bone or soft-tissue tumours. According to a Kaplan–Meier analysis, limb survival was 76% (95% confidence interval (CI) 64.1 to 88.5) after a mean follow-up of 4.7 years (one month to 17 years). Peri-prosthetic infection was the most common indication for subsequent amputation (eight patients). Survival of the prosthesis without revision was 48% (95% CI 34.8 to 62.0) at two years and 25% (95% CI 11.1 to 39.9) at five years post-operatively. Failure of the prosthesis was due to deep infection in 22 patients (37%), aseptic loosening in ten patients (17%), and peri-prosthetic fracture in six patients (10%). Wear of the bearings made a minor revision necessary in 12 patients (20%). The mean Musculoskeletal Tumor Society score was 23 (10 to 29). An extensor lag > 10° was noted in ten patients (17%).

These results suggest that limb salvage after extra-articular resection with a tumour prosthesis can achieve good functional results in most patients, although the rates of complications and subsequent amputation are higher than in patients treated with intra-articular resection.

Cite this article: Bone Joint J 2013;95-B:1425–31.

To date, all surgical techniques used for reconstruction of the pelvic ring following supra-acetabular tumour resection produce high complication rates. We evaluated the clinical, oncological and functional outcomes of a cohort of 35 patients (15 men and 20 women), including 21 Ewing’s sarcomas, six chondrosarcomas, three sarcomas not otherwise specified, one osteosarcoma, two osseous malignant fibrous histiocytomas, one synovial cell sarcoma and one metastasis. The mean age of the patients was 31 years (8 to 79) and the latest follow-up was carried out at a mean of 46 months (1.9 to 139.5) post-operatively.

We undertook a functional reconstruction of the pelvic ring using polyaxial screws and titanium rods. In 31 patients (89%) the construct was encased in antibiotic-impregnated polymethylmethacrylate. Preservation of the extremities was possible for all patients. The survival rate at three years was 93.9% (95% confidence interval (CI) 77.9 to 98.4), at five years it was 82.4% (95% CI 57.6 to 93.4). For the 21 patients with Ewing’s sarcoma it was 95.2% (95% CI 70.7 to 99.3) and 81.5% (95% CI 52.0 to 93.8), respectively. Wound healing problems were observed in eight patients, deep infection in five and clinically asymptomatic breakage of the screws in six. The five-year implant survival was 93.3% (95% CI 57.8 to 95.7). Patients were mobilised at a mean of 3.5 weeks (1 to 7) post-operatively. A post-operative neurological defect occurred in 12 patients. The mean Musculoskeletal Tumor Society score at last available follow-up was 21.2 (10 to 27).

This reconstruction technique is characterised by simple and oncologically appropriate applicability, achieving high primary stability that allows early mobilisation, good functional results and relatively low complication rates.

Cite this article: Bone Joint J 2013;95-B:1410–16.