We present the development and results of a nationwide, prospective, observational follow-up programme including patient-reported outcome measures (PROMs) for the Swedish Hip Arthroplasty Register. The programme started in 2002 and has gradually expanded to include all units performing total hip replacement in Sweden. The self-administered PROMs protocol comprises the EQ-5D instrument, the Charnley class categorisation and visual analogue scales for pain and satisfaction. These current analyses include 34 960 total hip replacements with complete pre- and one-year post-operative questionnaires. Patients eligible for total hip replacement generally report low health-related quality of life and suffer from pain. One year post-operatively the mean EQ-5D index increased to above the level of an age- and gender-matched population, with a considerable reduction of pain (p < 0.001). Females, younger patients and those with Charnley category C reported a lower EQ-5D index pre-operatively than males, older patients and Charnley category A or B, respectively (all p < 0.001). In a multivariable regression analysis Charnley category C, male gender and higher age were associated with less improvement in health-related quality of life (p < 0.001). Nationwide implementation of a PROMs programme requires a structured organisation and effective data capture. Patients’ response rates to the Registry are good. The continuous collection of PROMs permits local and national improvement work and allows for further health-economic evaluation

We assessed the reliability, accuracy and variability of closed-wedge high tibial osteotomy (HTO) using computer-assisted surgery compared to the conventional technique. A total of 50 closed-wedge HTO procedures were performed using the navigation system, and compared with 50 HTOs that had been performed with the conventional technique. In the navigation group, the mean mechanical axis prior to osteotomy was varus 8.2°, and the mean mechanical axis following fixation was valgus 3.6°. On the radiographs the mean pre-operative mechanical axis was varus 7.3°, and the mean post-operative mechanical axis was valgus 2.1°. There was a positive correlation between the measured data taken under navigation and by radiographs (r > 0.3, p < 0.05). The mean correction angle was significantly more accurate in the navigation group (p < 0.002). The variability of the correction was significantly lower in the navigation group (2.3° vs 3.7°, p = 0,012). We conclude that navigation provides reliable real-time intra-operative information, may increase accuracy, and improves the precision of a closed-wedge HTO

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis.

After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy.

Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve.

Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment.

Cite this article: Bone Joint J 2020;102-B(5):556–567.

The aim of this study was to establish the natural course of unrevised asymptomatic pseudotumours after metal-on-metal (MoM) hip resurfacing during a six- to 12-month follow-up period. We used repeated metal artefact reduction sequence (MARS)-magnetic resonance imaging (MRI), serum metal ion analysis and clinical examination to study 14 unrevised hips (mean patient age 52.7 years, 46 to 68, 5 female, 7 male) with a pseudotumour and 23 hips (mean patient age 52.8 years, 38 to 69, 7 female, 16 male) without a pseudotumour. The mean post-operative time to the first MARS-MRI scan was 4.3 years (2.2 to 8.3), and mean time between the first and second MARS-MRI scan was eight months (6 to 12). At the second MRI scan, the grade of severity of the pseudotumour had not changed in 35 hips. One new pseudotumour (Anderson C2 score, moderate) was observed, and one pseudotumour was downgraded from C2 (moderate) to C1 (mild). In general, the characteristics of the pseudotumours hardly changed. Repeated MARS-MRI scans within one year in patients with asymptomatic pseudotumours after MoM hip resurfacing showed little or no variation. In 23 patients without pseudotumour, one new asymptomatic pseudotumour was detected. This is the first longitudinal study on the natural history of pseudotumours using MARS-MRI scans in hip resurfacing, and mirrors recent results for 28 mm diameter MoM total hip replacement. Cite this article: Bone Joint J 2013;95-B:1626–31

Epidural anaesthesia, with and without opiate, is widely used in total hip arthroplasty (THA). It may cause urinary retention, leading to catheterisation, and a subsequent increase in the likelihood of deep infection. We investigated prospectively the rate of urinary catheterisation in patients after THA performed under general anaesthesia, with or without peri-operative fentanyl and bupivacaine opiate epidural anaesthesia. Of 173 patients, 75 received general anaesthesia alone and 98 both general and epidural management. The post-operative rate of catheterisation was 14.7% in those who received general anaesthesia alone and 13.3% in those who received both. Our findings suggest that the rate of post-operative urinary catheterisation does not increase when general anaesthesia is supplemented by epidural anaesthesia using fentanyl and bupivicaine

Objectives. There are several reports clarifying successful results following open reduction using Ludloff’s medial approach for congenital (CDH) or developmental dislocation of the hip (DDH). This study aimed to reveal the long-term post-operative course until the period of hip-joint maturity after the conventional surgical treatments. Methods. A long-term follow-up beyond the age of hip-joint maturity was performed for 115 hips in 103 patients who underwent open reduction using Ludloff’s medial approach in our hospital. The mean age at surgery was 8.5 months (2 to 26) and the mean follow-up was 20.3 years (15 to 28). The radiological condition at full growth of the hip joint was evaluated by Severin’s classification. Results. All 115 hips successfully attained reduction after surgery; however, 74 hips (64.3%) required corrective surgery at a mean age of 2.6 years (one to six). According to Severin’s classification, 69 hips (60.0%) were classified as group I or II, which were considered to represent acceptable results. A total of 39 hips (33.9%) were group III and the remaining seven hips (6.1%) group IV. As to re-operation, 20 of 21 patients who underwent surgical reduction after 12 months of age required additional corrective surgeries during the growth period as the hip joint tended to subluxate gradually. Conclusion. Open reduction using Ludloff’s medial approach accomplished successful joint reduction for persistent CDH or DDH, but this surgical treatment was only appropriate before the ambulating stage. Cite this article: Bone Joint Res 2014;3:1–6

Objective. Mortality rates reported by the National Joint Registry for England and Wales (NJR) were higher following cemented total knee replacement (TKR) compared with uncemented procedures. The aim of this study is to examine and compare the effects of cemented and uncemented TKR on the activation of selected markers of inflammation, endothelium, and coagulation, and on the activation of selected cytokines involved in the various aspects of the systemic response following surgery. Methods. This was a single centre, prospective, case-control study. Following enrolment, blood samples were taken pre-operatively, and further samples were collected at day one and day seven post-operatively. One patient in the cemented group developed a deep-vein thrombosis confirmed on ultrasonography and was excluded, leaving 19 patients in this cohort (mean age 67.4, (. sd. 10.62)), and one patient in the uncemented group developed a post-operative wound infection and was excluded, leaving 19 patients (mean age 66.5, (. sd. 7.82)). Results. Both groups had a similar response with regards to the levels of C-reactive protein (CRP), interleukin 6 (IL-6) and tumour necrosis factor-alpha (TNFα). CD40 levels rose significantly on the cemented group over day one to day seven compared with that of the uncemented group, which occurred over the first 24 hours. The CD14/42a levels demonstrated a statistically significant increase in the cemented group (p < 0.001 first 24 hours and p = 0.02 between days one and seven). . Conclusions. The uncemented and cemented groups demonstrated significant changes in the various parameters measured at various time points but apart from CD14/42a levels, there was no significant difference in the serum markers of inflammation, coagulation and endothelial dysfunction following cemented TKR. Cite this article: Bone Joint Res 2014;3:108–16

Up to 20% of patients are not satisfied with the outcome following total knee replacement (TKR). This study investigated the pre- and post-operative predictors of dissatisfaction in a large cohort of patients undergoing TKR. We assessed 1217 consecutive patients between 2006 and 2008 both before operation and six months after, using the Short-form (SF)-12 health questionnaire and the Oxford Knee Score. Detailed information concerning comorbidity was also gathered. Satisfaction was measured at one year when 18.6% (226 of 1217) of patients were unsure or dissatisfied with their replacement and 81.4% (911 of 1217) were satisfied or very satisfied. Multivariate regression analysis was performed to identify independent predictors of dissatisfaction. Significant (p < 0.001) predictors at one year included the pre-operative SF-12 mental component score, depression and pain in other joints, the six-month SF-12 score and poorer improvement in the pain element of the Oxford Knee Score. Patient expectations were highly correlated with satisfaction. Satisfaction following TKR is multifactorial. Managing the expectations and mental health of the patients may reduce dissatisfaction. However, the most significant predictor of dissatisfaction is a painful total knee replacement

Pre-operative computerised three-dimensional planning was carried out in 223 patients undergoing total hip replacement with a cementless acetabular component and a cementless modular-neck femoral stem. Components were chosen which best restored leg length and femoral offset. The post-operative restoration of the anatomy was assessed by CT and compared with the pre-operative plan. The component implanted was the same as that planned in 86% of the hips for the acetabular implant, 94% for the stem, and 93% for the neck-shaft angle. The rotational centre of the hip was restored with a mean accuracy of 0.73 mm (. sd. 3.5) craniocaudally and 1.2 mm (. sd. 2) laterally. Limb length was restored with a mean accuracy of 0.3 mm (. sd. 3.3) and femoral offset with a mean accuracy of 0.8 mm (. sd. 3.1). This method appears to offer high accuracy in hip reconstruction as the difficulties likely to be encountered when restoring the anatomy can be anticipated and solved pre-operatively by optimising the selection of implants. Modularity of the femoral neck helped to restore the femoral offset and limb length

We have reviewed 1858 patients who had undergone a cervical laminoplasty and identified 43 (2.3%) who had developed a C5 palsy with a MMT (MRC) grade of 0 to 2 in the deltoid, with or without involvement of the biceps, but with no loss of muscular strength in any other muscles. The clinical features and radiological findings of patients with (group P; 43 patients) and without (group C; 100 patients) C5 palsy were compared. CT scanning of group P revealed a significant narrowing of the intervertebral foramen of C5 (p < 0.005) and a larger superior articular process (p < 0.05). On MRI, the posterior shift of the spinal cord at C4–5 was significantly greater in group P, than in group C (p < 0.01). This study is the first to correlate impairment of the C5 nerve root with a C5 palsy. It may be that early foraminotomy in susceptible individuals and the avoidance of tethering of the cord by excessive laminoplasty may prevent a post-operative palsy of the C5 nerve root

1. Two hundred and eleven cases of arthroplasty of the hip have been studied in an attempt to establish the causes of success and failure by comparing the excellent, good and bad results. 2. The findings suggest that the result of an arthroplasty depends largely upon four factors: the surgical approach to the hip joint, the acetabular roof, the interposition substance, and the early post-operative complications. 3. Some important points in the technique of operation and in the post-operative management are described

We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance. A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved

Our aim in this retrospective study of 52 children with spastic hemiplegia was to determine the factors which affected the amount of residual pelvic rotation after single-event multilevel surgery. The patients were divided into two groups, those who had undergone femoral derotation osteotomy and those who had not. Pelvic rotation improved significantly after surgery in the femoral osteotomy group (p < 0.001) but not in the non-femoral osteotomy group. Multiple regressions identified the following three independent variables, which significantly affected residual pelvic rotation: the performance of femoral derotation osteotomy (p = 0.049), the pre-operative pelvic rotation (p = 0.003) and the post-operative internal rotation of the hip (p = 0.001). We concluded that there is a decrease in the amount of pelvic rotation after single-event multilevel surgery with femoral derotation osteotomy. However, some residual rotation may persist when patients have severe rotation before surgery

The patellar clunk syndrome describes painful catching, grinding or jumping of the patella when the knee moves from a flexed to an extended position after total knee replacement (TKR). The posterior stabilised TKR had been noted to have a higher incidence of this problem. Mobile-bearing posteriorly stabilised TKRs have been introduced to improve patellar tracking and related problems by a mechanism of self-alignment. We evaluated the patellar clunk syndrome in 113 knees in 93 patients with such a TKR at a mean follow-up of 2.3 years (2.0 to 3.2). The syndrome was identified in 15 knees (13.3%). Logistic regression analysis showed that the absolute value of the post-operative angle of patellar tilt was significantly associated with the occurrence of patellar clunk (p = 0.025). Patellar tracking should be carefully checked during surgery

This prospective multicentre study was undertaken to determine whether the timing of the post-operative administration of bisphosphonate affects fracture healing and the rate of complication following an intertrochanteric fracture. Between August 2008 and December 2009, 90 patients with an intertrochanteric fracture who underwent internal fixation were randomised to three groups according to the timing of the commencement of risedronate treatment after surgery: Group A (from one week after surgery), Group B (from one month after surgery), and Group C (from three months after surgery). The radiological time to fracture healing was assessed as the primary endpoint, and the incidence of complications, including excessive displacement or any complication requiring revision surgery, as the secondary endpoint. The mean time to fracture healing post-operatively in groups A, B and C was 10.7 weeks (. sd. 4.4), 12.9 weeks (. sd. 6.2) and 12.3 weeks (. sd. 7.1), respectively (p = 0.420). At 24 weeks after surgery, all fractures had united, except six that had a loss of fixation. Functional outcomes at one year after surgery according to the Koval classification (p = 0.948) and the incidence of complications (p = 0.386) were similar in the three groups. This study demonstrates that the timing of the post-operative administration of bisphosphonates does not appear to affect the rate of healing of an intertrochanteric fracture or the incidence of complications

A consecutive series of 372 patients who underwent surgery for disorders of the rotator cuff involving arthroscopic subacromial decompression and open or arthroscopic repairs of the cuff were prospectively investigated as to the comparability of subjective and objective assessment scores of shoulder function. Assessments were made before operation and at 3, 6, 12, 18 and 24 months after surgery using the Disabilities of the Arm, Shoulder, and Hand score, the Oxford shoulder score and the Constant-Murley score, which was used as a reference. All scores were standardised to a scale of 0 to 100 for comparison. Statistical analysis compared the post-operative course and the mean score for the subjective Disabilities to the Arm, Shoulder and Hand score and Oxford shoulder score, with the objective Constant score at each interval. A strong correlation was evident between both subjective scores and the Constant score. We concluded that both the subjective scores would be useful substitutes for the Constant score, obviating the need for a trained investigator and the specialist equipment required to perform the Constant score

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation. The strength of the construct removes the need for post-operative immobilisation

We performed a meta-analysis of modern total joint replacement (TJR) to determine the post-operative mortality and the cause of death using different thromboprophylactic regimens as follows: 1) no routine chemothromboprophylaxis (NRC); 2) Potent anticoagulation (PA) (unfractionated or low-molecular-weight heparin, ximelagatran, fondaparinux or rivaroxaban); 3) Potent anticoagulation combined (PAC) with regional anaesthesia and/or pneumatic compression devices (PCDs); 4) Warfarin (W); 5) Warfarin combined (WAC) with regional anaesthesia and/or PCD; and 6) Multimodal (MM) prophylaxis, including regional anaesthesia, PCDs and aspirin in low-risk patients. Cause of death was classified as autopsy proven, clinically certain or unknown. Deaths were grouped into cardiopulmonary excluding pulmonary embolism (PE), PE, bleeding-related, gastrointestinal, central nervous system, and others (miscellaneous). Meta-analysis based on fixed effects or random effects models was used for pooling incidence data. In all, 70 studies were included (99 441 patients; 373 deaths). The mortality was lowest in the MM (0.2%) and WC (0.2%) groups. The most frequent cause of death was cardiopulmonary (47.9%), followed by PE (25.4%) and bleeding (8.9%). The proportion of deaths due to PE was not significantly affected by the thromboprophylaxis regimen (PA, 35.5%; PAC, 28%; MM, 23.2%; and NRC, 16.3%). Fatal bleeding was higher in groups relying on the use of anticoagulation (W, 33.8%; PA, 9.4%; PAC, 10.8%) but the differences were not statistically significant. Our study demonstrated that the routine use of PA does not reduce the overall mortality or the proportion of deaths due to PE

The management of joint replacement in lysosomal storage diseases has not been well reported. We present three patients with progressive degenerative changes of the hips who required bilateral total hip replacement in early childhood. The stature of the patients make it essential to have access to appropriately scaled prostheses. Consideration has to be given to associated disorders of the skeleton which must be carefully screened to ensure safety in providing appropriate anaesthesia as well as ensuring that there is no cardiac abnormality. In one patient, a periprosthetic fracture was sustained in one hip in the early post-operative course requiring internal fixation. The patient made a full recovery and all six hips were clinically and radiologically satisfactory at mid-term review

The establishment of a suitable animal model of repair of the rotator cuff is difficult since the presence of a true rotator cuff anatomically appears to be restricted almost exclusively to advanced primates. Our observational study describes the healing process after repair of the cuff in a primate model. Lesions were prepared and repaired in eight ‘middle-aged’ baboons. Two each were killed at four, eight, 12 and 15 weeks post-operatively. The bone-tendon repair zones were assessed macroscopically and histologically. Healing of the baboon supraspinatus involved a sequence of stages resulting in the reestablishment of the bone-tendon junction. It was not uniform and occurred more rapidly at the sites of suture fixation than between them. Four weeks after repair the bone-tendon healing was immature. Whereas macroscopically the repair appeared to be healed at eight weeks, the Sharpey fibres holding the repair together did not appear in any considerable number before 12 weeks. By 15 weeks, the bone-tendon junction was almost, but not quite mature. Our results support the use of a post-operative rehabilitation programme in man which protects the surgical repair for at least 12 to 15 weeks in order to allow maturation of tendon-to-bone healing