Journal of Orthopaedic Surgery

To examine the prognostic indicators associated with outcome following rotator cuff surgery.

A retrospective evaluation of records on 1120 shoulders (1067 patients) with rotator cuff tear treated by surgery was performed. Preoperative, intra-operative and postoperative factors were analysed by Kendall's Tau-b correlation analysis and logistic regression analysis.

Positive correlations were seen between the type of tear and the number of tendons involved, retraction, age, degeneration, subacromial bone spur, surgical technique, preoperative and postoperative muscle power, surgical outcome, and preoperative abduction on Kendall's Tau-b analysis. There was a positive correlation seen between degenerative change and age, number of tendons involved, retraction, preoperative pain, tear type, and preoperative muscle power on logistic regression analysis. Additionally, positive correlations were seen between good surgical postoperative outcome and postoperative activities of daily living, preoperative pain, postoperative muscle power, preoperative activities of daily living, tear type, preoperative external rotation, preoperative muscle power, number of tendons involved, preoperative pain, and duration of symptoms.

Ageing was found to be the major factor in progressive degeneration of the rotator cuff, and should be considered the single most important contributing factor in the pathogenesis of rotator cuff tears. In addition, degenerative tendonopathy appeared the primary pathology in rotator cuff tear, preceding hypertrophic spur formation. Rotator cuff tears are therefore unlikely to be initiated by impingement; rather, they develop as an intrinsic degenerative tendonopathy.

To evaluate the long-term outcome following use of osteochondral autografts for the treatment of osteonecrosis of the femoral condyle.

Clinical, radiographic and arthroscopic findings were evaluated at follow-up. Patients were 14 women and 2 men, with a mean age of 64.9 years (range, 58–74 years). The osteochondral lesion was equivalent to Lotke 1-B in 12 knees, and was equivalent to 1-C in 4 knees. Preoperative femoral tibia angle ranged from 178° to 190°.

The follow-up period ranged from 28 months to 111 months (mean, 67 months). Functional scores improved from 60 to 75 preoperatively to 80 to 100 postoperatively, and the grafts were satisfactorily accepted. Patients with a femoral tibia angle of less than 180° in particular were found to respond favourably.

Transplant surgery using osteochondral autografting appeared effective for the treatment of osteonecrosis of femoral condyle.

To report the outcome of displaced subcapital neck of femur fractures in the independent elderly (>70 years) managed with total hip arthroplasty through a modified Hardinge approach.

Between 1998 and 2000, a surgeon performed a cemented hip replacement using a modified lateral approach in 35 consecutive patients in the Hawke's Bay Regional Hospital, Hastings. Medical charts and out-patient follow-up clinic records were reviewed with respect to outcomes, with particular reference to complications. Independent review of functional outcome was completed at one year postsurgery using a questionnaire.

At an average follow-up of 1.8 years (range, 1–3 years), no patient needed further surgery. One patient had died, giving a mortality rate at one year of 2.9%. All other medical complications were successfully treated. The overall prevalence of early medical complications was 43%. There were no dislocations, and 80% of patients had a good clinical outcome at their latest follow-up.

The modified lateral approach of Hardinge minimises the incidence of postoperative dislocation. However, there was a high incidence of medical complications and aggressive treatment of such complications was necessary, both preoperatively and postoperatively. The number of pre-existing medical conditions was a significant factor influencing patient morbidity.

To determine the outcome of treatment for minimally displaced femoral neck fractures using multiple threaded pins versus sliding compression screws for internal fixation.

The medical records of 62 consecutive elderly patients with minimally displaced intra-capsular femoral neck fractures who underwent internal fixation of the fracture (37 with multiple threaded pins, and 25 with sliding compression screws) were reviewed. Clinical and radiological assessment of fracture healing at follow-up visits were noted.

In the 55 patients seen for follow-up at 3 months, 21.9% (n=7) of those treated by pinning demonstrated non-union of the fracture, and 0% of fractures treated with sliding compression screws (p=0.02). 46 patients were seen for follow-up at 1 year, with 10% (n=2) of those treated with sliding compression screws found to have osteonecrosis of the femoral head. The 2 fractures in the group treated by pinning demonstrating non-union at 3 months failed to unite by 1 year (p=0.11). 34 patients were seen for follow-up for at least 2 years, with no additional complications noted.

Using sliding compression screws to treat minimally displaced femoral neck fractures can achieve a higher union rate than using pinning. The reason may be the better stability in the osteoporotic bone. However, osteonecrosis of the femoral head may occur with use of sliding compression screws because of greater intramedullary vascular damage as a result of wider reaming.

To define the centre of the hip joint and the bone stock around the hip joint from the supra-acetabular portion or pelvic brim so as to avoid penetration of guidewire into the hip joint when performing internal fixation using the anterior approach.

A total of 42 cadavers were utilised. Measurements were completed before and after cutting the pelvis into 4 pieces. Before cutting the pelvis, the centre of the hip joint was measured on the pelvic brim. After cutting the pelvis, the bone stock around the hip joint was measured in each section. The pelvic brim and the anteroinferior iliac spine were utilised as guide points in the measurements, because these parameters could be determined during an anterior surgical procedure.

On the pelvic brim, the reflected centre of the hip joint centre was located approximately 3.2 mm anterior to the distal edge of the anteroinferior iliac spine. The mean minimum bone stock of the pelvic brim was 14.0 mm in the centre of the hip joint section.

This study described the anatomical reference points around the hip joint, and the ways in which they can be utilised to increase the safety of the anterior approach for internal fixation. It is important to define the centre of the hip joint from the supra-acetabular portion or pelvic brim, given that it is not visualised during surgery using an anterior approach.

To evaluate outcome following supracondylar nailing for distal femur fractures.

The clinical and radiological outcome for 13 patients treated between January 1995 and December 1998 at the University Malaya Medical Center was assessed. Patients were seen for follow-up for a mean duration of 20.2 months.

There were no cases of non-union or infection. Overall assessment of clinical outcome based on the criteria of Schatzker and Lambert was graded excellent in 6 patients, good in 3 patients, fair in 3 patients, and one graded as a failure.

Supracondylar nailing for fixation of supracondylar (Arbeitsgemeinschaft für Osteosynthesefragen [AO] type A) and less comminuted intercondylar (AO type C1 and C2) fractures is recommended by the authors.

To evaluate the clinical and radiological outcome in patients undergoing small stem Exeter total hip replacement.

A total of 46 small stem Exeter total hip replacements were performed on 44 consecutive patients (18 men and 26 women) attending the University of Malaya Medical Centre. The mean age at the time of operation was 58 years (range, 24–81 years). Of the 46 procedures performed, 35 were primary total hip replacements and 11 were revision operations, with aseptic loosening of the original implant being the main indication for revision. The main indications for surgery in primary cases were avascular necrosis and rheumatoid arthritis. Clinical and radiographic outcomes were assessed at 6 weeks', 12 weeks', 6 months' follow-up, and annually thereafter. Postoperative cementing technique was also assessed.

The mean follow-up period was 4 years. The mean Oxford Hip Score improved from 46 points preoperatively to 17 points at the final follow-up examination. There were no revision operations, no implant breakages, and no excessive migration of the implants. The potential complications of implant failure due to smaller implant size and increased patient activity were not observed.

Due to the smaller size of Asian femora, the small stem Exeter implant is a very useful development. This study suggests that it will perform as well as its larger counterparts.

To examine the long-term effects of hip arthrodesis in terms of gait adaptations.

Motion analysis was performed on 9 patients who underwent unilateral hip arthrodesis between 1979 and 1991. A standard clinical gait analysis 3-dimensional model for the lower limb was used to calculate the effect of the fused hip on walking, compared with the contralateral normal hip.

Significant (p<0.05) gait adaptations noted in the fused side were, compensatory hip hiking during the swing-phase, a 24% reduction in hip adduction moment, a 37% decrease in genu-varus moment, 80% reduced hip power, and excessive pelvic tilt.

It appears that the excess pelvic tilt observed was to achieve relative hip extension via increased relative lumbar lordosis, while the decreased coronal plane moments of the hip and knee observed were to reduce joint loading on the affected side.

To evaluate the clinical and radiological outcomes following cementless primary hydroxyapatite-coated total hip arthroplasty.

A retrospective study of 69 patients (82 hips) who underwent uncemented hydroxyapatite-coated Anatomic Benoist Girard total hip replacement between October 1991 and October 1995 at our institution was conducted. Patient records were reviewed. All patients were evaluated clinically using the Merle D'Aubigne hip score, and osteointegration was assessed radiographically by analysing the bone implant interface in the 7 zones of Gruen on follow-up review.

The mean follow-up period was 7.3 years. Clinical results were excellent with an improvement seen in clinical score from 9.9 preoperatively to 16.5 at last review. A total of 15% of patients recorded some thigh discomfort, which was intermittent and not functionally limiting, except in 2 cases. There were 3 cases of severe acetabular osteolysis and loosening requiring revision surgery, and 4 cases of localised proximal femoral osteolysis around well-ingrown implants. There were few perioperative complications, with the exception of 5 dislocations of which 3 were recurrent and required a revision procedure.

Clinical and radiological outcomes following cementless hydroxyapatite-coated total hip arthroplasty were seen to be favourable in this medium-term retrospective study.

To ascertain the effects of a clinical pathway in our institution.

This retrospective and comparative study was performed on all patients undergoing total knee arthroplasty over a 5-year period. This period covered the 30 months prior to the introduction of the pathway (group 1), and the 30 months following its introduction (group 2).

There was a significant reduction in the duration of hospital stay of group 2 patients (p<0.0001), with 62.8% of these patients staying less than 8 postoperative days. There was a reduction in the number of patients with thromboembolic complications (p<0.05) and no increase in overall complications or readmission rate. There was a trend to increased use of rehabilitation services among group 2 patients.

Clinical pathway implementation resulted in a significant reduction in the length of stay, and achieved a more efficient management of hospitalised patients without compromising outcome.

To document the incidence of proximal deep vein thrombosis and pulmonary embolism in 58 consecutive Japanese patients undergoing total hip arthroplasty or total knee arthroplasty.

Patients were routinely examined for proximal deep vein thrombosis by B-mode ultrasonography before and after surgery. Those patients who had ultrasonographic findings of deep vein thrombosis were also investigated for pulmonary embolism by ventilation-perfusion lung scan.

The incidence of deep vein thrombosis after total hip arthroplasty and total knee arthroplasty were 9.1% and 4.0% respectively, and the incidence of pulmonary embolism were 3.0% and 0%, respectively. There were no cases of fatal pulmonary embolism.

The incidence of deep vein thrombosis and pulmonary embolism in Japanese patients may have increased over the last few decades.

To survey Malaysian orthopaedic surgeons' attitudes to and use of venous thromboembolic disease prophylaxis.

A total of 144 orthopaedic surgeons from various governmental and private institutions responded to a questionnaire.

Only slightly more than half of these surgeons considered venous thromboembolic disease as common a problem in Malaysia as in western countries. The majority of surgeons (91.0%) reported using prophylaxis selectively for patients based on various indicators such as risk grading of surgery, obesity, and malignancy etc. Bleeding tendencies were cited as the greatest fear against the use of pharmacological prophylaxis. Low-molecular-weight heparin appeared to be the most commonly used pharmacological prophylaxis, used either singly or in combination with other forms of prophylaxis. The majority of surgeons employed prophylaxis until their patients were mobile.

There should be greater awareness among surgeons in Malaysia of the need for protection against venous thromboembolic disease. Current practice needs to be reviewed and further recommendations made for existing protocols.

To investigate the incidence of deep vein thrombosis (DVT) following total knee arthroplasty in an Asian population.

A prospective study of 149 consecutive cases of total knee arthroplasty done for osteoarthritis was conducted over a 5-year period. All patients underwent duplex ultrasonographic assessment of the lower limbs within the first postoperative week.

The incidence of proximal DVT was found to be 4.38% in this study. Symptomology was statistically significant in predicting the presence of proximal DVT in all cases. General anaesthesia was associated with a statistically significant–higher incidence of DVT as compared with regional anaesthesia. There was a significant association between a sedentary lifestyle and the development of DVT.

The incidence of proximal DVT in Asian patients after total knee arthroplasty is higher than that previously reported for this demographic group.

To conduct a median nerve conduction study on patients with carpal tunnel syndrome and investigate the relationship between nerve conduction study parameters and clinical grading.

A nerve conduction study was performed on 60 upper limbs of 37 patients with idiopathic carpal tunnel syndrome, and the relationship between the clinical grade and various study parameters was assessed.

The amplitude of the sensory nerve action potential and the motor nerve action potential differed according to clinical grading, but this pattern was not seen for sensory nerve conduction velocity, motor nerve conduction velocity, or motor nerve terminal latency and clinical grading.

The amplitude of the sensory nerve action potential and motor nerve action potential reflect the functional state of axons, and are useful parameters for assessing clinical grading based on nerve conduction velocity.

To explore the role of Joshi's external stabilisation system fixator in correcting cases of clubfoot peculiar to India, we studied cases of neglected clubfoot, dropout cases of plaster-of-paris cast treatment, or failed surgical procedures that had been followed for a minimum period of 2 years.

26 children underwent 44 Joshi's external stabilisation system procedures at the Central Institute of Orthopaedics at the Safdarjung Hospital, New Delhi, between January 1998 and December 1999 for the conditions of interest. Three-dimensional correction was achieved by use of the distractor device.

Excellent results were obtained in 77% of the cases, good results in 13%, and poor results in 9% of the cases. Complications in half of the cases were -pintract infections, which eventually healed on an out-patient basis without any residual sequelae.

The Joshi's external stabilisation system frame is ideally suited for the child in whom clubfoot deformities remain uncorrected by plaster-of-paris casts and manipulation, as well as for recurrent clubfoot. Casting after complete correction not only protects the osteopenic bones while the pin-tracts heal, but also maintains correction and allows gradual weightbearing.