Journal of Orthopaedic Surgery

To measure the femoral tunnel length created through a far medial portal and determine its correlation with body height, limb length, and thigh length in 404 Indian patients undergoing anterior cruciate ligament (ACL) reconstruction.

364 male and 40 female Indian patients aged 18 to 51 (mean, 26.8) years underwent ACL reconstruction by a single surgeon using the hamstrings tendon autograft. Their body height, limb length, and thigh length were measured by a single assessor, as was the femoral tunnel length.

The mean femoral tunnel length was 34.5 mm. It was <30 mm in 28 patients and <25 mm in 2 patients. The correlation coefficients of the femoral tunnel length with body height, limb length, and thigh length were 0.485 (p<0.0001), 0.426 (p<0.0001), and 0.304 (p<0.0001). No patient had posterior wall blowout fracture.

The femoral tunnel length positively correlated with body height, limb length, and thigh length in 404 Indian patients.

To compare anterior cruciate ligament (ACL)–injured and ACL-intact patients as well as males and females in terms of tibial plateau slopes to determine their association with ACL injury.

Magnetic resonance images (MRI) of the knee of 310 male and 179 female skeletally mature Indian patients (mean age, 40 years) with (n=170+29) or without (n=140+150) ACL injury were reviewed. Their medial and lateral tibial plateau slopes (MTPS and LTPS), medial tibial plateau depth (MTPD), and lateral tibial plateau height (LTPH) were measured using MRI.

The ACL-injured and ACL-intact groups were comparable in terms of MTPS (6.72° vs. 6.73°, p=0.07), LTPS (5.68° vs. 5.70°, p=0.09), MTD (1.74 vs. 1.73 mm, p=0.356), and LTH (2.21 vs. 2.22 mm, p=0.393). Males and females were also comparable in terms of MTPS and LTPS in both ACL-injured and ACL-intact groups.

ACL-injured and ACL-intact patients as well as males and females were comparable in terms of the tibial plateau slope parameters.

To review the outcome of unilateral total knee arthroplasty (TKA) in patients with bilateral knee osteoarthritis (OA) to determine whether unilateral TKA can achieve good health-related quality of life (HRQoL).

Records of 68 women and 25 men with severe bilateral knee OA who underwent unilateral TKA on the more symptomatic knee by a single surgeon and did not return for the second TKA within 2 years were reviewed. Outcome at 6 months and 2 years was assessed using the mental and physical component summary (MCS and PCS) of the Short-Form 36 (SF-36) for HRQoL as well as the Oxford Knee Score (OKS) and Knee Society Score (KSS) for knee-specific outcome.

The SF-36, OKS, and KSS improved significantly after unilateral TKA. Respectively for MCS and PCS of SF-36, OKS, and KSS knee and function scores, 65%, 89%, 98%, 98%, and 98% of patients reported absolute improvement at 2 years. Respectively for PCS, OKS, and KSS function score that a minimal clinically important difference (MCID) was established, 77%, 96%, and 80% of patients achieved MCID at 2 years.

Unilateral TKA achieves good outcome in HRQoL at 2 years in patients with bilateral knee OA.

To evaluate the clinical outcome in 108 total knee arthroplasty (TKA) patients with a medial-lateral balanced versus unbalanced gap after a mean follow-up of 34 months.

64 women and 44 men (mean age, 69.5 years) underwent computer-assisted TKA for osteoarthritis using a cemented fixed-bearing cruciate-retaining prosthesis. The medial-lateral gap difference (measured with the prosthesis in situ and the patella reduced) was balanced (≤2 mm) in 81 patients and unbalanced (>2 mm) in 27 patients. After a mean follow-up of 34 months, patients were assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire for pain, stiffness, and physical function. Scores were normalised to 0% (worst) to 100% (best).

The balanced and unbalanced gap groups were comparable in terms of age, severity of osteoarthritis, and proportion of pre- and postoperative mechanical alignment. Compared with the balanced gap group, the unbalanced gap group had a larger medial-lateral extension gap difference (0.75±0.57 vs. 2.02±1.15 mm, p=0.001) and medial-lateral flexion gap difference (0.79±0.63 vs. 2.98±2.13 mm, p=0.001) and lower normalised total WOMAC score (84.9±18 vs. 74.8±20.8, p=0.017).

WOMAC score is better in TKAs with a medial-lateral balanced (<2 mm) gap.

To evaluate the regression of fear of falling (FOF) and identify its risk factors in patients with severe knee osteoarthritis before and one year after total knee arthroplasty (TKA).

11 men and 57 women with a mean age of 73 years and a mean body mass index of 30.36 kg/m² who had severe (grade 3 or 4) knee osteoarthritis and knee pain of ≥1 year were included. Two weeks before and one year after TKA, patients were asked about their FOF status and falls history. Patients were asked to complete the Physical Activity Scale for the Elderly, Short Form 36 (SF-36), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaires. Clinical performance was assessed using the Berg Balance Scale and Timed Up and Go (TUG) test.

Of the 68 patients, 56 (82.4%) had FOF preoperatively and 30 (44.1%) had FOF one year after TKA (p<0.001). The strongest predictors for FOF preoperatively were fallers (odds ratio [OR]=9.83, p=0.028), mental component summary (MCS) score of SF-36 (OR=0.88, p=0.024), and TUG (OR=3.4, p=0.013). The strongest predictors for FOF one year postoperatively were fallers (OR=16.51, p=0.041), patients with ≥2 chronic diseases (OR=17.33, p=0.011), physical function score of WOMAC (OR=1.015, p=0.005), and MCS score of SF-36 (OR=0.86, p=0.015).

TKA positively affected FOF and gradually reduced the FOF rate over a year period after TKA in an elderly population.

To evaluate the 5-year outcome of arthroscopic transphyseal anterior cruciate ligament (ACL) reconstruction in 19 adolescent athletes.

14 male and 5 female adolescent athletes aged 12 to 16 (mean, 13.9) years with Tanner stage 2 or 3 open physes underwent arthroscopic transphyseal ACL reconstruction by a single surgeon and were followed up for 5 years. Patients were evaluated using the numerical rating score (NRS) for pain, knee osteoarthritis outcome score (KOOS), International Knee Documentation Committee (IKDC) score, Tegner Activity Scale, and Lysholm Score, as well as the leg length discrepancy, femorotibial alignment, varus or valgus deformities, active and passive knee range of motion.

At 5-year follow-up, physes were closed in all patients. The mean NRS for pain improved from 7.2 to 1.6; the KOOS improved from 55.3 to 88; the mean IKDC score improved from 34.5 to 84; the mean Tegner Activity Scale improved from 2.7 to 8.2 and was comparable with that before injury (8.4); and the mean Lysholm score improved from 36.3 to 84.6. All except 2 patients returned to their pre-injury level of sports activity after a mean of 25 weeks. The 2 exceptions had a 2+ Jerk test and a 3+ Lachman test; one of them also had positive signs for a lateral meniscal lesion. Both had sustained a second trauma not long before the 5-year follow-up. Two patients had reduced sensitivity in the anteromedial aspect of the proximal third of the tibia. One patient had leg length discrepancy of +1.5 cm owing to overgrowth response of the physis.

Transphyseal ACL reconstruction is a viable option for skeletally immature patients, with high reproducibility, a high rate of return to sport, and a low incidence of growth disturbance. Early surgery can prevent the onset of meniscal lesions and early osteoarthritis.

To use a 3-dimensional computed tomography (CT) bone database to evaluate the risk of distal contact between the rasp tip and the endosteal cortical bone.

Using a 3-dimensional CT bone database, the rasps for Exeter stems of 125 mm in length and body size 1, with a femoral offset of 37.5, 44, or 50 mm were compared with those for Exeter stems of 150 mm in length and same body size with the corresponding femoral offset. Rasp geometry was determined using an engineering drawing software.

Of the 631 femurs in the database, 238 (187 Caucasian and 51 Asian) were of appropriate femoral offset and proximal body size to receive a stem with an offset of 37.5, 44, or 50 mm. Of these, 145 (115 Caucasian and 30 Asian) femurs were of champagne-flute type; the prevalence was comparable between the 2 populations (61% vs. 59%, p=0.729). When using the 150-mm rasp, 70 (55 Caucasian and 15 Asian) of the 238 femurs had distal contact between the rasp and femoral cortex; the prevalence was comparable between the 2 populations (29% vs. 29%, relative risk=1.0, p=1.0). Distal contact between the rasp and femoral cortex occurred more commonly in champagne-flute-type femurs than other femurs in the anteroposterior plane (28% [41/145] vs. 2% [2/93], relative risk=13.1, p<0.001) and in the mediolateral plane (27% [39/145] vs. 14% [13/93], relative risk=1.92, p=0.019). When using the 125-mm rasp, only one femur (with a canal flare index of 4.52) had distal contact in the mediolateral plane with an offset of 37.5 mm. Distal contact between the rasp and femoral cortex occurred more often with the 150-mm rasp than the 125-mm rasp in both planes (p<0.001).

The use of a shorter stem may enhance anatomic fit in patients with a narrow femoral canal and prevent distal contact between the rasp and femoral cortex.

To review 437 hips in 404 patients who underwent total hip arthroplasty (THA) or hemiarthroplasty using the Accolade TMZF stem to determine the incidence and risk factors of distal femoral cortical hypertrophy (DFCH).

Records of 437 hips in 169 men and 235 women aged 26 to 100 (mean, 65.7) years who underwent THA (n=293) or hemiarthroplasty (n=144) using the Accolade TMZF femoral stem by 2 senior surgeons and were followed up for a mean of 54.7 months were reviewed. Clinical outcome was assessed using the modified Harris Hip Score and visual analogue score for pain. Proximal femoral geometry and canal flare index were assessed on preoperative radiographs, and DFCH, stem position, subsidence, loosening, and stress shielding were assessed on postoperative radiographs according to the Gruen zone.

Of 437 hips, 27 (6.2%) developed DFCH and 410 did not. Hips with DFCH had a higher incidence of thigh pain (18.5% vs. 2.2%, p<0.001) and earlier onset of thigh pain (12.3 vs. 20.8 months, p=0.015), compared with those without. Nonetheless, all femoral stems were well-fixed, and no osteolysis or loosening was detected. The 2 groups achieved comparable clinical outcome in terms of Harris Hip Score and pain. The mean canal flare index was higher in hips with than without DFCH (3.706 vs. 3.294, p=0.002). The mean vertical subsidence of the femoral stem was lower in hips with than without DFCH (1.5 vs. 3.4 mm p<0.001). Subsidence negatively correlated with the canal flare index (correlation coefficient= −0.110, p=0.022). The incidence of the DFCH increased with each unit of increment in canal flare index (odds ratio [OR]=1.828, p=0.043) and each year younger in age (OR=0.968, p=0.015).

The incidence of DFCH in hips with the Accolade TMZF stem was 6.2%. Patients with a higher canal flare index and younger age had a higher incidence of DFCH. Nonetheless, DFCH did not affect clinical outcome or femoral stem stability.

To review the outcome of total hip arthroplasty (THA) using a short femoral stem in 33 hips.

Records of 33 hips in 20 men and 10 women aged 25 to 40 (mean, 30) years who underwent cementless THA using a short femoral stem by a single senior surgeon were reviewed. The diagnosis included avascular necrosis (n=9), ankylosing spondylitis (n=12), rheumatoid arthritis (n=7), post-traumatic arthritis (n=4), and Hurler syndrome (n=1). Clinical outcome was assessed using the Harris Hip Score. Radiological outcome was assessed according to a modified Gruen zoning system. Stem positioning (neutral, varus, valgus) and bone contact were evaluated, as were fixation and early host response as well as subsidence and changes in the calcar region (zone 5). Trabecular response (trabecular attachment), spot welds, cortical hypertrophy, and pedestal formation were determined. Heterotopic ossification was graded by the Brooker classification.

The mean follow-up period was 6.5 years. The mean Harris Hip Score improved from 40 to 90. All hips achieved immediate postoperative stability. No patient had thigh pain. Four hips had varus placement (5°–7°) of the stem; all were asymptomatic and remained stable without any migration. Evidence of proximal load transfer (endosteal spot welds) between the endosteum and the stem in zones 2 and/or 4 was noted in 12 hips on both sides and in 8 hips on the lateral side only. At one year, all stems showed evidence of osseointegration. None had subsidence or progressive varus migration. There was no radiolucent line or osteolysis around the stem, pedestal formation or buttressing at the prosthesis tip, or cortical hypertrophy. One patient had grade I heterotopic ossification that was not clinically significant. One patient had a 1.5 cm leg lengthening. One patient had a discharging sinus, a loosened acetabular component, and intrapelvic migration at 2 years and underwent implant removal and debridement. One patient developed a crack in the proximal femur even with the smallest stem. The stem was fixed with cerclage wiring and remained stable with no migration.

A short femoral stem design that transfers load proximally through a prominent lateral flare achieved good short-term outcome in younger patients. Nonetheless, the ease of removal and preservation of bone at the time of revision should guide the choice of the design of the short stem.

To review the outcome of acetabular revision with bone grafting and cementation for aseptic loosening after primary Charnley low-friction hip arthroplasty with structural bulk autografts in 15 patients.

Records were reviewed for 3 men and 12 women aged 31 to 72 (mean, 53) years who underwent acetabular revision with bone grafting and cementation for aseptic loosening at a mean of 12.4 (range, 6.6–20.3) years after primary Charnley low-friction hip arthroplasty with superolateral structural bulk autografts from the femoral head for dysplastic hip (n=14) or bone loss secondary to acetabular fracture (n=1).

After a mean follow-up of 6.7 (range, 1.1–14.5) years, the mean Merle d'Aubigné and Postel score improved from 8.55 to 16.5. Bridging trabeculae was noted in 10 hips and graft remodelling in 5 hips. Five hips had ectopic ossification of Brooker grade 1 to 2. The mean hip centre of rotation was 21.6 (range, 16.2–30.6) mm. Two women required re-revision for aseptic loosening of the acetabulum after 8.5 and 6.6 years. The first one underwent re-revision with solid allograft for superolateral deficiency of the acetabulum. The second one underwent re-revision with solid and morselised bone allografts for loosened acetabulum. One patient had superior migration of the acetabulum for 9 mm at year 2, but it was asymptomatic. One patient had a dislocation that was reduced with manipulation under anaesthesia. Three patients had trochanteric non-union and presented with lateral thigh pain and tenderness, but no further surgery was performed.

The medium-term outcome of acetabular revision with bone grafting and cementation is satisfactory. Repeat bone grafting is required to restore the anatomic acetabular position and bone loss secondary to acetabular loosening.

To assess the effect of frequent small distractions with a magnetically controlled growing rod (MCGR) on spinal length gain and achieved distraction length in children with early-onset scoliosis (EOS), and to determine whether the law of diminishing returns applies to this group of patients with MCGR.

A consecutive series of 3 males and 4 females with EOS who underwent MCGR implantation at a mean age of 10.2 years and were followed up for a mean of 3.8 years were reviewed. Distraction was aimed at 2 mm monthly. The coronal Cobb angle, T1-S1 length gain, and achieved distraction length were measured at 6-monthly intervals.

The mean total number of distractions was 31. Four of the patients had problems that may have affected distractions. The mean coronal Cobb angle improved post-operatively and was maintained throughout the follow-up period. The mean T1-S1 length gain and achieved distraction length varied over the follow-up period and did not diminish with repeated lengthening.

Frequent small distractions with the MCGR for EOS enable T1-S1 and achieved distraction length gain without significant reduction in gain after repeated lengthening.

To review the outcome of 32 consecutive patients who underwent 4-level anterior cervical discectomy and fusion (ACDF) with cages and plates and were followed up for at least 5 years.

Records of 19 men and 13 women aged 48 to 69 years who underwent 4-level ACDF with cages and plates for myelopathy (n=11) or myeloradiculopathy (n=21) at C3 to C7 by a single surgeon and were followed up for a minimum of 5 years were reviewed. Clinical outcome was assessed using the visual analogue scale (VAS), Neck Disability Index (NDI), and modified Japanese Orthopaedic Association (JOA) score for pain or myelopathic symptoms. Radiographic evaluation included fusion rate, range of motion, cervical lordosis (C2-to-C7 Cobb angle), and disc height.

The mean follow-up was 66 months. All patients had good recovery of muscle strength and resolution of limb sensory disturbance, except for 4 who still had some numbness. The mean VAS for neck and arm pain improved from 14.2 to 6.84 (p=0.012); the mean NDI improved from 31.62 to 12.17 (p<0.01); and the mean JOA score improved from 10.1 to 13.9 (p=0.027). The mean percentage of recovery was 62.9. The mean Cobb angle improved from 10.24° to 1.28° (p=0.019); the mean disc height improved from 4.12 to 6.58 mm (p<0.01). 30 (94%) patients achieved solid fusion.

Multilevel ACDF using PEEK cages and plates is safe and effective for multilevel cervical spondylotic myelopathy and achieves satisfactory mid-term outcome.

To review the outcome of single-stage posterior instrumentation for progressive tubercular thoracic and thoracolumbar kyphosis in 45 patients.

Records of 16 men and 29 women aged 20 to 59 (mean, 34.1) years who underwent single-stage posterior instrumentation for active thoracic (n=27) or thoracolumbar (n=18) tuberculosis by a single surgeon and were followed up for a minimum of 5 years were reviewed. Neurological status was evaluated using the Frankel grading system. Pain was assessed using the visual analogue score (VAS). Disability status was assessed using the Oswestry Disability Index (ODI). Outcome was graded according to the Kim and Lee criteria. Kyphosis at presentation, preoperation (after one month of conservative therapy), immediate postoperation, and 5-year follow-up was measured on radiographs to determine the kyphosis progression, correction of deformity, postoperative loss of correction, and residual deformity.

Respectively for 27 and 18 patients with thoracic or thoracolumbar involvement, at 5 years the mean VAS score improved from 5.5 to 1.9 (p<0.001) and from 6.8 to 1.5 (p<0.001), whereas the mean ODI improved from 60.8 to 11.7 (p<0.001) and from 57.5 to 7.6 (p<0.001). The outcome was excellent in 17 and 11, good in 7 and 5, and fair in 3 and 2 patients, respectively. The mean kyphosis progression from presentation to preoperation was from 20.2° to 26.2° and from 10.3° to 14.1°, respectively, whereas the corresponding mean predicted kyphosis progression was from 15.5° to 48.1° and from 13.8° to 50.4°. The respective mean correction of deformity was −8.1° and −8.5°; the respective mean residual deformity was 4.1° and 6.8°; and the respective mean loss of correction at 5 years was 1.9 and 1.9. Two patients had a dural tear, and 3 patients had a transient root injury. Two diabetic patients had superficial wound infection. One patient had downward migration of one rod at 30 months but remained asymptomatic.

Single-stage posterior instrumentation combined with continued chemotherapy for a minimum 12 months is a viable option for early progressive thoracic and thoracolumbar tubercular kyphosis.

To compare the 6-month outcome of Weil osteotomy with distal metatarsal mini-invasive osteotomy (DMMO) in 33 patients with lesser toe metatarsalgia.

Records of 33 patients who underwent Weil osteotomy (n=20, 41 toes) or DMMO (n=13, 22 toes) for lesser toe metatarsalgia by a single surgeon were reviewed. 25 of them had a concurrent procedure on the 1st toe. Outcome at 6 months was assessed using the visual analogue score (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal (MTP-IP) score, and the RAND-36 score.

The 2 groups were comparable in terms of age, gender, and preoperative MTP joint range of motion (ROM), VAS for pain, AOFAS lesser toe MTP-IP score, and RAND-36 scores. At 6 months, the Weil osteotomy group had a higher RAND-36 (mental) score (92 vs. 78, p=0.026), and the DMMO group had a higher percentage of toes with greater MTP joint ROM (p=0.043). All patients achieved bone union within 6 months. Two patients in the DMMO group had prolonged oedema until 3 months post-surgery.

DMMO is a safe and reliable alternative to Weil osteotomy for metatarsalgia and can preserve ROM of the MTP joints.

To review the outcome of Z-plasty of the flexor hallucis longus (FHL) tendon at the tarsal tunnel for checkrein deformity in 8 patients.

Records of 6 males and 2 females aged 14 to 67 (mean, 39.5) years who underwent Z-plasty (lengthening) of the FHL tendon at the tarsal tunnel for checkrein deformity in the first and second toes by a single surgeon were reviewed. All patients had undergone 3 months of conservative treatment. The mean time from injury to surgical treatment was 8.4 (range, 5–12) months. All patients had associated injuries including distal tibiofibular fracture (n=6), distal fibular fracture (n=1), and crush injury around the ankle (n=1); they were treated with intramedullary nailing (n=6), long leg splinting (n=1), and short leg splinting (n=1).

After a mean follow-up of 3.4 (range, 1–7) years, the FHL tendon was lengthened by a mean of 1.7 (range, 1.6–1.8) cm, and the mean American Orthopedic Foot and Ankle Society hallux score increased from 59 (range, 52–67) to 89 (range, 80–90). No patient had recurrence, nerve injury, or tarsal tunnel syndrome, although one patient had sensory disturbance of the posterior tibial nerve in the forefoot, which resolved spontaneously at week 2.

Z-plasty of the FHL tendon at the tarsal tunnel is a viable option for correction of checkrein deformity.

To review the outcome of arthrodesis of the hallux metatarsophalangeal (MTP) joint in 23 patients.

Records of 9 men and 14 women aged 27 to 88 (mean, 57) years who underwent arthrodesis of the hallux MTP joint using an intramedullary device and an intra-osseous device were reviewed. Indications for surgery were severe hallux valgus (n=15), hallux rigidus (n=6) and rheumatoid arthritis (n=2). Outcome measures included visual analogue score (VAS) for pain, the American Orthopaedic Foot and Ankle Society (AOFAS) hallux score, bone union, hallux valgus angle (HVA), dorsiflexion angle (DA), complications, revision, and patient satisfaction.

The mean follow-up was 19 (range, 6–38) months. The mean AOFAS score improved from 29 to 75.4 (p<0.0001) and the mean VAS for pain improved from 8.1 to 2.4 (p<0.0001). 20 (86%) of the patients were satisfied with the outcome. The mean HVA was 14° and the mean DA was 22°. 19 (83%) of the toes had a well-aligned hallux. 21 (91%) of the patients achieved arthrodesis of the hallux MTP joint. The remaining 2 patients underwent revision surgery for failed fusion or infected non-union; they continued to have transfer metatarsalgia despite bone union.

The intramedullary and intra-osseous devices for arthrodesis of the hallux MTP joint achieved good outcome in terms of AOFAS score, VAS for pain, HVA, DA, bone union, and patient satisfaction.

To evaluate the effect of combined use of ibandronate and eldecalcitol for 6 to 12 months on bone mineral density (BMD) and bone strength of the proximal femur in postmenopausal Japanese women with osteoporosis.

BMD and bone strength of the proximal femur were evaluated in 78 postmenopausal women (mean age, 73.6 years) who underwent treatment for osteoporosis with combined use of ibandronate and eldecalcitol for at least 6 months. BMD was measured at the lumbar spine, femoral neck, and total hip using dual-energy X-ray absorptiometry (DXA) at baseline and every 6 months thereafter. Hip structure analysis of the narrow neck and intertrochanter was performed by a radiologist using DXA images.

Respectively for the lumbar spine, femoral neck, and total hip, BMD significantly increased (from baseline) by 4.54%, 2.31%, and 1.56% at 6 months and by 5.92%, 3.02%, and 2.70% at 12 months. In hip structure analysis, most parameters improved significantly. Respectively for the narrow neck and intertrochanter, BMD significantly increased (from baseline) by 2.37% and 2.71% at 6 months and by 3.46% and 3.52% at 12 months; cross-sectional area significantly increased by 1.83% and 3.39% at 6 months and by 2.91% and 3.46% at 12 months; section modulus significantly increased by 2.42% and 4.11% at 6 months and by 4.84% and 3.26% at 12 months; cortical thickness significantly increased by 2.49% and 3.33% at 6 months and by 3.73% and 3.37% at 12 months; and buckling ratio significantly decreased by 2.97% and 2.57% at 6 months and by 3.86% and 2.99% at 12 months.

Combined use of ibandronate and eldecalcitol for 6 months significantly improved bone strength of the proximal femur in postmenopausal Japanese women with osteoporosis.

To evaluate changes in blood circulation of the femoral cortex in rabbits using scintigraphy before and after cable cerclage alone or combined with an intramedullary Kirschner wire.

Ten New Zealand rabbits were used. For the right femur, a 2-mm-thick cable was placed around the mid-diaphyseal region and squeezed with a 400-N force and locked with a clip. For the left femur, a 1.8-mm Kirschner wire was inserted retrogradely into the medullary canal, and a 2-mm-thick cable was applied using the same technique. The blood perfusion ratio of the region of interest (ROI) before and after surgery was evaluated using scintigraphy.

For the right femurs, the mean ROI perfusion ratio decreased by 45% from 2.51 to 1.37 after intervention (p=0.001). For the left femurs, the mean ROI perfusion ratio decreased by 56% from 2.12 to 0.92 after intervention (p<0.001). The mean ROI perfusion ratio post-intervention was higher in the right than left femurs (p=0.017).

Cable cerclage around the femoral cortex significantly decreased blood circulation in the area.

To evaluate cellular activity in milled versus unmilled surface of the femoral head in 21 patients who underwent robot-assisted total hip arthroplasty (THA).

The femoral head of 21 consecutive patients who underwent robot-assisted THA for osteonecrosis was used. 10 cc of trabecular bone from the entire milled surface was obtained using a curette. The same amount of trabecular bone was obtained at least 1 cm away from the milled surface and served as a matched control. Cell morphology, viability, osteocalcin activity, and alkaline phosphatase activity in milled versus unmilled surface were assessed.

Cell morphology of the milled or unmilled surface was comparable; cells were smaller in the milled surface. Cell viability was a mean of 40% higher in the milled surface (107.4% vs. 67.2%, p<0.001); cell viability at 5 time points was comparable in each group. Osteocalcin activity of cells was slightly higher in the milled surface (1.43 vs. 1.24 ng/ml, p=0.69). Alkaline phosphatase activity of cells was slightly higher in the unmilled surface (150 105 vs. 141 789 U/L, p=0.078).

The milled and unmilled surfaces of the femoral head were comparable in terms of cell morphology, viability, osteocalcin activity, and alkaline phosphatase activity.

To report our experience with the PRECICE nail for limb lengthening in 23 patients.

Records of 15 female and 8 male patients aged 14 to 38 (mean, 23.6) years who underwent lengthening of the tibia (n=6) or femur (n=21) using the PRECICE nail were reviewed. The reasons for lengthening included trauma (n=7), hemihypertrophy (n=2), focal femoral deficiency (n=2), Ellis-van Creveld syndrome (n=1), hip septic arthritis sequelae (n=1), hereditary multiple exostosis (n=1), club foot sequela (n=1), congenital tibial pseudoarthrosis (n=1), fibrous dysplasia (n=1), idiopathic limb length discrepancy (n=7), and cosmetic (n=1).

The mean follow-up duration was 20.72 months. The mean lengthening was 48.20 mm, and the mean acute angular correction was 15.5°. The mean time to full weight-bearing was 5.15 months, and the mean consolidation index was 1.12 months/cm. The mean maturation index was 0.78 months/cm. One patient had nail breakage during the consolidation phase. The nail was replaced by an intramedullary nail until consolidation, after which another PRECICE nail was used to treat the residual shortening. Eight patients had over-lengthening and the nails were driven back to the desired length. No patient had infection.

The PRECICE nail is a viable option for lengthening of the femur and tibia.

To evaluate perioperative blood loss and blood transfusion requirement in patients who underwent dynamic hip screw plate fixation for a stable trochanteric fracture with or without preoperative intravenous tranexamic acid (TXA).

49 men and 11 women (mean age, 56.5 years) who underwent open reduction and internal fixation with a dynamic hip screw plate for a stable trochanteric fracture by a single surgeon were equally randomised to receive either a single dose of intravenous TXA (15 mg/kg) 15 minutes prior to surgery or an equal volume of normal saline by slow infusion. Intra- and post-operative blood loss and the need for blood transfusion were assessed, as was any thromboembolic adverse event.

The TXA and control groups were comparable in terms of age, gender, body mass index, blood pressure, pulse rate, time from injury to surgery, operating time, and preoperative haematological data. Blood loss was lower in the TXA than control group intraoperatively (320.3 vs. 403.33 ml, p<0.001), during 0 to 24 hours (61.67 vs. 186.67 ml, p<0.001), and during 24 to 48 hours (27 vs. 86.67 ml, p<0.001), as well as the total volume (408.97 vs. 676.67 ml, p<0.001). Respectively for the TXA and control groups, 27 and 30 required 28 and 41 units of blood intra-operatively (p<0.001), and 6 and 15 required 6 and 15 units of blood postoperatively (p=0.014). No patient had any thromboembolic adverse event.

TXA is safe and effective in reducing blood loss in dynamic hip screw plate fixation for stable trochanteric fractures.

To review the records of 363 patients with severe gluteal muscle contracture to determine its mechanism, underlying pathology, and treatment outcome.

Records of 136 males and 227 females aged 5 to 18 (mean, 12.2) years who underwent Z-plasty for bilateral (n=347) or unilateral (n=16) severe gluteal muscle contracture were reviewed. Severe gluteal muscle contracture was classified as typical (n=52) or special (n=311). The typical type is associated with symptoms of positive out-toe gait, Ober sign, back-extending test, cross-leg test, squatting with knee side-by-side test, and hip dysfunction. It is further subdivided into mild (n=0), moderate (n=40), or severe (n=12). The special type is associated with additional symptoms of pelvic tilt and leg length discrepancy (<2 cm in 181 hips, 2–4 cm in 82 hips, and >4 cm in 48 hips). 311 hips had pelvic tilt and 47 hips had lumbar compensatory scoliosis. Treatment outcome was assessed at 6 months. Hip functional score was assessed at the final follow-up.

The mean hospitalisation period was 11 days. After a mean follow-up of 1.5 years, the mean hip functional score improved from 8.03 to 11.69; improvement was higher in children (age 5–13 years) than in adolescents (age 14–18 years) [3.7 vs. 2.9, p<0.001]. At 6 months, outcome was excellent in 280 hips, good in 80, fair in 3 hips, and poor in 0. The 3 hips with fair outcome had persistent slight pelvic tilt and swaying gait. Two of them had preoperative leg length discrepancy >4 cm, and intra-operatively the contracture band severely affected the joint capsule. The third patient did not comply with postoperative exercises.

Surgical treatment for severe gluteal muscle contracture achieved good outcome.

To review the outcome of Wagner double intertrochanteric osteotomy for trochanteric overgrowth and a short femoral neck in 7 adolescents.

Records of one male and 6 females aged 15 to 20 years who underwent modified Wagner osteotomy for trochanteric overgrowth and a short femoral neck by a single senior surgeon were reviewed. The diagnoses were coxa vara (n=2), developmental dysplasia of the hip (n=3), Leg-Calve-Perthes (n=1), and proximal femoral focal deficiency (n=1). Radiological indication for double intertrochanteric osteotomy included a neck-shaft angle (NSA) <120° or a centre trochanter distance (CTD) <28 mm. Function was evaluated using the Children's Hospital Oakland Hip Evaluation Scale (CHOHES). The articulotrochanteric distance (ATD), CTD, NSA, and the distance between the centre of the femoral head and the centre of the acetabulum (MZ) were measured on radiographs.

The mean follow-up duration was 61 (range, 28–86) months. The ATD improved from 16±11.5 mm to −6.3±10.2 mm (p=0.018), the CTD from 27.9±3.5 mm to 36.4±7.1 mm (p=0.018), the NSA from 112°±24.4° to 131°±16° (p=0.028), the MZ from 12.7±6.5 mm to 7.7±4.2 mm (p=0.028), and the CHOHES score from 62.1±8.7 to 84±9.6 (p=0.017). One patient had delayed union. Two patients had persistent Trendelenburg gait. Two patients declined second-stage surgery for acetabular dysplasia after solving the femoral side problems at the first stage. One of them developed hip arthrosis.

Double intertrochanteric osteotomy is a viable treatment option for adolescents with trochanteric overgrowth and a short femoral neck.

To review the long-term outcome of Rockwood capsular shift for recurrent shoulder dislocation secondary to trauma.

Records of 30 males and 4 females who underwent Rockwood capsular shift for recurrent (≥2 episodes) anterior shoulder dislocation were reviewed. An additional Bankart repair with different techniques was performed in 24 of the patients by 2 different surgeons. The outcome was assessed using the Western Ontario Shoulder Instability Index (WOSI) and the Western Ontario Osteoarthritis of the Shoulder (WOOS) index questionnaires, the modified Rowe score, and the Constant-Murley score. Shoulder range of motion (ROM) was measured. Degenerative joint changes were evaluated on radiographs.

During a mean follow-up of 13 (range, 10–16) years, 6 (18%) patients had a mean of 1.2 recurrent dislocations. Four of the patients reported a traumatic event during recurrent dislocation. Of the 6 patients, 3 had undergone a Bankart lesion repair. Better Rowe and adjusted Constant scores were associated with lower age at first dislocation, at the index surgical procedure, and at follow-up. Four patients developed glenohumeral osteoarthritis: 2 were mild or moderate and 2 were severe and symptomatic. Glenohumeral osteoarthritis was associated with follow-up duration (p=0.03) and poorer Rowe score (p=0.012), adjusted Constant score (p=0.001), and WOOS score (p=0.006).

Rockwood capsular shift can preserve shoulder ROM, with rates of recurrent dislocation and degenerative joint changes comparable with other techniques.

To evaluate the outcome of percutaneous radiofrequency ablation under guidance of 3-dimensional fluoroscopy in 17 patients with osteoid osteoma.

Records of 11 male and 6 female consecutive patients aged 4 to 28 (mean, 13.8) years who underwent radiofrequency ablation under guidance of 3-dimensional fluoroscopy for osteoid osteoma and were followed up for a mean of 15.8 (range, 12–28) months were reviewed. All patients had been treated with analgesics but failed to achieve lasting pain relief. Visual analogue score (VAS) for pain was assessed pre- and post-operatively. Absence of pain was considered recovery.

The mean operating time was 55 (range, 20–95) minutes, and the mean length of hospital stay was 2.8 (range, 2–7) days. The mean amount of radiation was 390.2 (range, 330.5–423.6) mGy/cm. Relief of pain occurred within the first 24 hours in 11 patients and by the end of the first week in 3 patients. Pain persisted in 3 patients at one month; they underwent revision surgery and achieved complete recovery. The mean VAS for pain was 7.2 (range, 6–9) in 17 patients preoperatively and decreased to 0.64 (range, 0–2) in the 14 patients with pain relief and 0.66 (range, 0–1) in the 3 patients after revision surgery. Two patients had severe discharge from the wound secondary to fat necrosis, which resolved within a week with antibiotics and local dressings. No patient had cellulitis, vasomotor instability, neurovascular injury, fracture, or deep infection.

Percutaneous radiofrequency ablation under guidance of 3-dimensional fluoroscopy is a viable treatment option for osteoid osteoma.