Varus malalignment has no influence on clinical outcome in midterm follow-up after total knee replacement

Background

Varus malalignment after total knee replacement is mentioned to be a major risk factor for postoperative pain and functional impairments. This wide spread opinion is based on the historical data derived from implantations performed in the late 1970s and early 1980s. We tested the hypothesis whether significant varus malalignment leads to minor functional results and early loosening using modern implants and operating techniques.

Methods

Two hundred and eighteen knee joints (184 patients) having been replaced with a PFC Sigma or Natural Knee II with a minimum follow-up of 5 years were included in this case control study. From the 30 most varus malaligned knees (30 patients) 25 patients were available for clinical and radiographical examination (group A) and were compared with a control group without significant varus malalignment that was matched for sex, age and implant (group B). The Knee Society Score (KSS), the WOMAC and the SF36 were determined.

Results

No implant showed radiological signs of loosening or had been revised. The deviation from the mechanical axis was 6.3° [3.9°–10.7° varus] in group A and 0° [2.6° valgus to 2.1° varus] in group B (P < 0.001). The KSS was 158 [99–199] points in group A and 142 [78–198] points in group B (n.s.). The WOMAC did not reveal any significant differences between the groups either (group A 22 ± 27 points, group B 21 ± 21 points). Likewise in the SF36, neither in the sum nor in the individual scores was a significant difference found between groups A (56 ± 24 [8–90] points) and B (56 ± 18 [26–86] points).

Conclusions

The present data do not support the assumption that there is a correlation between varus malalignment and a bad medium-term radiological and clinical outcome after total knee arthroplasty. This questions the indication for revision of painful and varus malaligned prostheses, since an improvement of the clinical outcome is not to be expected.     

Fractures of the glenoid neck

Glenoid neck fractures are uncommon and have received little attention in the literature. However, these injuries involve a major articulation and can cause considerable morbidity if significantly displaced. Consequently, a review of current diagnostic and therapeutic principles with respect to these potentially challenging fractures is justified. The vast majority of glenoid neck fractures are undisplaced or insignificantly displaced (Type I fractures) and are managed without surgery. Type II fractures, however, are significantly displaced, making surgical management a consideration. Significant displacement is defined as translational displacement greater than or equal to 1 cm or angulatory displacement greater than or equal to 40° (in either the coronol or transverse plane). The primary surgical approach is posterior; however, a superior extension is often necessary. Fixation devices include K-wires, 3.5 mm reconstruction plates, and 3.5 mm cannulated lag screws. Follow-up care and rehabilitation are absolutely critical to optimizing the final functional result.     

Femoral neck fracture--the cause of death of Emperor Charles IV

We present the oldest documented case of femoral neck fracture of a particular person in the history of orthopaedic surgery. Examination of the skeleton of Charles IV, the King of Bohemia and Roman Emperor living in XIVth century has revealed a fracture of the left femoral neck. This fracture was most probably an indirect cause of his death as it resulted in pneumonia, the immediate cause of death. This fact has been confirmed by contemporary chronicles. Received: 19 July 2000     

Outcome of glenoid neck fractures

The aim of this study was to analyze the outcome of extraarticular glenoid neck fractures with respect to glenoid neck malunion and rotator cuff injury. These fractures are often considered to have a favorable outcome if treated conservatively. More recent studies reveal that the outcome is not uniformly good, but the cause of poor outcomes has not been investigated. Our study identified 9 patients who had sustained a glenoid neck fracture of the scapula within the last 10 years and who were treated conservatively with immobilization and then early active motion. Their functional and anatomic outcomes were analyzed by clinical examination and validated scoring systems, including the Oxford questionnaire and Constant score. Plain radiography and magnetic resonance imaging were correlated to outcome. None of the 9 patients were pain-free, and some had poor Oxford and Constant scores. Pain was associated with glenoid neck malunion and evidence of subacromial bursitis or rotator cuff tendinopathy (or both).     

Functional and clinical outcome of total shoulder arthroplasty with oversized glenoid

Background

The Epoca-Reconstruction-(Reco)^?-Glenoid has been developed to treat patients with cuff-tear-arthropathy. The glenoid component of this system has a hemispheric shape that canopies the humeral head. This design is believed to provide a stable fulcrum and restore normal deltoid function. The purpose of this study was to analyse strengths and disadvantages of the Epoca-Reco^?-Glenoid in cuff-tear-arthropathy patients. Changes in functional outcome using Constant-Murley-Scoring(CMS), CMS sub-scoring parameters and radiological outcome were analysed. For this purpose, a classification for radiologic lucency was proposed. Diverging results, influencing factors and alternative treatment options have been discussed to analyse weaknesses and enhance future development of this arthroplastic model.

Materials and methods

23 patients aged 68?±?8.4?years with irreparable cuff-tear-arthropathy refractory to physiotherapeutic treatment were treated with Reco-Glenoid Total-Shoulder-Arthroplasty (TSA). Pre-operative standardized evaluations included history, physical examination, radiographs, computer tomography and clinical scorings. The post-operative controls included physical examination with CMS, video documentation and radiological evaluation.

Results

After a median follow-up time of 38?±?18?months, the CMS had been significantly improved (p?p?p?=?0.006) was achieved. Significantly, inferior results in functional outcome and higher lucency rates were observed in female patients and in patients treated with small glenoid components. The follow-up rate was 100?%.

Conclusion

The semi-constraint reconstruction glenoid prosthesis model in cuff-tear-arthropathy patients significantly improves shoulder function, however, it yields controversial results, with satisfactory results in male and poor results in female patients. Revision rate of the female cohort and loosening of the glenoid component in this short-term follow-up is of concern. Further investigations taking BMD, osteopenic conditions and influence of surface area in smaller individuals into consideration are recommended, to determine whether this is the underlying cause of the inferior results in females.     

肩胛颈、肩胛盂骨折的手术治疗

1999年 4月～ 2 0 0 2年 10月 ,我院收治肩胛颈、肩胛盂骨折 9例 ,采用切开复位、重建钛钢板塑形固定 ,效果满意。1　材料与方法1.1　病例资料　本组 9例 ,均为男性 ,年龄 2 3～ 4 5岁。交通事故伤 7例 ,坠落伤 2例。肩胛颈骨折 6处 ,骨折块前后移位 10mm并骨折端重叠移位 ;盂缘及盂窝骨折 5处 ,骨折块移位超过 10mm ,肱骨头呈半脱位或不稳定状 ,盂窝关节面高低不平超过 5mm。合并肩胛冈骨折 3例 ,肩胛体骨折 4例。复合同侧肱骨、尺桡骨及第 3肋骨骨折 1例 ,臂丛神经损伤 1例 ,桡骨远端骨折 1例 ,C7椎体骨折 1例。1.2　手术方法　全麻后 ,…     

肩胛盂、肩胛颈骨折后路微创手术的解剖及临床研究

[目的]为肩胛盂、肩胛颈处骨折的后路微创手术提供解剖学基础,并探讨临床疗效。[方法]8具成人尸体标本,观察在不切断三角肌、冈下肌及小圆肌情况下手术入路能显露的肩胛颈与肩胛盂范围。临床合并有肩胛盂、肩胛颈处骨折的肩胛骨骨折共21例,IdebergⅡ型13例,Ⅲ型4例,Ⅳ型3例,Ⅴ型1例,采用后路微创内固定术治疗。根据肩关节功能Constant评分、视觉模拟疼痛评分(VAS)综合判断疗效。[结果]微创后入路可以完整显露肩胛颈及大部分后方肩胛盂(显露范围68.67%~52.31%,平均60.34%)。21例临床病例均获随访,肩关节功能Constant评分末次优良率为95.3%~90.01%,平均91.82%;末次Constant肩关节评分较术前平均提高41.2分,VAS评分平均降低6.3分。[结论]后路微创手术治疗肩胛盂、肩胛颈处骨折,可获得满意疗效。     

The clinical relevance of glenoid labrum lesions

This study describes the microscopic and macroscopic appearance of the glenoid labrum in 106 unselected shoulder specimens. In a prospective investigation the clinical relevance of endoscopically confirmed lesions of the glenoid labrum in 46 patients is examined. Fibrillation (76%), detachment (50%), rupture (35%), and ossification (21%) of the glenoid labrum were the most frequent alterations in our autopsy material. Only 17 shoulders showed an intact limbus--despite the presence of the lesions of the labrum in 45 cases, none of the followed-up patients reported symptoms that could be related to this structure. Only in one patient, did part of the labrum have to be excised. According to the present results, we consider that most lesions of the glenoid labrum have little clinical relevance.     

The influence of surgical technique on clinical outcome of laparoscopic Nissen fundoplication

Background: During laparoscopic Nissen fundoplication (LNF), it is unclear whether the short gastric vessels (SGV) should be divided, the crura reapproximated, or the wrap sutured to the crus. Methods: Since first performing LNF, we have consistently utilized a <2.5-cm wrap performed over a >50 Fr dilator. Other technical details have varied, and these are reviewed in terms of early clinical outcome. Of 105 consecutive patients undergoing LNF, two were converted to open operation (2%). In the remaining 103 patients with ≥3-month follow-up (mean 17 months), the initial 46 (group 1; 45%, mean age ± SEM = 47 ± 2 years) had selective division of the SGV, crural closure, and wrap fixation. In this group, 32 patients (70%) underwent SGV division, 30 patients (65%) had crural closure (10 anteriorly/20 posteriorly), and 14 patients (30%) had the wrap sutured to the crus. During the subsequent 57 LNFs (group 2; 55%, 47 ± 2 years), all patients underwent SGV division, posterior crural closure, and suture of the wrap to the crus. Results: Clinical outcome at ≥3 months was compared between the two groups. The frequencies of mild reflux symptoms, meteorism, and persistent dysphagia were similar in the two groups. However, the incidences of slippage of the wrap into the chest and the need for secondary intervention (esophageal dilatation and/or laparoscopic reoperation) decreased significantly from 15% and 13% of patients in group 1, respectively, to no occurrences in group II. Chi-square analyses revealed that combinations of these technical variables were significantly related to the improved outcome in group II. Conclusion: Based on these data demonstrating improved clinical outcome, we recommend routine division of the SGV, posterior closure of the crura, and fixation of the wrap to the crus during LNF. Received: 28 March 1996/Accepted: 11 June 1996     

Lymphomas occurring late after solid-organ transplantation: influence of treatment on the clinical outcome

BACKGROUND: Posttransplant lymphoproliferative disorders (PTLDs) that occur late after solid-organ transplantation are usually a monoclonal proliferation frequently characterized by the lack of the Epstein-Barr virus genome in tumor cells. The clinical outcome and the best management for patients who present with late PTLDs still remain unclear. PATIENTS AND METHODS: Thirty patients who developed PTLDs more than 12 months (range 13-156) after heart, kidney, or liver transplantation were retrospectively evaluated. Median age was 36.7 years (range 1-70). Fifty-five percent of patients presented with advanced-stage (III-IV) lymphoma, 43% of patients presented with B symptoms, and 40% of patients showed extranodal involvement. Twenty-four cases (75%) were categorized as monoclonal monomorphic PTLD. RESULTS: Three patients died of progressive multiorgan failure before any treatment was initiated. Overall, 17 (63%) patients obtained a clinical response (14 patients had complete remission [CR] and 3 patients had partial remission [PR]). Eight (47%) patients are still alive and in CR, two (12%) patients died in CR, and seven (41%) patients relapsed. With a median follow-up of 6 months (range 0.5-42.8), the median overall survival was 6.2 months. Both clinical response and survival were significantly influenced by the treatment. Indeed, all patients treated for limited disease with surgery or radiotherapy in combination with modulation of immunosuppression obtained CR and are still alive and in CR. On the contrary, 33% of patients who received chemotherapy obtained a clinical response, whereas 15% of patients who received chemotherapy showed progressive disease and 50% of patients who received chemotherapy died of toxicity (infectious or multiorgan failure). CONCLUSIONS: We suggest that patients with late PTLDs and limited disease may benefit from local treatment. For patients who require chemotherapy, we suggest that it should be administered to minimize the risk of infection complications.     

Conservative treatment of scapular neck fracture: the effect of stability and glenopolar angle on clinical outcome

The aim of this study was to determine the effect of stability and glenopolar angle on the clinical outcome of conservatively treated scapular neck fractures. Eighteen patients with scapular neck fractures were treated with conservative treatment. Twelve of the 18 patients had surgical neck fractures, whilst six of them had anatomical neck fractures. Anteroposterior radiographs and computerised tomography were performed for each patient. Glenopolar angle was measured through anteroposterior radiographs in the scapular plane. After 3-5 weeks of immobilisation, a rehabilitation programme was started, throughout which all the patients were treated in a 3-phase rehabilitation programme. The mean follow-up was 25 months, and the Constant score was 78.83+/-8.12 point (range: 68-94 points). Patient gender and the type of scapular neck fractures had no effect on functionality or clinical outcome (p>0.05), whilst associated injuries significantly affected the clinical outcome (p<0.05). There was a positive correlation between the Constant score and glenopolar angle (r=0.891, p<0.05) and between the age and glenopolar angle (r=0.472, p<0.05).