Mean Oxford Score Research Articles

Tapered Fluted Titanium Stems in the Management of Vancouver B2 and B3 Periprosthetic Femoral Fractures

Surgeons have several implant choices when managing Vancouver B2 and B3 periprosthetic fractures about the hip. Few long-term studies have reported outcomes for tapered fluted titanium stems. We determined (1) survival, with femoral revision as the end point, of distal taper stems in the treatment of Vancouver B2 and B3 periprosthetic fractures at our institution, (2) radiographic outcomes, and (3) quality of life and hip function after revision. Of the 200 patients with Vancouver B2 or B3 periprosthetic fractures treated with femoral revision between February 2000 and February 2010, 55 (38 B2, 17 B3) were treated with modular tapered titanium stems. Of the surviving 47 patients, one was lost to followup, leaving 46 (30 B2, 16 B3) available for review at a mean of 54 months (range, 24-143 months). Initial indications for using these implants were treatment of periprosthetic fractures where less than 4 cm of diaphyseal fit was available, but this evolved during the study period to all fractures unless no diaphysis remained, in which case complex revision techniques were used. Radiographs were assessed to establish fracture healing, stem subsidence, and bone stock restoration. Quality of life and hip function were assessed using WOMAC, Oxford, SF-12, UCLA activity level, and satisfaction scores. Two femoral stems were revised: one subsided and was revised at 12 months; the other had deep infection and underwent two-stage revision at 49 months. Radiographic review showed one nonunion, with maintenance or improvement of bone stock in 89% of patients. Subsidence occurred in 24%. Mean Oxford score was 76 of 100, WOMAC function and pain scores were 75 and 82 of 100, satisfaction score was 91 of 100, and SF-12 mental and physical scores were 53 and 40 of 100. We report encouraging short-term results in terms of survival of distal taper stems in the treatment of B2 and B3 periprosthetic fractures. Although subsidence was frequent, most migrated less than 3 mm without correlation to poor pain and functional scores.

Knee arthrodesis using a customised modular intramedullary nail in failed infected total knee arthroplasty

Knee arthrodesis is used to treat patients with failed infected total knee arthroplasty (TKA). Among fixation methods, intramedullary nailing increases the chances of bone union but may carry a risk of infection around the nail. This risk is not well understood, because available case-series studies were not confined to patients with knee infection. Infection recurrence rates after knee arthrodesis with intramedullary nailing used to treat failed infected TKA are similar to those seen with other fixation methods. We retrospectively reviewed 31 cases of knee arthrodesis with fixation by a modular intramedullary nail performed at a subspecialized center treating complex osteoarticular infections (CRIOAC). The antibiotic regimen was determined based on multidisciplinary discussions and microbiological studies of preoperative and intraoperative specimens. Mean follow-up was 50 ± 22 months (range, 28-90 months). Arthrodesis was performed in one stage (n=6) or two stages (n=25). Success was defined as presence, after a postoperative follow-up of at least 24 months, based on the following criteria: normal erythrocyte sedimentation rate and/or C-reactive protein, no wound inflammation or sinus tract, no revision surgery, and no antibiotic treatment. Bone union was not a criterion for a successful arthrodesis procedure. Removal of the fixation material was required in three patients and long-term palliative antibiotic therapy in three patients (fixation material in place with repeated positive specimens) for a total of six failures due to infection (6/31, 19.4%). None of the patients experienced mechanical failure (no breakage of the material and no fixation failure of the nails designed to allow osteointegration). The mean leg length discrepancy was 10 ± 10 mm (range, 5-34 mm) and the mean Oxford score was 41 ± 11 (range, 23-58). The 50-month rate of arthrodesis survival to revision surgery for nail removal was 77.8 ± 4% and the 50-month rate of arthrodesis survival without revision surgery for persistent infection was 74.6 ± 4.2%. The infection recurrence rate was higher than with other fixation methods but remained acceptable (19.4%). Use of a modular intramedullary nail prevented major leg-length discrepancies, which are often poorly accepted by the patients, and allowed immediate weight bearing despite the often severe bone loss. Level IV, retrospective cohort study.

External Fixation for Displaced 2-part Proximal Humeral Fractures

Studies have reported conflicting results regarding external fixation for displaced proximal humeral fractures. Compared with open reduction and internal fixation, external fixation for displaced proximal humeral fractures avoids dissection and soft tissue stripping and leads to higher union rates, a lower incidence of avascular necrosis, less scaring of the scapulohumeral interface, and faster rehabilitation. Some authors have reported good or excellent results and minimum complications compared with open reduction and internal fixation; however, others have reported that external fixation does not ensure acceptable reduction and fracture stability, especially in patients with osteoporosis.This article describes 18 patients with displaced 2-part fractures of the surgical neck of the humerus treated with closed reduction and external fixation using the Tension Guide Fixator (Gexfix SA, Carouge, Switzerland) external fixation system between 2010 and 2011. The patients included 14 women and 4 men with a mean age of 39 years. Mean follow-up was 18 months (range, 15-24 months). Fracture union; function using the Constant score, University of California Los Angeles score, Oxford score, and Quick Disabilities of the Arm, Shoulder and Hand shoulder score; and complications were evaluated. All patients experienced fracture union at a mean of 11 weeks (range, 9-13 weeks). The Tension Guide Fixator was removed without anesthesia at the outpatient clinic at a mean of 6 weeks (range, 4-8 weeks) with no loss of reduction or secondary displacement after removal. At 1-year follow-up, mean Constant and University of California Los Angeles scores were excellent, mean Oxford score showed satisfactory joint function, and mean Quick Disabilities of the Arm, Shoulder and Hand score showed minimal pain with no disability.

Cemented Versus Cementless Modular Head Partial Prostheses in Femoral Neck Fractures of Elderly Patients: Comparison of Early Functional Results

Objective: In this study, we aimed to compare early functional results of cemented versus cementless modular head partial prostheses used in femoral neck fractures of elderly patients. Methods: We included 28 (21 female and 7 male) elderly patients who were accessible for the functional scoring and were treated by use of modular head partial prostheses due to a femoral neck fracture in our hospital between 2006 and 2008. Eleven hemiarthroplasties were cemented and 17 were cementless. Mean age was 74.6 years and mean follow-up period was 27 months. The Oxford hip scoring system was used for the functional evaluation of patients. Results: The mean Oxford score of the patient group treated with cemented modular head partial prostheses was 26.7 points and of the patient group treated with cementless modular head partial prostheses was 22.9 points. Mean Oxford scores and the distribution of patients in terms of Oxford classes showed no statistically significant difference between the cemented and the cementless groups (p>0.05). Conclusion: We obtained similar early functional results with cemented and cementless modular head partial prostheses used in femoral neck fractures of elderly patients. (JAREM 2012; 2: 1-5)

Stabilization of Acromioclavicular Joint Dislocation using the ‘Surgilig’ Technique

BackgroundDisruption of the coracoclavicular ligaments may be associated with dislocation of the acromioclavicular joint, resulting in pain and functional disability. The Surgilig (Surgicraft Ltd, Redditch, UK) is a synthetic ligament used to reconstruct the ligaments, thereby stabilizing the joint.MethodsBetween 2004 and 2009, 50 patients with acromioclavicular joint dislocation were reconstructed using the Surgilig system. Five patients were lost to follow-up; hence, 45 patients underwent review. Patients were evaluated clinically and radiologically at an average of 26.9 months (range 6 months to 60 months) postoperatively using the Oxford, University of California, Los Angeles (UCLA) and Simple Shoulder scoring systems.ResultsThe mean Oxford score was 45.31 (SD 4.52, range 35 to 48), the mean UCLA score was 31.38 (SD 5.07, range 11 to 35) and the mean Simple Shoulder score was 10.92 (SD 1.7, range 6 to 12). Ninety-one percent of patients were completely satisfied with the procedure and outcome. Few complications were encountered, with no recorded infections. However, one patient underwent early revision for persistent instability. Six patients had the screw removed at a later stage as a result of local skin irritation. Removal of the screw did not result in recurrent instability.DiscussionThe present study is the largest reported mid-term results using the Surgilig technique, and appears to be successful for treating both acute and chronic injuries, with high patient satisfaction and excellent functional results.

The Delta III reverse shoulder replacement for cuff tear arthropathy

The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard anatomical shoulder replacements depend on a functioning rotator cuff, and hence may fail in the presence of tears in the cuff. Many designs of non-anatomical constrained or semi-constrained prostheses have been developed for cuff tear arthropathy, but have proved unsatisfactory and were abandoned. The DePuy Delta III reverse prosthesis, designed by Grammont, medialises and stabilises the centre of rotation of the shoulder joint and has shown early promise. This study evaluated the mid-term clinical and radiological results of this arthroplasty in a consecutive series of 50 shoulders in 43 patients with a painful pseudoparalysis due to an irreparable cuff tear and destructive arthritis, performed over a period of seven years by a single surgeon. A follow-up of 98% was achieved, with a mean duration of 39 months (8 to 81). The mean age of the patients at the time of surgery was 81 years (59 to 95). The female to male ratio was 5:1. During the seven years, six patients died of natural causes. The clinical outcome was assessed using the American Shoulder and Elbow score, the Oxford Shoulder Score and the Short-form 36 score. A radiological review was performed using the Sirveaux score for scapular notching. The mean American Shoulder and Elbow score was 19 (95% confidence interval (CI) 14 to 23) pre-operatively, and 65 (95% CI 48 to 82) (paired t-test, p < 0.001) at final follow-up. The mean Oxford score was 44 (95% CI 40 to 51) pre-operatively and 23 (95% CI 18 to 28) (paired t-test, p < 0.001) at final follow-up. The mean maximum elevation improved from 55° pre-operatively to 105° at final follow-up. There were seven complications during the whole series, although only four patients required further surgery.

Computer navigated total knee arthroplasty: The learning curve

The learning curve for computer navigated total knee arthroplasty (TKA) is not well defined. We collected data prospectively on a consultant surgeon's first 50 navigated TKAs. Over the same period, matching data was taken from 50 consecutive cases performed by an expert who has performed over 1000 navigated TKAs. From the first case, the novice navigator was able to achieve the same standard as the expert in terms of post-implant mechanical alignment in the coronal and sagittal planes. Equally, at 6 weeks and one year post-surgery there was no significant difference in the mean Oxford score, mechanical axis and range of movement for the two groups of patients. Operative time was significantly longer for the novice surgeon in the first 20 cases (92 versus 73 min, p < 0.001), but by the final 20 cases there was no difference (72 versus 74 min, p = 0.944). This study shows that the learning curve for navigated TKA is approximately 20 cases and that a beginner can reproduce the results of an expert from the outset.

The Exeter Universal cemented femoral component at 15 to 17 years

The first 325 Exeter Universal stems (309 patients) implanted at the originating centre were inserted between March 1988 and February 1990 by a group of surgeons with differing experience. In this report we describe the clinical and radiological results at a mean of 15.7 years (14.7 to 17.3) after operation with no loss to follow-up. There were 97 patients (108 hips) with replacements still in situ and 31 (31 hips) who had undergone a further procedure. With an endpoint of revision for aseptic loosening, the survivorship at 17 years was 100% and 90.4% for the femoral and acetabular component, respectively. The mean Merle D'Aubigné and Postel scores at review were 5.4 (SD 0.97) for pain and 4.5 (SD 1.72) for function. The mean Oxford score was 38.4 (SD 9.8) (0 to 48 worst-to-best scale) and the mean combined Harris pain and function score was 73.2 (SD 16.9). Radiological review showed excellent preservation of bone stock in the proximal femur and no failures of the femoral component.

The Metasul metal-on-metal articulation in primary total hip replacement

We report the clinical and radiological outcome at ten years of 104 primary total hip replacements (100 patients) using the Metasul metal-on-metal bearing. Of these, 52 had a cemented Stuehmer-Weber polyethylene acetabular component with a Metasul bearing and 52 had an uncemented Allofit acetabular component with a Metasul liner. A total of 15 patients (16 hips) died before their follow-up at ten years and three were lost to follow-up. The study group therefore comprised 82 patients (85 hips). The mean Oxford score at ten years was 20.7 (12 to 42). Six of 85 hips required revision surgery. One was performed because of infection, one for aseptic loosening of the acetabular component and four because of unexplained pain. Histological examination showed an aseptic lymphocytic vasculitis associated lesion-type tissue response in two of these. Continued follow-up is advocated in order to monitor the long-term performance of the Metasul bearing and tissue responses to metal debris.

The relationship between obesity and the age at which hip and knee replacement is undertaken

We audited the relationship between obesity and the age at which hip and knee replacement was undertaken at our centre. The database was analysed for age, the Oxford hip or knee score and the body mass index (BMI) at the time of surgery. In total, 1369 patients were studied, 1025 treated by hip replacement and 344 by knee replacement. The patients were divided into five groups based on their BMI (normal, overweight, moderately obese, severely obese and morbidly obese). The difference in the mean Oxford score at surgery was not statistically significant between the groups (p > 0.05). For those undergoing hip replacement, the mean age of the morbidly obese patients was ten years less than that of those with a normal BMI. For those treated by knee replacement, the difference was 13 years. The age at surgery fell significantly for those with a BMI > 35 kg/m(2) for both hip and knee replacement (p > 0.05). This association was stronger for patients treated by knee than by hip replacement.

PDS sling fixation of Neer type 2 fractures of the distal clavicle—A simple technique with excellent results

Introduction: Distal third fractures of the clavicle account for approximately 10–15% of clavicle fractures. Non union rates following conservative management can be as high as 30%. Many techniques have been described, including external fixation, k-wire fixation, and most recently, hook plate fixation. Non-absorbable sutures, and slings have also been utilised. All of these techniques are associated with complications. In addition, Hook plates require a second operation to remove the plate. This study reports the results of a simple technique using a PDS loop in the fixation of Neer type 2 fractures of the clavicle, performed in our institution. Methods: Twelve patients with Neer type 2 fractures operated by a single surgeon over three years were included in the study. The mean age was 45 (14 to 63). There were 7 male and 5 female patients. Standard postoperative protocols were followed in all patients. A 1.5 PDS cord looped around the coracoid was used to hold the reduced medial clavicular shaft fragment. Patients were followed up postoperatively at two, six and twelve weeks. Final outcomes were assessed using radiographs and the Oxford and DASH scoring systems at twelve months. Results: Ten fractures united within twelve weeks. All of these patients returned to their pre-injury activity level. There were two non unions, both in non compliant patients. One of these non unions remained asymptomatic and one patient was lost to follow up. The mean Oxford score at 12 months was 14.25 (range 12 to 16) and the mean DASH score was 5 (4–7). Conclusion: We conclude that this technique is safe, simple and cost effective. It achieves high rates of union without the need for implant removal. As with other techniques, proper patient selection is essential. We recommend this technique as an excellent treatment option when dealing with these notoriously difficult fractures.

Hook-plate fixation of unstable lateral clavicle fractures: A report on 63 patients

Background Hook-plate fixation of unstable lateral clavicle fractures has given promising results in previous reports, but numbers of patients have been small. We assessed the results of this technique in 63 patients.Patients and methods 63 patients with unstable lateral clavicle fractures were operated on at Oulu University Hospital during 1997–2004, using a clavicle hook-plate. Fracture union and complications were assessed retrospectively from case records and radiographs. The subjective part of the Constant score, Oxford shoulder questionnaire data and subjective shoulder value (SSV) were assessed after an average of 3.6 years in 58 patients. 31 patients were reviewed at the outpatient clinic, using complete Constant scores and radiographs of both acromioclavicular joints.Results 59 fractures united uneventfully. There was 1 case of delayed union and 3 nonunions, but only 1 of these required surgery. Additional complications involved 1 case of infection, 1 frozen shoulder and 3 cases of late fracture medial to the plate. The mean Oxford score was 15, the mean for the subjective part of the Constant score was 32, and the SSV was 86%.Interpretation Clavicle hook-plate fixation of unstable lateral clavicle fractures results in a good union rate and good shoulder function.

Metal-on-metal resurfacing of the hip in patients under the age of 55 years with osteoarthritis

The results of conventional hip replacement in young patients with osteoarthritis have not been encouraging even with improvements in the techniques of fixation and in the bearing surfaces. Modern metal-on-metal hip resurfacing was introduced as a less invasive method of joint reconstruction for this particular group. This is a series of 446 hip resurfacings (384 patients) performed by one of the authors (DJWM) using cemented femoral components and hydroxyapatite-coated uncemented acetabular components with a maximum follow-up of 8.2 years (mean 3.3). Their survival rate, Oxford hip scores and activity levels are reviewed. Six patients died due to unrelated causes. There was one revision (0.02%) out of 440 hips. The mean Oxford score of the surviving 439 hips is 13.5. None of the patients were told to change their activities at work or leisure; 31% of the men with unilateral resurfacings and 28% with bilateral resurfacings were involved in jobs that they considered heavy or moderately heavy; 92% of men with unilateral hip resurfacings and 87% of the whole group participate in leisure-time sporting activity. The extremely low rate of failure in spite of the resumption of high level occupational and leisure activities provides early evidence of the suitability of this procedure for young and active patients with arthritis.