We propose a grading system for contrast free MRI images of tennis elbow and evaluate the inter and intra observer variability of their interpretation.
Our proposed grading system of 1 to 5 based on the pattern around the common extensor tendon was used. Images of the symptomatic and contralateral non symptomatic elbows were graded blindly twice with an interval of 1 month by each surgeon. Each surgeon graded 176 MRI images twice. The grades were subsequently grouped into (I) grades 1 to 2 and (II) grades 3 to 5
The inter observer agreement between consultant A and B was 82.46%, between A and C 67.1% and between B and C 80.1%. It was also noted that there were systematic differences to the inter observer variability. Consultant A graded the images 3 to 5 on both occasions 52.9% of the time, consultant B graded 3 to 5 on both occasions 37.8% of the time and consultant C graded 3 to 5 on both occasions 23.3% of the time.
Between 1989 and 1992 a randomised prospective study was undertaken in which 102 cases adjudged suitable for UKR were allocated to receive either a St Georg Sled UKR or a Kinematic Modular TKR. Both cohorts had a median age of 68 and a similar sex distribution and preoperative knee score. Regular follow up has been maintained. As reported the early results favoured UKR. All cases have now been assessed after a minimum of 10 years using modified WOMAC, Oxford and Bristol Knee Scores (BKS) as well as radiographs.
At 10 years the UKR group had better Oxford and WOMAC scores as well as significantly more excellent results (19:14) and fewer fair and poor results on the BKS. Both groups averaged over 105′ of flexion but 61% of the UKR and only 15% of the TKR group had 120′ or more of flexion.
The UKR group had better scores with Oxford: 38 v 34 /48 and WOMAC: 17 v 21 /60 and more excellent results (19 v 14) and fewer fair and poor results on the BKS (4 v 6). The range of movement improved in UKA`s from 107 degrees to 117 degrees, whereas the range decreased in TRK`s from 107 degrees to 104 degrees. Sixty-one percent of the UKR and only 16% of the TKR group had more than 120 degrees of flexion.
Traditionally midshaft clavicle fractures have been treated conservatively. It is recognized that displaced and shortened fractures may be better treated operatively. In particular, patients with greater than 20 mm of shortening and 100 percent displacement have a symptomatic non union rate of 30 percent. The standard technique used previously has been via plate fixation with LC-DCP or DCP. However in the last 5 years intramedullary fixation has been popularized. “Rockwood intramedulary clavicular pin” remedies the past treatment issues including poor blood supply, painful prominent hardware and stress raiser related to removal of metal work.
The aim of the study was to determine the effects of 0 Ticron suture soaked in polyhydroxybutyrate (PHB) on the histological and mechanical properties of healing meniscal tears in the red-white zone in an established animal model.
To determine whether the Dynamic Condylar Screw, DCS, is suitable in treating pathological subtrochanteric fractures of the femur and the incidence of failure with this device. Nineteen sequential and unselected patients with twenty femurs with pathological subtrochanteric fractures, or impending fractures, were identified, which had been treated with DCS. Mean age was seventy. Follow up was until functional union (minimum follow up 18 months) or until death. Primary tumour was identified in seventeen of the nineteen cases. Grade of surgeon was recorded as was the use of adjunctive measures at the time of surgery (PMMA). Subsequent failure, cause and need for revision was noted. Operative morbidity was low and initial pain relief good in all cases. Two fractures went on to unite. Eight original implants survived until the patient died (mean survival time 24 days). Ten implants failed (50%). Failure resulted from fracture through the DCS plate in eight cases and cut out of the screw in the other two. Of these, five patients (6 femurs) went on to further operative procedures. The others were either deemed unfit (3 cases) or refused further surgery (1 case). In the light of newer intramedullary techniques we feel the DCS should be used with caution in this type of fracture. DCS in this fracture is associated with a high degree of failure.
Surgeons often protect Tendon-bone reconstructions such as rotator cuff repairs by off loading them. We investigated the effect of limb position and boundary conditions in an in-vitro rabbit patella tendon-bone repair model. Patella tendons were repaired back to the tibia in eight hindlimb cadavers with 2 mitek anchors(Mitek, Westwood, MA) and 3-0 Ethibond (Ethicon, Sommerville, NJ) using two techniques, one involving simple sutures and the other involving crossing over between the sutures. A loading mechanism through the patella tendon was constructed using static weights over a pulley mechanism. The contact area and force at the PT-bone interface were measured using a TekScan pressure sensor (6911, TekScan, South Boston, MA). The contact footprint (area and normal force) was acquired under four configurations: (1) knee full extension with interface unloaded, (2) knee 45° flexion with interface unloaded, (3) knee full flexion with interface loaded by limb weight alone, (4) tendon loaded with limb weight and 20N force applied through tendon loading mechanism. The contact area force footprint changed substantially between the different suture techniques and loading configurations. Crossing over of sutures appears to provide an increased and more evenly distributed force across the tendon-bone interface. Repair off-loading was accompanied by a decrease in the contact footprint force and pressure. The force in both suture techniques increased with increasing flexion angle and was substantially increased by both bearing the weight of the dependent limb and by an axial load in the patellar tendon. Off loading a repair may not provide optimal environment for healing.
In Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) the total blood loss is composed of ‘visible’ blood loss from the surgical field and wound drainage, and blood loss into the tissues which is ‘hidden’. Blood management should be aimed at addressing the total blood loss. 56 TKAs and 46 THAs were prospectively studied. TKAs were performed with tourniquet. After tourniquet release, all drained blood was salvaged and significant volumes reinfused. No reinfusion was used for THAs. The true total blood loss was calculated in the following way: Patient Blood Volume (PBV) is: [1] PBV = k1 x height3 + k2 x weight + k3 Therefore patient total Red Blood Cell volume (RBCv) is: RBCv = PBV x Hct. (where Hct is Haematocrit) Total RBCv loss = PBV x (Hct preop – Hct postop) + ml RBC transfused The result is reconverted to Whole Blood volume. Hidden Loss = Total Loss – Visible Loss. In TKA, the mean total true blood loss was 1474ml. The mean hidden loss was 735ml. Therefore hidden loss is 50% of the total loss and the total true loss following TKA is twice the visible volume. In THA, the mean total true blood loss was 1629ml. The mean hidden loss was 343ml. Thus hidden loss in THA is much smaller. (21%) Total loss is 1.3 times the visible loss. In the TKA group, comparing patients with large losses receiving reinfusion and those with small losses not receiving reinfusion, the proportion of total true loss which was hidden was the same, at 50%. Patients with Body Mass Index (BMI) >
30 were compared with those with a BMI <
30 and no correlation was found between BMI and Hidden Loss. Joint Replacement Surgery involves a ‘hidden’ blood loss which is not revealed and cannot be measured or reinfused in practice, but which should be taken into account when planning blood loss management. In TKA it is substantial. In THA it is much smaller and probably not of as much clinical concern. Hidden loss is no greater in the Obese patient.
At 10 years the cumulative survival rate was 83% and at 15 years 78% (10 knees at risk). The “worst case scenario” where knees with pain or lost to follow up are added to revisions shows a 10 year survivorship of 74%.
Horse riding is a common pursuit and is more dangerous than believed. Most injuries of the hand and wrist are caused by falls, as in other sports. However, exclusive to riding are injuries sustained whilst leading a horse. Avulsion injuries are well recognised but little has been reported on phalangeal fractures in this situation. We report on seven cases that required hospitalisation in our hand unit, for injuries from horses over a two year period. Six of these patients sustained multi-fragmented spiral periarticular fractures involving the middle and proximal phalanx and one a horse bit. We will discuss in detail the mechanism of their injuries, the surgery undertaken, their post-operative rehabilitation and overall outcome. Furthermore we review the recommended horse handling technique and contrast it with the mechanism of injury in our cases. In our experience the fractures seen were unstable, comminuted and needed internal fixation. One patient developed a delayed union and three post-operative stiffness. Our results suggest that fractures whilst leading horses are more complex than recognised, usually need surgery and often have a relatively poor outcome. All of these cases were largely preventable and could be attributed to incorrect horse leading technique.
Previous clinical studies have studied tibiofibular torsion by measuring the angular difference between a proximal (often bicondylar) plane and a distal bimalleolar plane. We measured the angular difference between the proximal and distal posterior tibial planes as defined by ultrasound scans. We found no significant torsional difference between the right and left tibiae of 87 normal children, nor between their different age groups. The mean external torsion of 58 legs with congenital talipes equinovarus was 18 degrees; significantly less than the mean 40 degrees in the normal children and 27 degrees in the clinically normal legs of the 22 patients with unilateral congenital talipes equinovarus. We did not confirm the previously reported increase in external torsion with increasing age. The relative internal tibial torsion we have demonstrated in patients with congenital talipes equinovarus must be differentiated from the posterior displacement of the distal fibula observed by others and which may result from manipulative treatment. The relative internal tibial torsion we found in the clinically normal legs of children with congenital talipes equinovarus is further evidence that in this condition the pathology is not confined to the clinically affected foot.
The parameters of cellular proliferation and growth in the growth plates of immature rats were measured after unilateral tibial osteotomy and used to calculate growth rates. Distal osteotomy of one tibia was followed by a bilateral increase in the calculated growth rate of the distal growth plates. However, the ipsilateral distal growth plate grew faster than the contralateral between 12 and 18 days after operation, which appeared to be related to increased cell proliferation and height. Proximal osteotomy led to an increase in growth rates proximally which was more marked on the contralateral side. The lesser response of the ipsilateral growth plate may have been due to local impairment of blood supply, or to greater local release of metabolites after bony damage. Distal tibial osteotomy gave similar results to circumferential release of the distal tibial periosteum. Proximal osteotomy, however, produced a relative impairment of growth on the operated side. This may be of importance in the correction of childhood deformities associated with inequality of leg length.