Dynamic Hip Screw (DHS) is the most frequently used implant in management of intertrochanteric femoral fractures. There is a known statistical relationship between a tip-apex distance (TAD) >25mm and higher rate of implant failure. Our aim was to analyse all DHS procedures performed in our trust from seventeen months and compare their TAD values to the acceptable standard of ≤25mm. All patients undergoing DHS between April 2020-August 2021 were identified from our theatre system. Additionally, those presenting to hospital with implant failures were included. Patient demographics, date of surgery, fracture classification (AO) and date/mode of failure were recorded. Intraoperative fluoroscopy images were reviewed to calculate TAD, screw location and neck shaft angles by two independent observers.Background
Methods
We investigated whether an alternative tension band wire technique will produce greater compression and less displacement at olecranon (elbow) fracture sites compared to a standard figure of eight tension band technique. Olecranon fractures are commonly treated with tension band wiring using stainless steel wire in a figure of eight configuration. However recently published studies have raised doubts over the validity of the tension band concept proving that the standard figure of eight configuration does not provide fracture compression when the elbow is flexed. We propose an alternative tension band technique where the figure of eight is applied in a modified configuration producing greater compression across the fracture. An artificial elbow joint was simulated using artificial forearm (ulna) and arm (humerus) bones. The design simulated the action of the muscles around the elbow joint to produce flexion and extension. There were two arms to this investigation. (1) Standard tension band wire configuration with stainless steel. (2) Modified tension band wire configuration with stainless steel. The simulated elbow was put through a range of movement and sensors measured the compression at the articular and non-articluar surfaces of the fracture. Measurements were taken for compression with different weights applied to challenge both the techniques of tension band wiring. Measurements from the non articular surface of the fracture demonstrated greater compression with alternative tension band technique. However it was not statistically significant (ANOVA). Compression at the articular surface of the fracture exhibited statistically significant (p<0.05) greater compression with the alternative technique. Neither technique produced greater compression during flexion of the simulated elbow. The alternative tension band wiring technique proved superior in providing greater compression over the fracture site.
Most arthroscopies are conventionally done using a 30-degree scope (30DS), which gives good field of view. This is used both for diagnostic and therapeutic procedures. For certain procedures 70-degree scopes (70DS) are used where visualisation with a conventional 30DS is insufficient and an increased field of view is required around corners. There have been studies done in past which have compared field of view of a 30DS and a 70DS. There has been no study so far that has compared blind spot created directly in front of a 30DS and 70DS. The aim of this study was to determine and compare blind spot created while doing arthroscopy using a 30DS and a 70DS. A small box with a cannula at one end held firmly using plaster of Paris in horizontal position was made. This box was used to help hold 30DS and 70DS firmly in position while doing calculations. A scale was positioned on front of the scope to calculate the size of blind spot created at various distances. The 30DS and 70DS scopes were placed directly in contact with the scale at 0mm to start and markings on scale were used to calculate the diameter of blind spot created at various distances by moving the scopes at 5mm increment. Our study shows that with a 30DS there is no blind spot in the front. With a 70DS there is a significant blind spot that increases in size linearly as the distance of scope increases from the object in vision. It goes up to 4.4cm in diameter when the 70DS is at a distance of 5cm. The 70DS however provides a very wide field of vision was compared to 30DS. A 70DS provides a very large field of view and gives excellent visualization of structures around corners, but also has a significant blind spot directly in front of the scope tip which can be as large as 4.4cm at a distance of 5cm from the object in vision. Knowledge of this will help surgeons while using a 70DS and help avoid any missed pathology.
Current perception is that standard Cefuroxime only [C4] based prophylaxis regimen demonstrated higher association with C Difficile (C. Diff) diarrhoea. This has prompted change in antibiotics prophylaxis combination regimens like Flucloxacillin-Gentamycin (F-G], Teicoplanin- Gentamycin [T-G] and single dose Cefuroxime-Gentamycin [C-G]. The current study was done to investigate the association of C. Diff diarrhoea and surgical site infection (SSI) rate with Cefuroxime only regimen prophylaxis in fracture neck of femur surgery. A retrospective analysis for 2009–2012 was performed for 1502 neck of femur fracture patients undergoing surgery. The factors studied were ASA grade, SSI, C. Diff diarrhoea rates in patients with Cefuroxime (induction plus two doses) based prophylactic regimen. The data was obtained from coding department and further streamlined based on microbiology. 1242 patients were included in the study who received Cefuroxime only regimen. The Male : Female distribution was 353 : 889. The average ASA grade was 3. The analysis demonstrated that C. Diff diarrhoea rate in the study population was 1.29%. The SSI rate stood at 3.06% with superficial infection at 2.5 % and deep at 0.56 %. Our single centre based study demonstrated low C. Difficile related diarrhoea rates with Cefuroxime only regimen. The SSI rates were also low as compared to the current literature thus concluding that Cefuroxime only antibiotic regimen can safely be administered in neck of femur surgery.
TER is a viable surgical option in patients with advanced RA with painful stiff elbows. We retrospectively analysed 22 TER performed in 21 patients over a 12 year period by a single surgeon, with a mean follow up of 64 months (10–145). Disability of the arm, shoulder and hand (DASH) scores were performed pre-operatively and post-operatively in patients through postal questionnaires. The mean age was 59.1 years (32–78). There were 12 women and 9 men. The mean pre-operative DASH score was 72.3 (45.0–91.7) and post-operatively improved to 46.8 (21.7–94.2). Complications included infection, peri-operative fracture, peri-prosthetic fracture and aseptic loosening. There were 6 revisions performed, 2 for peri-prosthetic fracture, 2 for infection, 1 for intra-operative fracture and 1 for symptomatic aseptic loosening. Four patients had died due to unrelated causes. The 10 year survival rate with symptomatic aseptic loosening as the end point was 93% and revisions for all reasons was 69%. Follow up radiographs (in those without revision) were reviewed and 10 had satisfactory positioning of the prosthesis, 5 had loosening of the humeral or radial component and 1 had inadequate cement mantle but was clinically asymptomatic. TER is a rewarding procedure in with advanced RA. Our results are comparable to other published studies.
We retrospectively analysed a single surgeon series of 22 TER in 21 patients over a 12 year period. The mean age and follow up was 59.1 years and 64 months respectively. DASH scores assessed pre and post op confirmed a significant improvement. Complications included infection, intra-operative fracture, peri-prosthetic fracture and aseptic loosening. 6 revisions were performed for various reasons.4 patients had died due to unrelated causes. The 10 year survival rate with symptomatic aseptic loosening as the end point was 93%. 5 patients had radiological loosening but were clinically asymptomatic. TER is a rewarding procedure in with advanced RA.
We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity of the ankle. 11 consecutive patients (13 ankles) fulfilled the inclusion criteria over a 4-year period. All underwent surgical treatment using a flexible two hole plate and screws on the posterior aspect of distal tibial physis. Measurements were done on preoperative, intraoperative screening and 1-year post operative plain AP and lateral ankle radiographs. The anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA) and screw divergence angle (angle subtended by lines passing through the long axis of the screws) were used to assess the deformity correction. A 2 tailed student t-test was carried out on the initial and 1-year post-op measurements to determine statistical significance with a p value <0.05 considered as significant There were 10 residual clubfoot deformities, 2 post-traumatic deformities and 1 spinal tumor causing deformity. The average age of the patients was 10 years 5 months (range 4 to 13 years). There were 9 males and 2 females. The ADTA showed a statistically significant change with a p value of 0.0008 with a mean correction of 8.6 degrees (range of 2.3 to 15.6 degrees). The SDA demonstrated a mean correction of 15.4 degrees (range 0.3 to 41.8 degrees), p=0.002. The LDTA did not change significantly (p= 0.08), thus confirming no coincidental coronal plane deformity had occurred. 5 ankles required revision of fixation due to metalwork reaching its maximum limit of divergence at an average of 1 year. 2 ankles had screw pulled out due to osteolysis around the screw. There were no cases of infection. We report satisfactory short-term results of correction of calcaneus deformity using a flexible tension band plate and screws system.
The issues surrounding raised levels of metal
ions in the blood following large head metal-on-metal total hip replacement
(THR), such as cobalt and chromium, have been well documented. Despite
the national popularity of uncemented metal-on-polyethylene (MoP)
THR using a large-diameter femoral head, few papers have reported
the levels of metal ions in the blood following this combination.
Following an isolated failure of a 44 mm Trident–Accolade uncemented
THR associated with severe wear between the femoral head and the
trunnion in the presence of markedly elevated levels of cobalt ions
in the blood, we investigated the relationship between modular femoral head
diameter and the levels of cobalt and chromium ions in the blood
following this THR. A total of 69 patients received an uncemented Trident–Accolade
MoP THR in 2009. Of these, 43 patients (23 men and 20 women, mean
age 67.0 years) were recruited and had levels of cobalt and chromium
ions in the blood measured between May and June 2012. The patients
were then divided into three groups according to the diameter of
the femoral head used: 12 patients in the 28 mm group (controls),
18 patients in the 36 mm group and 13 patients in the 40 mm group.
A total of four patients had identical bilateral prostheses in situ
at phlebotomy: one each in the 28 mm and 36 mm groups and two in
the 40 mm group. There was a significant increase in the mean levels of cobalt
ions in the blood in those with a 36 mm diameter femoral head compared
with those with a 28 mm diameter head (p = 0.013). The levels of
cobalt ions in the blood were raised in those with a 40 mm diameter
head but there was no statistically significant difference between
this group and the control group (p = 0.152). The levels of chromium
ions in the blood were normal in all patients. The clinical significance of this finding is unclear, but we
have stopped using femoral heads with a diameter of ≤ 36 mm, and
await further larger studies to clarify whether, for instance, this
issue particularly affects this combination of components. Cite this article:
The Delta total shoulder replacement is a reversed, semi-constrained prosthesis and is recommended for the management of rotator cuff arthropathy and other difficult reconstructive shoulder problems. It was initially advised to use this prosthesis in patients older than 75. There were reports saying the complication rates of this prosthesis are high and patients' satisfaction and functional outcome is far from being satisfactory. In our study we wanted to evaluate results and complications of reverse shoulder arthroplasty in practice of single surgeon. In our study we reviewed patients who had reverse shoulder arthroplasty performed between 2001 and 2009. We evaluated them clinically and radiologically. We measured functional outcome using Constant score, we used Oxford Shoulder score to measure patients' subjective outcome. We compared our results to pre-operative Oxford Shoulder score (unfortunately no pre-op constant score was done). X-rays were assessed by independent surgeon who was not involved in care of the patients. Out of 36 reverse shoulder replacements performed by Mr. Sinha from 2001 to 2009 we managed to review in clinic 29 shoulders. 3 patients died from causes not related to surgery, 3 patients were too unwell to attend clinic, we lost 1 patient to follow up. Mean time from operation to follow up was 33 months (range 6 to 82 months). Average patients' age at time of surgery was 73,4 years (range: 44 to 90). Indications included rotator cuff arthropathy (86%), other indications were trauma (10%) and revision of failed hemiarthroplasty (4%). There were neither revisions nor infections in our group. There was 1 dislocation that occurred after operation, this was reduced under GA and never re-dislocated again. 12 patients (41%) were very pleased with result of surgery, 15 patients (52%) were satisfied and 2 patients said surgery did not meet their expectations. Mean Shoulder Oxford score improved from 20.8 (range 2 to 36) pre-operatively to 36.7 (range 20 to 48) during follow up. 3 patients had Oxford Shoulder score of 48 (maximum). Oxford shoulder score deteriorated in 2 cases (one in case when replacement was done to treat fracture). Post operative Constant score was 65.5. All patients but one declared overall improvement. 10 patients (34%) reported no pain at all. 5 patients who were 65 years old or younger at time of surgery did well and improved their shoulder function. In our experience reverse geometry shoulder replacement is a very good solution for rotator cuff arthropathy. Results in proximal humeral fracture are worse, but the number of patients we had was small and our experience is limited. Mid term results are very satisfactory overall, even in younger and more demanding patients. The complications were rare and overall patients' satisfaction very high. We think more research needs to be done to asses long term results, especially in younger population.
Deep vein thrombosis (DVT) in shoulder operations is rare although a few case reports exist. No definite guidelines exist and therefore it is difficult for the surgeon to decide on thromboprophylaxis. We prospectively evaluated the incidence of DVT following arthroscopic shoulder sub acromial decompression in 72 patients after obtaining local ethics committee approval. Patients with previous history of DVT and those on anticoagulants were excluded from the study. Pre and post-operative Doppler scans on 4 limbs were performed by a single consultant radiologist at an average of 3 weeks. All operations were performed by a single surgeon under GA in beach chair position as a day case procedure on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. No patient received any DVT prophylaxis. The average age of 54.6 years, 47 were classified as ASA 1, 15 as ASA 2 and 10 ASA 3.58 patients had additional interscalene nerve blocks for pain relief. The average operating time was 43 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVTs on Doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients.
Handgrip dynamometry has previously been used to detect pre - operative malnutrition and predict the likelihood of post - operative complications. This study explored whether a relationship exists between pre-operative pinch and power grip strength and length of hospital stay in patients undergoing hip and knee arthroplasty. We investigated whether handgrip dynamometry could be used pre - operatively to identify patients at greater risk of longer inpatient stays. 164 patients (64 male, 100 female) due to undergo lower limb arthroplasty (83 Total Knee Replacement, 81 Total Hip Replacement) were assessed in pre - admission clinic. Average measurements of pinch grip and power grip were taken from each patient using the Jamar hydraulic dynamometer (Jamar, USA). Duration of each inpatient stay was recorded. Patients with painful or disabling conditions involving the upper limb were excluded. Other clinical variables such as age and ASA grade were investigated as potential confounders of the relationship of interest and adjusted for.Purpose
Methods
We obtained approval from the local research and ethics committee and prospectively evaluated the incidence of Deep vein thrombosis (DVT) in arthroscopic shoulder sub acromial decompression in 72 patients. All patients were assessed clinically for DVT risks as per the established guidelines. Patients with previous history of DVT, those on anticoagulants and those positive for DVT on pre op scans were excluded from the study. All patients had doppler scans on 4 limbs performed by a single consultant radiologist at an average of 4 weeks pre and post operative period. All operations were performed by a single surgeon under GA in beach chair position with routine precautions for DVT, as a day case procedure. Arthroscopy and additional procedures were performed on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. Demographic data, co-morbidities, patient position, ASA risk, nerve blocks, surgery duration, medications, intra operative findings, were documented. No patient received any DVT prophylaxis. All patients were available for followup and clinical and doppler findings were documented at an average 4 week period. 3 patients had bilateral procedures. There were 38 female and 34 male patients with an average age of 54.6 years. 47 were classified as ASA1, 15 as ASA2 and 10 ASA 3. Common co morbidities included hypertension, diabetes, acid peptic disease in 34 patients. 37 patients had additional interscalene nerve blocks for pain relief. The average operating time was 52 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVT's on all doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients.
Leg length inequality following total hip replacement remains common. In an effort to reduce this occurrence, surgeons undertake pre-operative templating and use various forms of intra-operative measurements, including computer navigation. This study aims to delineate which measurement technique is most appropriate for measuring leg length inequality from a pelvic radiograph. Three observers took a total of 9600 measurements from 100 pelvic radiographs. Four lines were constructed on each of the radiographs, bisecting the acetabular teardrops (Methods 1/2), ishial spines (Method 3/4), inferior sacroiliac joint (Method 5/6) and inferior obturator foramen (Method 7/8). Measurements were taken from these lines to the midpoint on the LT and to the tip of the GT. The effect of pelvic positioning was also assessed using radiographs of a synthetic pelvis and femur using the same eight methods by a single observer (ED). Intra-observer variability was analysed using within subject standard deviation. Inter-observer variability was analysed using the coefficient of inter-observer variability (CIV).Aims
Method
This clinical study was performed to establish the prevalence of deep vein thrombosis and pulmonary embolism after shoulder surgery. The incidence of VTE complicating shoulder surgery is poorly described in literature. We reviewed retrospectively clinical records of all patients who had any surgical procedure performed on their shoulder between 2001 and 2009.‘Patients’ records were assessed for any admissions due to proven VTE; we looked for any radiological results suggestive of venous thromboembolism.Background
Methods
Plantar fasciitis is a frequently chronic and disabling cause of foot pain in adults. This prospective study aims to evaluate the analgesic effect of ultrasound guided dry needling in patients with chronic plantar fasciitis, refractory to conservative treatment. Patients undergoing dry needling for plantar fasciitis, followed by perifascial injection between Jan ′09 and Feb ′10 were identified. Pain scores were recorded on a visual analogue scale from 0 (no pain) to 10 (worst pain possible) before the procedure, 2 weeks and 6 weeks post procedure. Patients were also contacted in April to assess their current pain level. Responses were graded as excellent (> 75% pain score improvement), good (50-74%), fair (25-49%) and poor (<25% relief). Any complications or need for any further intervention were recorded.Background
Method and Materials
This clinical study was performed to establish the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after shoulder surgery. The incidence of venous thrombo-embolism complicating shoulder surgery is poorly described in literature. As VTE is a potentially fatal condition we wanted to make surgeons aware of the problem and to try to establish any risk factors contributing to it. We reviewed retrospectively clinical records of all patients who had any procedure performed on their shoulder between 2001 and 2009 in our institution. In operating theatre coding database we identified 920 patients. Their records were assessed for any admissions due to proven DVT or PE; we looked for any radiological results suggestive of or confirming venous thromboembolism. We identified 920 patients who had surgical procedure under GA on their shoulder. 126 patients had shoulder arthroplasty, other procedures commonly undertaken were: subacromial decompression, shoulder stabilization and shoulder manipulations. There was 1 fatal PE in this group – patient died within 48 hours following total shoulder replacement, post mortem revealed massive pulmonary embolism with no sing of neither upper nor lower limb DVT. There were 3 cases of symptomatic DVT confirmed by USS Doppler. No upper limb symptomatic DVT was identified. There were 7 patients who had negative tests for suspected thrombosis (2 negative tests for suspected PE, 5 negative tests for suspected DVT). There is very limited evidence in literature on VTE following upper limb surgery. Recent studies suggest that DVT incidence following arthroplasty is as high as 13%, with further 3% incidence of PE. In our study we examined occurrence of symptomatic VTE only. According to our results the incidence of symptomatic DVT following shoulder surgery is about 0.35% and symptomatic PE about 0.1 %. We did not manage to show any risk factors associated strongly with post operative DVT in our group. The prevalence of asymptomatic VTE is probably much higher and further research needs to be undertaken in that area. On base of our experience we would not recommend routine anticoagulation as a DVT prophylactic after shoulder surgery unless there are additional risk factors.
We compared cancellation rates with two different systems for operating booking. During 9 months of ‘Full Booking’ we gave each patient in the Outpatient Clinic an operating date. After a transition period, we then tried ‘Partial Booking’ (putting each patient on the waiting list and only giving dates after a Consultant-delivered Pre-Assessment Clinic (PAC) review at least 6 weeks before their target operating date.) This was one Consultant's firm, with Day Cases and urgent cases excluded, and a waiting time of nine months. Cancellations were defined as an operating date given that was not honoured. Cancellations due to bed crises were excluded. During the Full Booking phase there was a cancellation rate of 55%, with 64 cancellations out of a potential 116 operating slots. Of these: 29% condition improved, 22% date inconvenient, 19% unwell, 5% gone elsewhere/Private, 9% were moved due to Consultant leave dates, 3% Did Not Attend, and 12.5% date brought forward to fill a cancellation slot. During the Partial Booking phase, 23% of patients attending the PAC were removed from the waiting list without ever being given operating dates. (17 of 132 did not want the operation, 7 Did Not Attend, 6 were unfit). Of the 94 patients given dates, only 8 cancelled (8%). Four subsequently decided against surgery, and four had tests that suggested surgery would not be helpful. The improved efficiency could be due to PAC changes: Consultant presence, having six weeks to act on test results, and dates being agreed only after ‘passing’ PAC. Partial Booking had other benefits, with fewer queries, better informed consent and the optimum time to plan teaching lists, order kit and improve patients' fitness. The Government is still committed to Full Booking. Our cancellation rate improved from 55% to 8% when changing from Full Booking to Partial Booking.
This study investigated the anatomical relationship between the clavicle and its adjacent vascular structures, in order to define safe zones, in terms of distance and direction, for drilling of the clavicle during osteosynthesis using a plate and screws following a fracture. We used reconstructed three-dimensional CT arteriograms of the head, neck and shoulder region. The results have enabled us to divide the clavicle into three zones based on the proximity and relationship of the vascular structures adjacent to it. The results show that at the medial end of the clavicle the subclavian vessels are situated behind it, with the vein intimately related to it. In some scans the vein was opposed to the posterior cortex of the clavicle. At the middle one-third of the clavicle the artery and vein are a mean of 17.02 mm (5.4 to 26.8) and 12.45 mm (5 to 26.1) from the clavicle, respectively, and at a mean angle of 50° (12 to 80) and 70° (38 to 100), respectively, to the horizontal. At the lateral end of the clavicle the artery and vein are at mean distances of 63.4 mm (46.8 to 96.5) and 75.67 mm (50 to 109), respectively. An appreciation of the information gathered from this study will help minimise the risk of inadvertent iatrogenic vascular injury during plating of the clavicle.
Mortality after hip fractures in the elderly is one of the most important patient outcome measures. Sub-clinical thyroid dysfunction is common in the elderly population. This is a prospective study of 131 elderly patients with a mean (SD) age of 82.0 (8.9) years (range: 61–94) admitted consecutively to our trauma unit. The aim of the study was to determine the prevalence of sub-clinical thyroid dysfunction in an elderly cohort of patients with hip fracture and to determine if this affects the one year mortality. There were three times more women (n=100) than men (n=31) in this cohort. All patients underwent surgical treatment for the hip fracture. The prevalence of sub-clinical hypothyroidism (TSH >
5.5 mU/L) was15% (n=20) and of sub-clinical hyperthyroidism (TSH <
0.35 mU/L) was 3% (n=4). Overall 18% (n=24) of patients had a subclinical thyroid dysfunction. The twelve month mortality was 27% (n=36). Age, gender, heart rate at admission, pre-existing Coronary Heart Disease, ASA grade and presence of overt or subclinical thyroid dysfunction were analysed for association with twelve month mortality using a forward stepwise logistic regression analysis. Only ASA grade was found to significantly affect mortality at twelve months ( We conclude that sub-clinical thyroid dysfunction does not affect the one year mortality in elderly patients treated surgically for hip fracture.
We conducted a study comparing the midterm outcome of the Medial Pivot knee (MP) to the Posterior Stabilised (PS) knee.
Clostridium difficile associated diarrhoea (CDAD) has emerged as a healthcare associated infection of great clinical and economic significance especially in the frail and vulnerable group of fracture neck of femur patients. A major risk factor for the development of CDAD in patients who undergo operation for fracture neck of femur is the perioperative antibiotic exposure, with cephalosporins being particularly implicated. The type ‘027’ strains of C. Difficile are multi-resistant and cause severe morbidity and mortality. A retrospective audit was performed to study the effect of C. Difficile infection in operated fracture neck of femur patients.
We present the results of prospective evaluation of digital compared to plain radiographic pre-operative templating for primary total knee replacement. All consecutive patients undergoing primary knee replacement under the senior author (AS) were eligible. Patients with previous knee replacement or without calibrated digital or plain radiographs were excluded. Plain radiographs were templated against acetate templates supplied by the manufacturer. Digital images were templated with the help of commercial software TraumaCad. A 25mm spherical metal ball placed nearest to the affected knee joint acted as calibration object. AS performed all the templating. The ICC value for intra-rater reliability was 0.846 for tibial templating and 0.840 for femoral templating. PFC sigma cruciate substituting components were implanted in all patients. 28 consecutive patients between April 2006 and June 2007 were included. Accurate digital templating score was 80% for tibial implant and 40% for femur. Accuracy of analog templating was 55% for tibial implant and 50% for femur. There was no mismatch of over one size. The differences between templated and implanted sizes were plotted against their mean in Bland-Altman plot. The 95% confidence interval of the differences between digital and actual sizes were: 0.78 to − 0.75 sizes for tibial implant and 1.15 to −0.93 sizes for femoral implant. The 95% confidence interval of the differences between plain and actual sizes were: 0.38 to −0.99 size for tibial implant and 0.93 to −1.32 size for femoral implant. The two tailed P value for difference between digital and analog templating from a Wilcoxon matched pair signed rank test was 0.021 for tibia and 0.006 for femur. We found preoperative templating by the operating surgeon reliable and accurate but digital templating did not offer any additional advantage.
Clinical decision-making could be difficult when Magnetic resonance imaging (MRI) is used for the diagnosis of knee injuries. We retrospectively studied 565 knee arthroscopies done between 2002 and 2005, 110 of which had suspected ligamentous injuries, evaluated clinically, with MRI and subsequently by arthroscopy. The aim of the study was to know the extent of correlation of clinical, MRI features with arthroscopy and whether MRI could be justifiably used to deny an arthroscopy. All patients with a strongly suggestive history were examined in the clinic by experienced orthopaedic surgeons and MRI was requested. Clinical examination was repeated under anaesthesia by the operating surgeon who not necessarily had examined the patient initially. The clinical and arthroscopy findings were recorded systematically. 3 Radiology consultants of varying musculoskeletal experience reported the MRI films. The clinical and MRI findings were compared with arthroscopy for the extent of correlation. We observed that overall Sensitivity of MRI for meniscal injuries was 73%, being more for medial than lateral and 86% for cruciate ligament injuries. Clinical examination had a sensitivity of 33% and a specificity of 93% for meniscal injuries, sensitivity of 86% and specificity of 100% for cruciate injuries. MRI was not able to demonstrate synovial plicae in 13 knees and chondral defects in 3 knees. 96 Knees, which were normal clinically, were found to have meniscal tears on MRI in 65 and subsequently confirmed by arthroscopy in 39. We conclude that an accurately performed clinical examination with positive signs alone, will be justified for arthroscopy and a negative MRI will not be a sufficient evidence to deny an arthroscopy. Also the reporting will largely depend on the quality of information provided by the clinician, technical factors and the musculoskeletal experience of the person reporting the films.
Displaced comminuted intra-and extra-articular fractures of distal radius require anatomical reduction for optimum results. To assess clinical, functional and radiological results of volar-ulnar tension band plating of dorsally displaced comminuted fractures of distal radius, we used volar-ulnar tension band plating technique (without bone grafting) and early mobilisation to treat dorsally displaced and comminuted fractures of distal radius in 47 patients with an average age of 48 years (range, 19–76 years). Volar tilt, radial height, ulnar inclination and volar cortical angles were measured on the unaffected side. AO volar plate was pre-contoured to match the volar cortical angle of the unaffected side. The horizontal arm of the plate was fixed to the distal fragment first. When the longitudinal arm of the plate was brought onto the radial shaft, the displaced distal fragment was levered out anteriorly to restore the normal volar tilt. Adjustment in ulnar inclination and radial height can be made by medio-lateral and cephalo-caudal movement of the longitudinal arm of the plate. The average follow-up was 26 months (range 12–41 months). According to Gartland and Werley’s system 25 patients had excellent, 15 had good, 7 had fair functional results. The median Disability of Arm, Shoulder and Hand (DASH) score was 10 (range 0–60). Average grip strength as percentage of the unaffected side was 80 %. Average Palmarflexion was 61 degrees, Dorsiflexion 66 degrees, Ulnar deviation 34 degrees, Radial deviation 19 degrees, Supination 74 degrees and Pronation 80 degrees. According to Lidstrom and Frykman’s radiological scoring system 39 patients had excellent and 8 had good anatomical results.
The aim of this study was to evaluate whether duration of surgery correlates with the survival and final outcome of the patient with metastatic bone disease. Between 1999 and 2002, 23 consecutive patients with impending or complete pathological fractures of the femur due to metastatic bone disease caused by variety of malignancies or an unknown primary were reviewed. These fractures were treated with intramedullary fixation in the form of long intramedullary hip screw, long Gamma nail or AO nail. These patients were followed up clinically and radiologically until death from the primary disease. The results obtained demonstrate a mean survival time between 9 days to 12 months. Pain relief was achieved in 90% patients. Ambulatory status was improved in 47% patients. The postoperative course was complicated by four technical and five systemic complications. Intramedullary nailing is a safe and effective method in the treatment of metastatic bone disease. It provides good functional result with pain relief and improved mobility. The operating time does not predictably correlate with the survival and final outcome of the patient.
Breast carcinoma is the most common cause for bony metastases. Skeletal complications in women with meta-static breast carcinoma often occur multiple times in a single patient and significantly contribute to the patient morbidity. We describe a 62 year old lady with a known metastatic breast carcinoma who presented with simultaneous quadruple extremity diaphyseal long bone fractures after a trivial fall. To the author’s best knowledge, similar report has never been previously described in the literature. The wish and general condition of the patient, and concurrent occurrence of four long bone fractures dictated the non-operative mode of treatment in this case.Where the life expectancy is assumed to be less than six weeks, the multidisciplinary team should give careful consideration on selection of best treatment choice between simultaneous or sequential surgical fixation of multiple long bone fractures and conservative palliative treatment. With treatment suited for an end-of-life circumstance, the educational lesson for dissemination to the readers is that in a patient where there is an extremely high likelihood of imminent perioperative mortality after sustaining quadruple extremity diaphyseal proximal long bone fractures simultaneously, conservative palliative treatment should be primarily considered over an aggressive operative fixation.
Volar tilt, radial height, ulnar inclination and volar cortical angles were measured on the unaffected side. AO volar plate was pre-contoured to match the volar cortical angle of the unaffected side. Horizontal arm of the plate was þxed to distal fragment þrst. When the longitudinal arm of the plate was brought onto the radial shaft, the displaced distal fragment was levered out anteriorly to restore the normal volar tilt, ulnar inclination and radial height.
Debate continues about the origin of Dupuytren’s disease, which is usually in the palm but is seen elsewhere as ectopic lesions. We describe a young patient with Dupuytren’s disease extending proximal to the wrist crease in continuity with the palmar lesion. Our findings support the view that the condition starts within the palmar connective tissue, but there is no palmar aponeurosis in the forearm and the proximal extension probably started in the deep layer of the superficial fascia.