Background

Dual compartment knee replacement has been introduced to allow sparing of the cruciate ligaments and lateral compartment and preserve some biomechanics of knee function.

Recently biodegradable synthetic scaffolds (Trufit plug) have provided novel approach to the management of chondral and osteochondral lesions. The aim of this study was to assess our 2 year experience with the Trufit plug system.

22 patients aged 20 to 50 years old all presenting with knee pain over a 2 year period were diagnosed either by MRI or arthroscopically with an isolated chondral or osteochondral lesion and proceeded to either arthroscopic or mini arthrotomy Trufit plug implantation. In 5 patients plug implantation was undertaken along with ACL reconstruction (3), medial meniscal repair (1) and contralateral knee OCD screw fixation (1). Pre and post operative IKDC scores were obtained to assess change in knee symptoms and function.

At a mean follow up of 15 months (range 2 – 24 months) improved IKDC scores were achieved with the scores improving with time. 2 patients have had a poor result and have had further surgery for their chondral lesions. One patient had failure of graft incorporation at second look arthroscopy and went onto to have a good result after ACI. The second patient had good graft incorporation on second look but had progression of osteoarthritic degeneration throughout the other compartments of the knee which were not initially identified at the time of Trufit plugging.

We conclude that Trufit plug is an alternative method for managing isolated chondral and osteochondral lesions of the knee which avoids harvest site morbidity or the need for staged surgery.

Involvement of Patellofemoral joint (PFJ) has significant bearing in the management of osteoarthritis of the knee. The aim of this study is to assess the relationship between skyline radiographs, MRI and arthroscopic findings in the patellofemoral joint.

Data was collected prospectively from fifty-three patients who underwent arthroscopy. There were 36 males and 17 females in the group with mean age of 48 years (range 18-71). Arthroscopically PFJ arthritis was classified based on Outerbridge grading system. Patients with Outerbridge grade III and IV lesions were considered to have significant arthritis of the PFJ. Kellgren-Lawrence grading system was used to assess the skyline radiographs. Radiographically patients with grade III and IV Kelgren-Lawrence changes were considered to have significant osteoarthritis of the PFJ. MRI scans were also studied to assess involvement of PFJ. Thirty-two patients had MRI scan and 20 patients had skyline views done as part of preoperative work up. Arthroscopic findings were considered as gold standard.

MRI scan had specificity of 75%, sensitivity of 81%, positive predictive value of (PPV) 77 and negative predictive value of (NPV) 80% in diagnosing significant PFJ arthritis. Skyline radiographs had specificity of 100%, sensitivity of 50%, PPV of 100% and NPV of 57%. The overall accuracy of skyline radiographs in predicting significant PFJ arthritis was 70% and for MRI was 78%. We conclude that skyline radiographs has some value in he diagnosis of PFJ arthritis, however the sensitivity and negative predictive value is very is poor.

Background

Fracture non-union is still a major challenge to the orthopaedic surgeon and established non-union has zero probability of achieving union without intervention.

The knowledge of actual extent of the fracture in cases of isolated greater trochanteric fractures has paramount importance in decision-making. MRI has been the most common investigation to detect the intertrochanteric extension. However, to date there is no plain radiographic or MRI criteria to decide which fractures need surgery and which could be managed non-operatively. The aim of our study-was to assess whether the angle and the extent of the greater trochanteric fracture measured on plain radiographs could be used to predict the intertrochanteric extension.

We reviewed plain radiographs of 23 patients with isolated greater trochanteric fractures who also had MRI scans. We considered two parameters

extent of fracture in percentage along the intertrochanteric line and

Out of 23 patients, MRI scans revealed intertrochanteric extension in eight and they underwent surgical stabilisation. All these eight fractures had a fracture angle of 45° or less and the percentage of fracture extent of > 40%. All the 15 fractures with a fracture angle of > 45° did not show intertrochanteric extension on MRI scan. The mean angle of the fracture in those with MRI proven intertrochanteric extension was 33.5° (range 20°–45°) and in those with no intertrochanteric extension was 55.7° (Range 25°–125°). The mean percentage of length of fracture across the intertrochanteric line was 61.1% (47%–73%) and 39.6% (27%–62%) respectively.

We conclude that those isolated greater trochanteric fractures, with a fracture angle of more than 45° are unlikely to have an intertrochanteric extension. Those fractures with an extent of more than 40% and fracture angle less than 45° are likely to show inter trochanteric extension.

Introduction: Isolated greater trochanter fractures gained clinical importance because of the possibility of their inter-trochanteric extension.

Aim: To assess whether the direction and the extent of the fracture measured on plain radiographs could be used to predict the inter-trochanteric extension.

Materials and Methods: We reviewed plain radiographs and MRI scans of 24 patients who sustained isolated greater trochanter fractures between year 2003 and 2006. We considered two parameters

extent of fracture in percentage along the intertrochanteric line

Both these parameters were measured on a plain anteroposterior radiograph. To measure the length of fracture we have drawn a straight line along the medial border of femoral shaft extending proximally in to the pelvis. Then we measured the distance between the most superior point of the fracture line on the lateral cortex and the midpoint of lesser trochanter on the first line. Then we measured the length of the fracture starting from the most superior point on the lateral cortex. We estimated the percentage of this fracture length in relation to line.

To estimate the angle, again we have drawn a straight line along the medial border of femoral shaft extending proximally in to the pelvis. We have drawn another line in the direction of fracture staring from most superior point of fracture on the lateral cortex joining the first line. We measured the angle between these two lines (Fig 2). We used our Hospital PACS system to measure the angles and the length of the fracture.

Results: Out of 24 isolated greater trochanteric fractures as diagnosed by plain radiographs, MRI scans revealed intertrochanteric extension in nine (37.5%). On the plain anteroposterior radiograph, the mean angle of the fracture in those with MRI proven intertrochanteric extension was 34º (range 20º–45º). In those with no intertrochanteric extension on MRI scan, the mean angle was 55º (Range 25º–125º). The mean percentage of length of fracture across the intertrochanteric line was 62% (47%–73%) and 40% (27%–62%) respectively. All the fractures with MRI proven intertrochanteric extension had a fracture angle of < 45º and the percentage of fracture length of > 40%. All the 15 fractures with fracture angle more than 45º did not show intertrochanteric extension on MRI scan

Conclusions: We conclude that those isolated greater trochanteric fractures, with fracture angle of more than 45 º are unlikely to have an intertrochanteric extension. These patients could be mobilised without further MRI scans. Those fractures which fulfil the plain radiographic criteria of extension of more than 40% and fracture angle between 20º–40º are likely to show inter trochanteric extension. These patients need further clinical assessment and MRI scans to confirm the intertrochanteric extension.

The aim of this study was to determine the accuracy of Magnetic Resonance Imaging (MRI) scanning compared to arthroscopic findings in patients presenting with chronic ankle pain and/or instability. We reviewed all patients who underwent arthroscopy of the ankle between December 2005 to July 2008 in our institution.

A total of 105 patients underwent arthroscopy for chronic ankle pain and/or instability. Twenty-four patients underwent MRI prior to the procedure. We compared the MRI findings with arthroscopic findings. We specifically examined for the anterior talofibular ligament (ATFL), calcaneofibular cigament (CFL) and osteochondral lesions(OCD). Arthroscopic findings were considered as a gold standard. There were 12 female and 12 male patients with an average age 39 years (11–65). The time interval between the MRI scan and arthroscopy was 7 months (2–18). In our study MRI had 100% specificity for the diagnosis of ATFL and CFL tears and osteochondral lesions. However sensitivity was low particularly for CFL tears. The accuracy of MRI in detecting ATFL tear was 91.7%, CFL tear was 87.5% and osteochondral lesion was 83.3%.

We conclude that MRI scanning has a very high specificity and positive predictive value in diagnosing tears of ATFT, CFL and osteochondral lesions. However sensitivity was low with MRI. In a symptomatic patient negative results on MRI must be viewed with caution and an arthroscopy is advisable for a definitive diagnosis and treatment.

Purpose: Management of unstable or comminuted displaced fractures of the distal radius is difficult. We report our experience treating these fractures with AO volar plate fixation applying the principle of a volarulnar tension band platting. An attempt to introduce a new radiological classification for the accuracy of reduction is made. The classification includes 10 criteria.

Materials and Method: We reviewed clinically and radiologically 99 patients (101 fractures); 60 were type C and 41 were type A. The average follow up was 37 months (24 – 57). The average age was 46 years (19 – 81). Sarmiento’s modification of Gartland and Werley and Cooney’s modification of Green and O’Brien were used for clinical assessment. Lidstorm and Frykman used for radiological assessment.

Results: At final follow up the means of distal radius parameters were: volar tilt of 9°, radial inclination of 22°, radial height of 11mm and palmer cortical angle of 32°. The mean dorsiflexion was 61°, palmer flexion was 59°, pronation was 80° and supination was 76°. Grip strength was 86% of the opposite side. The average DASH score was 13.6. There was 13 poor results, 6 of them had a significant loss the initial reduction. There was significant correlation between our classification outcome and the clinical outcome.

Conclusion: AO volar plate fixation of unstable distal radius fractures provides a strong fixation that maintains reduction and allows early mobilisation.

Purpose: This study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap.

Materials and Method: Sixty-eight patients (72 breasts) had this operation between September 1999 and June 2002. fifty-four patients (58 breasts) were assessed. The average age was 50 year (range 30 – 66 year). Average follow up was 38 month (range 24 – 54 month). DASH and Constant-Murley were used for clinical assessment.

Results: Twenty-nine (50%) shoulders found to have a normal function; whereas, 11 (19%) shoulders had mild disability, 10 (17%) shoulders had moderate disability and 8 (14%) shoulders had severe disability. Only 6 (10%) patients reported being unsatisfied with their outcome; these were, from a shoulder function point view, 4 patients with sever disability, 1 patient with moderate disability and 1 patient with normal shoulder function. However, all these 6 patients were not satisfied with their breast reconstruction outcome.

Conclusion: This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients.

Aim: Osteoarthritis of the wrist is a well recognised cause of secondary carpal tunnel syndrome. The aim of the study is to compare the outcome following carpal tunnel decompression with regard to patient satisfaction. We compared the outcome of carpal tunnel decompression between patients with and with out osteoarthritis of the wrist.

Patients and Methods: The study was done retrospectively. Clinical notes of all the patients who underwent carpal tunnel decompression over a period of 8 years were verified. Twenty four patients who underwent surgical decompression for carpal tunnel syndrome secondary to osteoarthritis were identified by reviewing the notes and the radiographs. Control group consisted of 24 patients who under went carpal tunnel decompression but without osteoarthritis of the wrist. The control group was matched for age, sex, side, and neuro-physiological severity of the nerve compression. Clinical notes were verified to find whether the patients were satisfied with the symptom relief at the first post-operative follow up visit.

Results: There were 24 patients in the group with osteoarthritis of the wrist. The mean age of the patients was 71 years (range 33–89 years). There were 19 females and five males. The right hand was involved in 17 patients and the left was involved in 7 patients. The control group with out osteoarthritis also had similar distribution regarding age sex side, and neuro-physiological severity of nerve conduction. In the group with osteoarthritis of the wrist 17(71%) patients reported the their symptom relief as satisfactory and the rest seven(29%) reported the results as unsatisfactory. In the control group 23(96%) patients reported their symptom relief as satisfactory and one (4%) reported their results as unsatisfactory (P= 0.0325).

Conclusions: Patient satisfaction following surgical decompression in patients with secondary carpal tunnel syndrome due to osteoarthritis is significantly lower compared to patients with out osteoarthritis of the wrist. Patients with osteoarthritis of the wrist should be warned about the higher incidence of poor outcome prior to decompression.

Aim: To assess if commonly used scoliosis instrumentation activates metal detectors at airport security gates.

Methods: 20 patientswho had travelled by air following scoliosis surgery were included. The type of instrumentation, number of journeys, body mass index and whether the alarm was triggered off by the airport security detector was recorded. We asked the patients opinion regarding provision of documentary evidence of surgery.

Results: 10 patients had posterior instrumentation, 5 patients -Paediatric ISOLA,4 patients had anterior instrumentation and one patient, anterior and posterior instrumentation. 12 patients (60%) had travelled more than four times by air following surgery corresponding to 48 passes through an airport archway detector.5 patients out of 20 had set off the alarm while passing through the metal detector everytime of which 4 had posterior instrumentation and 1 anterior instrumentation. None of the patients with ISOLA instrumentation set of the alarm. Two patients had set off the alarm every time they passed through the metal detector and both of them had posterior instrumentation. 14 patients(70%) suggested that we should provide documentary evidence of surgery to avoid delays in the airport security check. 25 % of patients set of the metal detector alarm following scoliosis instrumentation.

Conclusion: Patients with posterior instrumentation are more likely to set off the alarm compared to patients with ISOLA instrumentation. It is important to be aware that scoliosis instrumentation can activate airport archway detectors in our present security climate and to provide documentation to patients in order to avoid embarassment and delays.

Infection following total knee arthroplasty is a serious complication. Recently there has been increasing incidence of isolation of multi-drug resistant bacteria from peri-prosthetic infections. The aim of our study is to identify the organisms causing delayed deep infections following primary total knee arthroplasty in the current situation. We also compared the differences in outcome based on the infecting organism. We undertook a retrospective study of all the patients who presented with delayed deep infection following primary total knee replacement during a six year period between April 1998 and March 2004. Organisms were isolated in 27 of the 31 patients who presented with delayed deep infection. Forty-four % of the organisms isolated were multi-drug resistant with increasing incidence of Methicillin resistant Staphylococcus aureus and multi-drug resistant Staphylococcus epidermidis infections. Successful outcome following an infected total knee arthroplasty was lower compared to the previous studies where there were fewer multi-drug resistant organisms. The average number of surgical procedures carried out was significantly higher when the organism isolated was multi-drug resistant. The number of patients with satisfactory outcome is significantly lower when the organism isolated is multi-drug resistant.

The aim of this study was to assess the accuracy of Magnetic Resonance Arthrography (MRA) in symptomatic shoulder joint instability. Data were collected prospectively from MR Arthrograms performed in 40 consecutive patients with recurrent symptomatic instability. MR Arthrograms included views in the stress ABER position of the shoulder. Subsequently all patients underwent an arthroscopic shoulder stabilisation and the arthroscopic and MR Arthrographic findings were correlated. In case of discrepancy the films and operative findings were reviewed.

There were thirty three male and seven female patients with a mean age of 28 years (range 18–40). MR Arthrography showed 37 anterior-inferior tears (22 displaced Bankart tears, 8 nondisplaced Bankart tears, 5 chronic ALPSA lesions and 2 AGL lesions) and 3 posterior lesions. There were 3 discrepancies of which 2 were cases of missed Bankart lesion on MRArthrogram and one case of reverse Perthes lesion present on MRArthrogram but not seen on arthroscopy. Despite a review of the films, the missed Bankart’s lesions were not visualised. In the present study, MR arthrography had a 95% sensitivity in detecting ligamentolabral pathology and a positive predictive value of 0.975 in diagnosing a lesion in recurrent shoulder instability.

The results show that MR Arthrogram is a highly useful tool for investigating recurrent shoulder instability with very high sensitivity and positive predictive value. Of the 40 patients who underwent arthroscopy there were only 2 cases where MR Arthrography did not demonstrate an arthroscopically detected abnormality.

Aims: To compare the preoperative knee function in patients of Asian origin and Caucasians living in the same community.

Background: The prevalence of osteoarthritis is high in all ethnic and demographic groups. The timing of surgery is important as poor preoperative functional status is related to poor postoperative function.

Methods: Prospective study of 63 Asian patients age and sex matched with Caucasian patients undergoing total knee arthroplasty. Pre operative Knee Society Clinical Rating System scores were recorded as a separate Knee Score and Knee Function.

Results: The mean preoperative Knee Score in Asian patients was 37.6 in comparison to 41.5 in Caucasians (p< 0.10) this difference was not statistically significant. The mean preoperative Knee Function in Asian patients was 32.5 in comparison to 45.0 in Caucasians (p< 0.0001) this difference was highly statistically significant.

Conclusions:Patients of Asian origin undergoing total knee arthroplasty have lower preoperative knee function to Caucasians. Cultural beliefs and social support explain part of this discrepancy but health care providers must also attempt to educate patients and close family members about the importance of timing the surgery to obtain the optimum benefits of pain relief and function.

The aim of our study is to identify the organisms causing delayed deep infections following primary total knee arthroplasty in the current situation. We also compared the differences in outcome based on the infecting organism.

We undertook a retrospective study of all the patients who presented with delayed deep infection following primary total knee replacement during a six year period between April 1998 and March 2004. We analysed the infecting organism, sensitivity of the organism to antibiotics, number of surgical procedure carried out and the outcome of the infected arthroplasty based on the infecting organism. Statistical analysis was done using Fisher’s Exact test for categorical data and Mann-Whitney U test for the non-parametric numeric data.

The mean age at the time of primary arthroplasty was 69.9 years (range 46 to 92 years, SD=10.8). The mean follow-up (time since the initial knee replacement) was 77.3 months (range 27–170 months,). The mean follow-up since the last surgical procedure to treat infection was 31 months (range 14–47 months). Organisms were isolated in 27 of the 31 patients who presented with delayed deep infection. Forty-four % of the organisms isolated were multi-drug resistant with increasing incidence of Methicillin resistant Staphylococcus aureus and multi-drug resistant Staphylococcus epidermidis infections. Successful outcome following an infected total knee arthroplasty was lower compared to the previous studies where there were fewer multi-drug resistant organisms. The number of patients with satisfactory outcome is significantly lower when the organism isolated is multi-drug resistant. Patients infected by multi-drug resistant organisms undergo higher number of surgical procedures compared to patients where the organism is not multi-drug resistant. We conclude that deep infection with MRSA and Methicillin resistant Staphylococcus epidermidis are on the rise. Outcome is significantly better when the organism isolated is non resistant Staphylococcus aureus.

Purpose: Management of the unstable or comminuted displaced fractures of the distal radius is difficult. We report our experience treating these fractures with AO volar plate fixation. An attempt to introduce a new radiological classification for the accuracy of surgical reduction is made. The classification includes 10 criteria and 100 points.

Methods: 124 patients had volar plate fixation performed between June 2000 and May 2003 using AO volar plate. We reviewed clinically and radiologically 101 patients; 60 were type C and 41 were type A (after failed conservative treatment). The average follow up is 37 months (24 – 57). The average age is 46 years (19 – 81). Postoperative regimen consisted of immediate physiotherapy and a wrist splint for three weeks. Cooney’s modification of Green and O’Brien and Sarmiento’s modification of Gartland and Werley were used for clinical assessment. Lidstorm and Frykman used for radiological assessment.

Results: At final follow up the means of distal radius parameters were: volar tilt of 9 degrees, radial inclination of 22 degrees, radial height is 11mm and palmer cortical angle of 32 degrees. The mean dorsiflexion was 61 degrees, palmer flexion was 59 degrees, pronation was 80 degrees and supination was 76 degrees. Grip strength was 86 percent of the opposite side. The average DASH score was 13.6. There was 14 poor results, 6 of them had significant loss the initial reduction. There was significant correlation between our classification and the clinical outcome.

Conclusion: AO volar plate fixation of unstable distal radius fractures provides strong fixation that maintains reduction and allows early mobilisation.

This study was performed to evaluate the efficacy of interscalene block combined with general anaesthetic for common surgical procedures of shoulder and the potential of this procedure for providing day case shoulder surgery.

114 consecutive patients undergoing shoulder surgery were audited using a questionnaire immediately after operation and at 6, 12 and 48 hours after operation. Pain scores were recorded based on visual analogue scale, type of operation, duration of operation, postoperative stay and complications. At 48 hours overall pain control was assessed and patients were asked about having their operation done as a day case.

104 patientswho responded to the questionnaire were included in the study. There were 52 males and 52 females with overall mean age of 49 years (range 18–85). 75 patients underwent arthroscopic decompression, 15 patients underwent arthroscopy assisted mini open cuff repair, 9 underwent open glenohumeral stabilisation and the rest five underwent open Mumford procedure. Mean operation time was 47 minutes (range 25–90). 97 (93%) patients had no pain immediately postoperatively, 76 (73%) patients were pain free at 6 hours and 39 (38%) were pain free at 12 hours. Mean pain scores art 6 hours was 3 and at 12 hours were 4. 101 patients said their pain was well controlled throughout the first 48 hours by simple oral analgesics. 84 (83%) patients expressed an opinion that they could have been managed as day case provided they were adequately counselled about the procedure. 6(5.7 %)patients showed signs of Horner’s syndrome that resolved by 12 hours. No other complications related to inter scalene block occurred.

This study has shown that interscalene block is a safe procedure providing sustained adequate pain relief after shoulder surgery. It could allow a high percentage of patients undergoing shoulder surgery to be discharged home on the day of surgery.

Purpose of Study: To assess the efficacy of two-stage correction (skeletal traction followed by Partial Fasciec-tomy) in treating severe Dupuytren’s contractures.

Material, Methods and Results: We retrospectively reviewed sixteen fingers in fifteen patients with severe Dupuytren’s contracture (Tubiana Grade III/IV), operated between April 2000 and July 2005. The mean age was 58 years (27 – 82 years).

All patients underwent an initial application of Orthofix external fixator with pins in the proximal and middle phalanx. The patients were advised to gradually distract the device 3-4 times a day, for two weeks. They were then brought back for removal of fixator and partial fasciectomy with closure of skin by V-Y plasty.

The results were assessed in thirteen patients, as two were lost to follow-up. The mean follow-up period was 30 months (6 – 64 months). The total mean preopera-tive extension deficit improved from 130 degrees to 38 degrees postop.; PIP joint deformity improved from a mean of 77 degrees to 33 degrees postop. and the mean TRAM (Total range of active movements) improved from 108 degrees to 165 degrees.

Functional assessment was done using Michigan Hand Outcome Questionnaire. Overall improvement in hand function was from a preoperative 34% to a postoperative 89%.; aesthetic improvement from a preop. of 46% to a postop of 81% and pain improvement from a preop of 66% to a postop of 96%.

One patient had recurrence, one had features of RSD (Reflex Sympathetic Dystrophy) and one had to undergo amputation due to poor tolerance and persistent infection.

Conclusion: Severe Dupuytren’s contracture is a challenging deformity to deal. The two-stage correction may be considered as an alternative method of treatment in cooperative patients. Our study has shown promising results with good patient satisfaction

Objective: To assess the effectiveness of intrathecal fentanyl in the relief of post operative pain in patients undergoing lumbar decompression or fusion. Morphine has been shown to be effective intrathecally in spinal surgery but there is an increased incidence of respiratory complications. Fentanyl has not been formally evaluated in this setting.

Design: This was a prospective randomized double blind trial. All patients received our standard analgesic regime with PCA via a syringe driver. They were also randomized to receive either 15 micrograms of fentanyl intrathecally, or nothing. The fentanyl was administered by the operating surgeon (GM) under direct vision one or two levels above the site of operation at the end of the procedure.

Subjects: 30 patients undergoing lumbar spinal surgery were prospectively recruited.

Outcome measures: VAS pain scores were taken at 2, 4, 24 and 48 hours post operatively. Time to first bolus delivery of morphine from the PCA was also recorded as was the total dose of morphine required.

Results: The patients randomized to receive fentanyl showed a significant increase in the time to first bolus delivery of morphine as well as a 40% reduction in the total morphine dose delivered. There was also a decrease in their mean VAS scores. There was no increased incidence of side effects in the group receiving fentanyl. No patients suffered respiratory compromise requiring treatment and only 2 patients required HDU observation overnight. The rest of the cohort left recovery after 2 hours to be nursed on an open ward.

Conclusion: Intrathecal fentanyl is effective at reducing morphine use via a PCA and mean pain VAS scores after lumbar spinal surgery. We would support its use over intrathecal morphine because of the reduced incidence of respiratory complications and the ability to nurse patients on the open ward.