Abstract

Displaced mid-shaft clavicle fractures have traditionally been treated non-operatively. New evidence supports the use of operative treatment with better functional results although with some risk of adverse complications. The patient's opinion in choosing one or the other option of treatment is important especially when a new therapeutic philosophy is introduced.

We aimed to obtain the patients' preference based on their opinion of various possible outcomes of each treatment method. A clinical decision tree was constructed based on probabilities for various outcomes from the current literature. We used clinical decision analysis based on Bayesian logic. A similar clinical decision analysis was done for a cohort of orthopaedic surgeons.

We interviewed 20 patients to obtain their health preferences on a numerical rating scale for each of the six possible outcomes for the conservative and operative treatments. Similar health preferences were obtained from 20 orthopaedic surgeons.

The cohort of patients were young (age range: 13 – 21, mean: 16 years) males involved in active sport. The results of the decision analysis demonstrated a strong preference for operative management in this cohort of patients (combined probability of 0.81 for operative treatment versus 0.61 for non-operative).

The cohort of orthopaedic surgeons were either career orthopaedic trainees or qualified orthopaedic surgeons with an age range of 28 – 41 years (mean age: 35 years). The results of the decision analysis demonstrated a weak preference for operative management in this cohort of surgeons (combined probability of 0.84 for operative treatment versus 0.77 for non-operative management).

Overall the young active patient is eight times more likely to prefer operative treatment over non-operative management compared to the well informed orthopaedic surgeon. Patient education is the key to a better informed patient who can make a balanced decision. Clinical decision analysis can be a useful tool in this process.

Statement: To present the early results of using new implants in the fixation of the hamstrings tendons for ACL reconstruction.

Background and Aim of the study: PINN-ACL system (Conmed UK, Linvatec UK ltd.), is a recently developed implant designed for transverse femoral fixation of hamstrings grafts in ACL reconstruction, allowing for increased pull out strength. It consists of a Graft Harness composed of Poly L-Lactic Acid with a high strength polyethylene fibre loop and a Cross pin composed of Self-Reinforced PLLA. Tibial fixation is achieved by a bioabsorbable Matryx Interference Screw; composed of Self-Reinforced 96L/4D PLA and beta-Tri-Calcium Phosphate(Linvatec Biomaterials ltd.)

We describe our early experience with this new system, the technique of fixation, short-term clinical results, functional outcome and MRI features of these implants.

Materials and Methods: A prospective data collection was undertaken over the past 12 months. The operative steps:, four strand hamstring preparation, tensioning, femoral fixation of graft with graft harness and cross pin, tensioning the graft and tibial fixation with bio- absorbable interference screw. More than 80% of the cases were performed without tourniquet. The follow up were made at 2,12,24,36 weeks and further evaluation as needed for the purpose of the study. Outcomes were assessed with Lysholm, Tegner and IKDC scores.

Results: 24 cases were performed in 23 cases. The mean age, gender and laterality were 34(17–51), 1.7M: 1F, 14L:10 R. The injury pattern: sports (77%) and RTA (11%)

Tunnel view of the harness was excellent in 79%. Linvatec Tensioner was used in 60%. Graft was not detached in 20%. The mean follow up period was 7 months (2 –12). At last follow up Lachman and pivot shift were negative in 85% and grade 1 in 15%, The mean postoperative scores were Tegner-7 (5–10), Lysholm-7 (5–10) and IKDC-71 (57–93) respectively.

1 wound problem required washout. The tibial screw twisted off at final turn in 1 patient. The cross pin drill missed the guide in 1 patient.

At 32 weeks MRI scan: the implants were still evident, However apart form 1 patient, there was no surrounding bone reaction and none showed tunnel widening.

Conclusion: Early results are encouraging, both operative technique and fixation. However, harness size is limited to 8 and 9 mm only and the implants were still evident at a mean period of 32 weeks against the manufactures claim of 24 weeks.

Introduction and aim: prosthesis displacement while attempting closed reduction of a dislocated total hip or during dislocation itself is a rare but significant complication. We have come across three cases and there are at least six case reports in the literature. The aim of our study is to conduct an in vitro biomechanical study to assess, whether application of bone cement over the shoulder of the stem confers any additional advantage in the pull out strength of the implant.

Materials and Methods: We used fourteen saw bones and cemented seven bones with a standard cementing technique and another seven bones with additional cement over the shoulder of the implant. A tensile testing machine was used to assess the pull out force needed in both groups. A comparision was done between both groups.

Results: The mean pull out force in the routine cementing technique was 2066N(S.D. 256.65) and for the group with the cement on the shoulder was 3220N(S.D. 312.22). The mean difference was 1154N. The results were analysed with two-tailed t- test, unequal variance and the difference was statistically significant with p value of 0.00045.

Conclusion: Our experiment confirms that application of the bone cement over the shoulder of the implant does give additional axial stability and should be practised routinely to reduce this complication.

Introduction: Dynamic Hip Screw (DHS) fixation is one of the most common orthopaedic surgical procedures. Tip Apex Distance (TAD) is a well recognised method of evaluating the screw position of the DHS. We studied the adequacy of fixation of DHS by assessing TAD and type of reduction.

Materials and Methods: We selected a random cohort of 102 patients who had DHS fixation and had the requisite clinico-radiologic data. TAD is defined as sum of the distance, in millimeteres, from the tip of the lag screw to the apex of femoral head, as measured on AP radiograph and Lateral radiograph, after correction has been made for radiological magnification. Tip apex distance of 25 mm or less is considered as good, 26–30mm as acceptable, 31–35mm as poor and more than 35mm as unacceptable.

Quality of reduction was assessed as per Sernbo. Good, if alignment was normal on AP and maximum 20 degrees angulation on lateral radiograph and less than 4mm of displacment of any fragment. To be labelled acceptable, a reduction had to meed the criteria of a good reduction with respect to either alignement or displacement, but not both. A poor reduction met neither.

Results: Mean TAD in our series was 24mm. (9.84 – 37.6). Our of this 58.82% were 25mm or less indicating good, 25.49% of them were 26–30mm indicating acceptable, 8.82% were 30–35mm indicating poor and 6.8% were more than 35mm indicating unacceptable. 39.21% patients had good reduction. 43.13% had acceptable reduction and 17.64% had poor reduction.

Conclusion: This study shows that only 58.82% of all patients having DHS fixation had good placement of the fixation device and only 39.21% had a good reduction. We conclude that complacency must not set in on DHS fixation and that we must endeavour for good reduction and placement in as many cases as possible.

Introduction There is no consensus on the superiority of either Chevron or Mitchell osteotomy in the treatment of hallux valgus. In the literature Chevron osteotomy is recommended for the mild and Mitchell’s for the moderate hallux valgus (HV) deformities. We reviewed outcomes of two of the most common distal first metatarsal osteotomies.

Aims To compare the results of Chevron vs Mitchell osteotomy in the treatment of HV.

To evaluate the co-relation between clinical outcome and radiological correction achieved after the two osteotomies.

Method We reviewed clinical notes and pre- and postoperative radiographs of a total of 111 operations including 61 Chevron and 50 Mitchell osteotomies in 90 patients.

We designed a patient-focused questionnaire to evaluate clinical outcomes that addressed the main functional outcomes concerning patients after bunion surgery. These included pain, usage of footwear postoperatively, cosmoses, development of transfer metatarsalgia and the repeatability of the procedure they had undergone. These questions were point based and a final clinical score was calculated for comparison with the radiological correction. This was also used as a measure of success of the procedure.

Conclusion There is a statistically significant radiological difference in HV angle correction and the loss of first metatarsal height as seen post-operatively between patients treated with Chevron and Mitchell osteotomies for HV correction (p=0.03 and p=0.0004 respectively). There is no statistically significant difference (p=0.6) in the clinical outcomes based on the newly designed patient-focused questionnaire with either Chevron or Mitchell osteotomies at a mean follow-up of 27 months post-operatively. Clinical outcome determined by patient-focused questionnaire remains the same in-spite of radiological differences noticed post-operatively between the two osteotomies.

Aim: To report on the bone histology of patients undergoing intramedullary stabilisation for a pathological fracture or a metastatic lesion in long bones.

Materials and methods: From 1999 to 2002, 36 long bones in 29 patients (seven had stabilisation of two long bones) were stabilised with an intramedullary nail in patients with a known primary tumour. Prophylactic fixation was performed in 19 bones with metastatic tumour and in 17 for a fracture. Of the 17 fractures, 13 were considered pathological and four were simple fracture unrelated to metastasis. Thirty-three nailings were done for proximal femoral lesions and three were for the humerus. Reaming samples were sent for histological analysis. The various sites of the primary tumour were Breast (13), Myeloma (6), Prostate (5), Lung (4), Unknown (3), Bladder (2), Oesophagus (1), Renal (1), Melanoma (1). The histological results were correlated with the clinical diagnosis.

Results: Thirty-six reaming samples were sent for histological analysis. Twenty-two samples correlated with the clinical diagnosis. Of the 22 tissue samples, two did not have a initial confirmed histological diagnosis of primary and the reaming samples helped to achieve this. Fourteen biopsies gave false negative results.

Conclusion: Approximately two-thirds of the time the reaming sample has correlated with clinical diagnosis. Sensitivity of this test is 61%.

Introduction

To achieve tibiotalocalcaneal arthodesis, implants described range from external fixator, compression screws and anterior plate and the more recent retrograde calcaneal locked intramedullary nail. Our aim is to assess the outcome of the AO cannulated blade plate for tibiotalocalcaneal arthrodesis.

Patients and methods

Four tibiotalocalcaneal arthrodeses were performed in three patients. The operative technique involves lateral approach to the distal fibula that was osteotomised and used as bone graft. The articular cartilage of ankle and subtalar joint was removed using an osteotome and congruent surfaces achieved. AO cannulated blade plate was applied on the lateral aspect to achieve compression. The postoperative protocol included a plaster cast for three months, followed by mobilization out of plaster.

Results and discussion

At the mean follow up of 10 months (range five to fourteen months) all patients were pain free on full weight bearing. The union was achieved at three months which was confirmed clinically and radiologically. There was no infection, wound breakdown, or loss of position at the ankle or subtalar joints. Mean preoperative American Orthopaedic Foot and Ankle Society ankle/hindfoot score was 21 and postoperative score 83. We conclude that the cannulated blade plate is an alternate technique for tibiotalocalcaneal arthodesis, with no moulding of the implant required to attain satisfactory alignment.

Up to 75% of patients develop metalwork related problems following ankle fracture fixation and require further open surgery to remove them. This second procedure can lead to significant morbidity. To minimise these complications, we developed a technique, for removing the metalwork percutaneously. This technique was used in 12 patients with metalwork problems related to malleolar implants. The majority of problems occurred with the distal fibular plate and the screws.

One stab incision was placed mid way between every two screws so that two screws could be removed though one incision. The plate was stripped from the distal fibula using a narrow osteotome and extracted through the distal or proximal stab wound. Lag screws were also removed through an anterolateral stab incision. When we were unable to palpate the screw head, we used a guide wire under image intensifier to locate the screw head and railroaded a cannulated screwdriver over the wire to lock into the head of the screw. Medial malleolar screws were removed in a similar fashion. The technique was undertaken as day case surgery. No complications were encountered. All patients remained symptom-free postoperatively.

We conclude that percutaneous removal of metalwork around ankle joint is a safe and effective technique, allowing the patient to quickly regain their preoperative level of activity.

Introduction

The existence of various techniques of ankle arthrodesis shows that there are pros and cons in each method. We describe our experience of ankle arthrodesis using a paediatric angle blade plate.

Materials and methods

10 ankle arthrodeses were performed in nine patients. All patients were reviewed independently in special clinics. The objective assessment was performed by detailed clinical examination and the subjective assessment was made including overall patient satisfaction. The American Orthopedic Foot and Ankle Society ankle/hind foot scoring system was used. The technique of ankle arthrodesis was similar in all patients using an anteromedial or anterolateral incision, preparation of articular surface and paediatric angle blade plate fixation with or without bone grafting. Time to union was assessed by clinical and radiological examinations.

Results

Radiological union was achieved in nine patients in a mean time of 16 weeks. Fibrous union occurred in one patient. Eight patients were very satisfied with their treatment. The patient with fibrous union had a marginal improvement of symptoms with pain score improved from nine to seven. The mean AOFAS score was 84.

Conclusion

Ankle arthrodesis with a paediatric angle blade plate is a useful method of managing intractable cases of ankle arthritis. The technique is simple and effective with excellent success rate.

Introduction

Inclusion of foot dominance in clinical examination of foot disorders is not routinely practised. The existence of foot dominance is not reported in the orthopaedic literature. We have evaluated foot dominance in a normal population and correlated it with hand dominance to highlight its existence and also to bring it into common practice.

Materials and methods

Demographic data was obtained from 468 healthy adult subjects. Those with pre-existing lower limb pathology were excluded from the study. Hand dominance was noted and each subject was then assessed for foot dominance by a blinded method. During the study all subjects were invited to come and stand on a set of weighing scales, and the leading foot was regarded as the dominant one. This was repeated three times for each subject.

Results

Two hundred and fifteen (46%) were males. Two hundred and fifty-three (54%) were females. Three hundred and ninety (83%) were right handed and 78(17%) were left-handed. Three hundred and fifty (75%) were right footed and 118 (25%) were left footed. Eighty-four per cent (328) of the right-handed lead with their right foot and 16% (62) lead with their left foot. Seventy-seven per cent (60) of the left-handed lead with their left foot and 23% (18) lead with their right foot.

Conclusion and Discussion

Foot Dominance seems important to recognise in the same way that we always ask about hand dominance. Further study obviously needs to be carried out to relate foot dominance with lower limb pathology. Are we more likely to injure or stress the dominant lower limb and is this reflected in the incidence of conditions such as fractured necks of femur, lower limb arthritis or foot disorders? We would certainly expect a correlation with the speed of rehabilitation of lower limb disorders depending on which limb is affected, and some existing evidence and the experiences of our physiotherapists support this. Further research is being undertaken to investigate this.