Abstract

Introduction: Up to 20% of Lisfranc injuries can go unrecognised with resultant long-term morbidity. Spontaneous relocation may mask the injury. Standard AP, lateral and oblique views of the foot are the primary radiological views. Weight bearing views may not be possible acutely and stress views may require anaesthesia. The standard AP view does not show the tarso-metatarsal joint clearly with alignment of the medial border of the second metatarsal to the medial border of the intermediate cuneiform all important.

Materials and methods: We used a tangential AP view of the tarso-metatarsal joint taken by tilting the x-ray beam cephalad. The degree of tilt was dictated by the declination angle of the first metatarsal seen on the lateral view of the foot (20–25 degrees for most people). Sixteen patients had standard AP, lateral and oblique views of their foot at the time of injury and were not diagnosed to have a Lisfranc injury. They remained symptomatic for an average period of 5 weeks (range, 2 to 15 weeks) before they had the tangential view of the Lisfranc joint.

Results: In all 16 patients the first and second tarso-metatarsal joint and the first inter-metatarsal space were more clearly visible. Thirteen patients had abnormal findings to confirm the diagnosis of Lisfranc injury and for 2 surgical treatment would have been appropriate if identified earlier than 14 and 15 weeks respectively.

Discussion and conclusion: This view confirmed the diagnosis in 13 patients who would have otherwise been discharged as a minor soft tissue injury.

We have also used this view successfully for injecting local anaesthetic in the tarso-metatarsal joints to elucidate the exact source of pain.

We recommend this simple view should be routinely used in addition to the standard AP, lateral and oblique views of the foot for mid foot injuries.

Introduction: Flexor tendon repair in zone 2 has a high re-rupture rate. Various pulleyplasties were described to reduce gliding resistance. In an experimental study on pig trotters, we performed pulleyplasty by meshing alike split skin graft and determined its effect on breaking strength and gliding resistance of repaired tendon.

Method: Phase 1: Two pairs of middle pulley of the same pig were pulled apart from bone on Universal testing machine. One of each pair were meshed (10 rows of 1mm slits 2 mms apart longitudinally).

Phase 2: The two ends of two repaired flexor tendons were attached to a tension load cell each. The proximal end load cell was connected to Universal testing machine. Gliding resistance was measured under saline before and after meshing.

Phase 3: The test was repeated on 4 specimens using a digital load scale. Ten observations of peak resistance were obtained each with normal pulley, meshed pulley, after edge tying of the pulley.

Results: Breaking strengths were 162 and 59 N in one pair and 89 and 50 N in another. The pulleys became 1.5 – 4 times stretchable.

Meshing increased the gliding resistance by approximately 20% and 30% in phase 2 and 3 respectively. Edge tying decreased the gliding resistance by 27% below that of normal pulley

Discussion and Conclusion: Meshing weakens significantly but breaking strength stayed above 50 N, which is more than average breaking strength of a tendon repair (30N, Norris et al). Meshed pulley were dragged farther and preventing it by edge tying decreased the gliding resistance.

No animal was killed for the study.

Introduction: Several patients with fracture neck of femur were noted to have alarmingly low postoperative haemoglobin unexplained by the intra-operative and postoperative blood loss. We conducted this study to determine the magnitude of preoperative fall in haemoglobin in patients with hip fractures.

Methods: Full blood count was repeated after a minimum of 12 hours of fluid resuscitation in 50 consecutive patients admitted with fracture neck of femur. Patients requiring blood transfusion prior to collection of second specimen were excluded. Patients were grouped according to the type of fracture (intracapsular, inter-trochanteric and sub-tro-chanteric).

Results: The average drop in haemoglobin of 0.8 (range,0–2.1), 0.8 (range,0–2.8) and 2.5 (range,0.6–4.9) gm/dl in intracapsular, inter-trochanteric and sub-trochanteric fractures respectively were statistically significant in all three groups (student-t-test, p-value < 0.05) but appears to be clinically significant in only sub-trochanteric group. By close analysis of data it is noted that although average drop in first two groups is low but at least 15 % of patients in both groups dropped their haemoglobin by 2 gm/dl or more. This can be compounded by the drop in haemoglobin following surgery, the average of which was 2.5 gm/dl (range,0–6.4)

Discussion and Conclusion: During this study at least 5 patients were saved from going to theatre with dangerously low haemoglobin with no cross-matched blood. There is clinically significant drop in haemoglobin prior to surgery in patients admitted with fracture neck of femur. On admission haemoglobin can be falsely reassuring. We recommend all patients with sub-trochanteric fracture and all patients with intra-capsular and inter-trochanteric fractures with haemoglobin of 12 gm/dl or less to have a repeat haemoglobin check prior to their surgery. This practice may reduce the morbidity and mortality associated with very low haemoglobin in this group of patients with high pre-existent co-morbidities.

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.

Conclusion: This relatively new technique has given good results in majority of patients. We recommend its use in displaced and comminuted fractures of distal radius in physiologically young patients with high need and demand.

Method: The diagnosis of Hoffa’s disease with acute or chronic impingement of the fat pad was made by clinical signs and confirmed by arthroscopic examination in 180 patients. One hundred and forty two patients had one or more associated lesions. Thirty eight patients with isolated Hoffa’s lesion were treated by arthroscopic resection of the affected part of the fat pad and were assessed using the Lysholm knee and Tegner activity level scales. Their average age was 39 years (range, 19–65 years). Thirty five patients performed regular sporting activities. A history of acute onset following injury was present in only 23 patients (56 %). The average duration of symptoms prior to surgery was 10 months (range, 1–26 months). Fourteen patients had one or more previous failed arthroscopies at other centres.

Results: There was a significant improvement in the symptoms, function of the knees and level of activity after the surgery at an average follow-up of 68 months. The average improvement in Lysholm scores were 47 and 58 at 3 months and 1 year respectively. This improvement was maintained through to the latest follow-up (4 to 8 years after surgery) in all but three patients. On Tegner activity level all but 5 returned to their pre-injury status. Three had minimal symptoms and two chose to step down the level of activity due to non-physical reasons. Natural history of the disease was observed both with and without surgery as many persevered with symptoms while they were treated by analgesics, physiotherapy and arthroscopic surgery without resection of the impinging fat pad. Statistically significant negative correlation was found between duration of symptoms and gain in Lysholm score after surgery (Pearson r = − 0.58). Two distinct etio-pathogenesis and three stages of the disease were identified. Chondromalacia of the articular cartilage especially of the patella was a common association. Special surgical technique is important to avoid the pitfalls.

We reviewed 13 patients with a complex fracture-dislocation of the proximal interphalangeal joint of a finger and one patient with a complex fracture-dislocation of the interphalangeal joint of thumb. We had treated these injuries using a pins and rubbers traction system which had been modified to avoid friction of the pins against the bone during mobilisation of the joint in order to minimise the risk of osteolysis. A Michigan hand outcome questionnaire was used for subjective assessment. The active range of movement (AROM) of the proximal and distal interphalangeal joints and the grip strength were used for objective assessment.

The mean follow-up was 34 months (12 to 49). The mean normalised Michigan hand outcome score was 84. The mean AROM of the proximal interphalangeal joint was 85° and that of the distal interphalangeal joint 48°. The mean grip strength was 92% of the uninvolved hand.

Twelve patients have returned to their original occupations. There has been no radiological osteolysis or clinical osteomyelitis. This modified traction system has given acceptable results with a low rate of complications. It is light, cheap, effective and easy to apply.

Introduction: Displaced intra and extra-articular fractures of distal radius require anatomical reduction in physiologically young patients.

Material and methods: We used volarulnar tension band plating technique (without bone grafting) and early mobilisation to treat dorsally displaced and comminuted fractures of distal radius in 47 physiologically young 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. 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.

Results: The average follow-up was 26 months. According to Gartland and Worleyñs system 26 patients had excellent, 14 had good, 6 had fair and 1 had poor results. The median Disability of arm, shoulder and hand (DASH) score was 10 (range, 0–60). According to Lidstrom and Frykmanñs radiological scoring system 39 patients had excellent and 8 had good anatomical results.

Conclusion:We believe this technique is technically demanding and requires good understanding of anatomy and force transmission in an intact and fractured distal radius. This relatively new technique of volarulnar tension band plating of distal radius has given good results in majority of patients. We recommend its use in displaced and comminuted fractures in physiologically young patients with high need and demand.

We studied 100 patients who had undergone endoprosthetic replacement of the proximal humerus between 1976 and 1998. The outcome was assessed with regard to the survivorship of the patients, the salvaged limbs and the prostheses. Function was determined in the 47 surviving patients, of whom 30 were assessed using the Musculo-Skeletal Tumour Society (MSTS) rating scale and 38 completed the Toronto Extremity Salvage Score (TESS) questionnaire.

The median age of the patients was 34 years (10 to 80). The mean follow-up period for surviving patients was nine years (2 to 20). The mean MSTS score at follow-up was 79% and the mean TESS score was 72%. The length of bone which was resected influenced the functional outcome. Abduction of the shoulder was to 45° in most patients. The overall survival was 42% at ten years and that of the limb without amputation 93%. The survival of the prostheses using mechanical failure as the endpoint was 86.5% at 20 years.

Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm with a low rate of complications at long-term follow-up.

Ten patients, who underwent treatment for complex fracture-dislocation of the proximal interphalangeal joint of finger and one patient for that of the interphalangeal joint of thumb with a modified pins and rubbers traction system, were reviewed to evaluate the clinical and functional results. Two patients had open fracture-dislocation, 5 had pilon fractures and 4 had fracture-dislocations. The system was modified to avoid rotation of the pins in the bone during joint mobilization, thus minimizing the risk of osteolysis due to friction of pins over the bone.

Michigan hand scoring system was used for subjective assessment and range of motion at proximal and distal interphalangeal joints and grip strength for objective assessment. Average follow-up was 18 months (range 3 months to 28 months). The average normalised Michigan hand score was 86. Based on Michigan scores, overall hand function was rated excellent in 8 patients, good in 2 and poor in 1. Eight patients have returned to their original jobs. The average arc of flexion in the proximal interphalangeal joint was 85 degrees and in the distal interphalangeal joint it was 47 degrees. The average grip strength was 95 percent of the uninvolved side. Two patients developed minor pin site infection, which did not necessitate pin removal or any alteration in the treatment regime. There have been no cases of osteolysis, osteitis or osteomyelitis. This modification of pins and rubbers traction system has given very acceptable results with a low complication rate. It is light, cheap, effective and easy to apply.

Reconstruction of the shoulder joint following resection of the proximal humerus for bone tumours remains controversial. We report the long term functional results of the simplest form of reconstruction – an endoprosthesis.

One hundred patients underwent endoprosthetic replacement of the proximal humerus between 1976 and 1998. Thirty eight had osteosarcoma, 17 had chondrosarcoma, 16 had metastases and 9 had Ewing’s sarcoma. Mean age was 36 years (range 10 to 80 yrs). Survivorship of patients and prostheses were calculated. Function was assessed using the Musculoskeletal tumour society (MSTS) and Toronto extremity salvage (TESS) scoring systems. Thirty patients could come to the clinics for MSTS scoring and 38 out of 49 alive patients replied to the TESS questionnaires sent out to them.

The overall survival of the patients was 42% at 10 years. Local recurrence (LR) arose in 16 patients, being most common in chondrosarcoma (26%) and osteosarcoma (22%) and arose in 50% of patients with these tumours who had marginal excisions. Of these 16 patients, 8 had forequarter amputations whilst the remainder had excisions and radiotherapy. Mean time to LR was 12 months and all but two of these 16 patients subsequently died within a mean of 18 months.

The prostheses proved reliable and dependable. Only 9 required further surgery of any sort, 2 needing minor surgery to correct subluxation and 7 needing revisions, one for infection after radiotherapy and six for loosening – three after trauma. The survivorship of the prosthesis without any further surgery was 86. 5% at 20years. The survivorship of the limb without amputation was 93% at 20 years.

The functional outcome was very predictable. Most patients had only 45 degrees of abduction although three patients had normal movements. The mean MSTS functional score was 79% and the mean TESS score was also 79%. There was a high level of patient satisfaction but difficulty was encountered especially in lifting and in all activities above shoulder height. Endoprosthetic replacement of the proximal humerus is a predictable procedure providing reasonable function of the arm below shoulder height. The endoprostheses have proved highly dependable with a low re-operation rate. There is a high risk of local recurrence after inadequate surgery which should be avoided if possible.

Open reduction and internal fixation of comminuted, displaced intra-articular or potentially unstable fractures of the distal radius with plate and screws has increasingly become a favoured treatment. Intra-operative assessment of fixation with the help of an image intensifier has always been difficult because of the anatomy of the distal radius which has an average ulnar inclination of 22 degrees and an average volar tilt of 14 degrees. These inclination and tilt produce superimposition of images and imaging of the implants placed as distal as possible to achieve satisfactory fixation often shows the screws to be penetrating the joint.

We describe two new radiographic views of the distal radius, which we used intra-operatively in ten patients undergoing open reduction and internal fixation of distal radius fractures. These are the tangential views of the articular surface of the distal radius taken by elevating the wrist so that the forearm makes an angle to the operating table to negate the effects of natural inclination and tilt in antero-posterior and lateral views. The images were compared with the images of standard antero-posterior and standard lateral views. Screws were thought to have been penetrating the joint in the standard lateral views of all of them and in the standard antero-posterior views of eight of them. However, no screw was seen penetrating the joint in these new views.

The tangential views showed correct relation of the screws with the articular surface and a more distal placement of the plate was possible. This enabled the screws to engage the sub-chondral bone and obtain bi-cortical purchase in presence of dorsal comminution. We recommend use of these views in open reduction and internal fixation of distal radius fractures.

The best method of femoral head containment in Legg-Calvé-Perthes’ disease (LCPD) is still controversial. Triple pelvic osteotomy allows desired rotation of acetabulum, reduces the relative stress, provides optimum femoral head cover and compensates for shortening. The iliac osteotomy was modified to interlock following acetabular rotation to provide extra stability and allow early mobilisation.

Material and methods: We reviewed 21 patients, who underwent interlocking triple pelvic osteotomy for severe Legg-Calvé-Perthes’ disease, to evaluate their clinical, radiological and functional results.

The mean patient age at presentation was 7 years and 7 months. Fourteen hips were in the fragmentation stage whereas 8 were in the early re-ossification stage. Seventeen hips were Herring group C and 5 were group B. Seventeen hips had 2 or more at risk radiological signs. The average period of follow-up was 51 months (range, 33 months to 80 months). The average gain in acetabular head index was 18% and that in centre-edge angle was 22 degrees, more than reported for any other single surgical procedure. According to the Harris hip rating system, there was an average gain of 35 points. Average gains in abduction, internal rotation and flexion were 17, 12 and 28 degrees respectively. The average gain in length of the limb was 6.4 mm.

Interlocking triple pelvic osteotomy in LCPD provides good cover of the femoral head, good symptom relief and markedly improved range of motion. Assessment of a few patients approaching maturity has shown a congruent hip joint with a spherical femoral head.