We retrospectively assessed the value of identifying impinging osteophytes using dynamic computer simulation of CT scans of the elbow in assisting their arthroscopic removal in patients with osteoarthritis of the elbow. A total of 20 patients were treated (19 men and one woman, mean age 38 years (19 to 55)) and followed for a mean of 25 months (24 to 29). We located the impinging osteophytes dynamically using computerised three-dimensional models of the elbow based on CT data in three positions of flexion of the elbow. These were then removed arthroscopically and a capsular release was performed.

The mean loss of extension improved from 23° (10° to 45°) pre-operatively to 9° (0° to 25°) post-operatively, and the mean flexion improved from 121° (80° to 140°) pre-operatively to 130° (110° to 145°) post-operatively. The mean Mayo Elbow Performance Score improved from 62 (30 to 85) to 95 (70 to 100) post-operatively. All patients had pain in the elbow pre-operatively which disappeared or decreased post-operatively. According to their Mayo scores, 14 patients had an excellent clinical outcome and six a good outcome; 15 were very satisfied and five were satisfied with their post-operative outcome.

We recommend this technique in the surgical management of patients with osteoarthritis of the elbow.

Cite this article: Bone Joint J 2014;96-B:237–41.

Introduction

Atypical femoral fracture focused on relation of bisphosphonate use, frequently. However, the mechanism of atypical femoral fracture was not yet clarified. Atypical femoral fractures have been kept femoral shaft cortical thickness and BMD, practically. We hypothesized that atypical femoral fractures were associated with impaired bone quality and curvature of femoral shaft.

Background

Excellent results with use of tapered wedged cementless stem have been reported. The purpose of this study was to clarify the indication of tapered wedged cementless stems for patients with poor bone quality.

INTRODUCTION

Progressive polyethylene wear is associated with the occurrence of osteolysis, which can lead to component loosening and subsequent revision. Massive wear of the polyethylene liner may result in the penetration of the femoral head through the metal shell. Although metallosis after total hip arthroplasty has been well documented in the literature, extensive metallosis with polyethylene wear-through has been only sparsely described. The purpose of the present study was to assess clinical findings and the results of revision total hip arthroplasty in these cases.

Background

Anatomical reduction and stable internal fixation has been recommended as the standard treatment for fracture dislocations of the tarsometatarsal (Lisfranc) joint. Many methods of fixation have been utilised including K-wires and screw fixation, the latter being the preferred method as it provides a stronger more stable construct. However, the screws require removal after the injury has healed.

We present a different method and technique of stabilisation utilising memory staples. The technique is extra-articular and avoids breaching the TMTJ joint surface, is simple and avoids the necessity of removal of hardware.

Introduction

The aetiology of hallux valgus is almost certainly multifactoral. The biomechanics of the first ray is a common factor to most. There is very little literature examining the anatomy of the proximal metatarsal articular surface and its relationship to hallux valgus deformity.

The aetiology of hallux valgus is well published and largely debated. Hypermobility at the TMTJ was initially described by Morton, but it was not till Lapidus that its association with hallux valgus was hypothesized. However, little has been published on the anatomy of the tarsometatarsal joint. Our aim was to determine whether there was an anatomical basis for the coronal hypermobility in hallux valgus.

Equinus contracture of the ankle due to a tight Gastrocnemius has been implicated in the pathogenesis of a number of foot and ankle conditions. There are numerous described procedures for release of the Gastrocnemius such as the Strayer procedure.

Our indications for release are in patients with a symptomatic forefoot and an equinus contracture of 5 degrees or more in extension as defined by the Silfverskiöld test. The release is usually combined with a reconstructive procedure. The advantages of our technique are its simplicity, excellent visualisation of the tendon and sural nerve, good wound healing and patient comfort post-operatively.

The procedure can be performed without tourniquet. A 2.5cm incision is made over the medial calf, just distal to the Gastrocnemius muscle indentation. The deep fascia is incised and the edge of the tendon can be visualised. Blunt digital dissection is performed on either side of the tendon to develop a plane. A metal Cusco speculum is inserted to visualise the full width of the tendon. The tenotomy is performed starting medially and the last 5mm of the lateral tendon is left uncut. This reduces the chance of iatrogenic injury to the nerve. The tendon bridge can be left if correction is sufficient, otherwise passive dorsiflexion of the ankle results in completion. Post-operatively, patients are able to mobilise fully with crutches and passive ankle physiotherapy is commenced immediately.

We performed 22 MAGS procedures in 17 patients. There were no Sural nerve injuries and no wound complications. All patients were delighted with cosmesis. Average pre-operative equinus contracture with the leg extended was 18 degrees. Average intra-operative correction of 24 degrees was obtained and at 3 months follow-up, all patients were able to dorsiflex past neutral.

Aseptic loosening and osteolysis may cause significant periprosthetic femoral bone destruction, often necessitating bypass of the deficient proximal femur to obtain stable fixation in the distal diaphysis. The purpose of the present study was to report our results of femoral component revision using a distally locked revision femoral stem for the treatment of the severe proximal femoral bone loss.

We evaluated 21 hips in 20 patients who underwent revision hip arthroplasty associated with Paprosky grade-IIIB or IV femoral deficiencies. Three hips were associated with a Vancouver type-B3 periprosthetic femoral fracture. The mean age at the time of revision was 70.8 (51–82) years old with 5 men and 15 women. The mean duration of follow-up was 5.1 years. The femoral implant used for the revision was the Cannulok Revision Prosthesis in 16 hips and the Huckstep interlocking stem in five. Gaps between the stem and the host bone were filled and impacted with bone chips and morselized bone prior to stem insertion.

One femoral implants were resected because of deep infection Subsidence was absent and stable fixation was achieved in all patients. Non-progressive radiolucent lines in zones 1 and 7 according to Gruen’s classification were detected in five cases. Cortical hypertrophy around the interlocking screws were seen in ten cases. No disadvantages or complications of the interlocking screws were observed. All the fractures have united within three to five months. Intraoperative fractures in the diaphyseal area occurred in five hips in which trochanteric osteotomy was used.

A diaphyseal fixation of the femoral stem with distal interlocking screws appears to provide primary axial and rotational stability of the prosthesis and early mobilization. This implant may provide a satisfactory alternative for the management of revision hip surgery in the presence of a loose femoral component with massive bone loss. Longer-term follow-up data from this study will be needed to confirm these outcomes.

Aseptic loosening and osteolysis may cause significant periprosthetic femoral bone destruction, often necessitating bypass of the deficient proximal femur to obtain stable fixation in the distal diaphysis. The purpose of the present study was to report our results of femoral component revision using a distally locked revision femoral stem for the treatment of the severe proximal femoral bone loss.

We evaluated 21 hips in 20 patients who underwent revision hip arthroplasty associated with Paprosky grade-IIIB or IV femoral deficiencies. Three hips were associated with a Vancouver type-B3 periprosthetic femoral fracture. The mean age at the time of revision was 70.8 (51–82) years old with 5 men and 15 women. The mean duration of follow-up was 5.1 years. The femoral implant used for the revision was the Cannulok Revision Prosthesis in 16 hips and the Huckstep interlocking stem in five. Gaps between the stem and the host bone were filled and impacted with bone chips and morselized bone prior to stem insertion.

One femoral implants were resected because of deep infection Subsidence was absent and stable fixation was achieved in all patients. Non-progressive radiolucent lines in zones 1 and 7 according to Gruen’s classification were detected in five cases. Cortical hypertrophy around the interlocking screws were seen in ten cases. No disadvantages or complications of the interlocking screws were observed. All the fractures have united within three to five months. Intraoperative fractures in the diaphyseal area occurred in five hips in which trochanteric osteotomy was used.

A diaphyseal fixation of the femoral stem with distal interlocking screws appears to provide primary axial and rotational stability of the prosthesis and early mobilization. This implant may provide a satisfactory alternative for the management of revision hip surgery in the presence of a loose femoral component with massive bone loss. Longer-term follow-up data from this study will be needed to confirm these outcomes.

Introduction: The Taylor Spatial Frame (TSFTM, Smith & Nephew, Memphis) has gained international recognition for the fixation of complex long bone fractures and deformity correction. It’s application with transverse wires can be difficult in some anatomic regions, and fixation of frames with half pins is gaining clinical popularity. Half-pins cause minimal transfixion of the surrounding soft tissues and can be inserted into anatomically safe areas.

Aims: This study aimed to compare the stiffness characteristics of a TSF frame fixed with transverse wires to fixation with half pins.

Materials and methods: Experiments were carried out in the biomechanics laboratory at Cardiff university. All mechanical testing was performed with a servo-hydraulic test frame (MTS-858 Mini Bionix II®, MTS Corp., Minneapolis). Custom built mounts were used to attach the bone rigidly to one end of the machine and TSF ring to the other. Rings were fixed with 1.8mm transverse wires or hydroxyapatite coated 6.5mm half pins with 45°, 60°, 75° and 90° divergence angles. Bone was loaded with axial load to 400N and torque to 20Nm. Load/displacement curve data were analyzed for slope and displacement.

Results: For larger diameter rings (180mm) there was no statistically significant difference in axial stiffness between the transverse wires (with 2 rings) and the half pins (p> 0.05). For 155mm diameter rings half pins provided statistically higher axial stiffness than transverse wires (p= 0.036). Half pins gave significantly more torsional stiffness for both ring diameters when compared to transverse wires (p< 0.05). As in axial stiffness, small diameter rings showed increased stiffness in torsion. There was an increase in axial and torsional stiffness as the divergence angle between the wires or pins increased (p< 0.05).

Conclusion and clinical relevance: Half pins provide greater stiffness to TSF frames and allow axial micro-motion as well. This work provides a rationale for clinical decision making in construction of a TSF frame.

Total Knee Arthroplasty (TKA) has been widely performed and successful clinical outcomes have been achieved for the patients with knee osteoarthritis which is generally known to cause ADL problem. Clinical and radiographic evaluations are commonly used when evaluating postoperative outcomes, among which kinetic analysis and gait analysis are considered essential to investigate the more detailed effect of the treatment. There is a controversy whether performing TKA on both knees simultaneously is appropriate in treating patients with bilateral knee osteoarthritis, in terms of the speed and effectiveness of gait recovery. In this study, we reviewed the significance of performing simultaneous bilateral TKA, by the results of preoperative and postoperative gait analysis.

Materials and Methods: Total of eight patients, all female and diagnosed of bilateral knee osteoarthritis, were treated with TKA and reviewed. Mean age was 70 years old (60–74). For prosthesis, we used Scorpio NRG PS, and ADVANCE, with cementation for all. No patella was replaced. Some had unilateral TKA, and some were treated bilaterally as needed. We examined distance factors (step length and step width), gait velocity, and gait barycentric factors (single-support phase and Ratio of center of gravity maximum values). We performed the analysis preoperatively, postoperatively at 1 month, 3 months, and 6 months. We used the floor pressure gauge (NITTA CORPORATION) and the three-dimensional motion analysis device (DITECT Co. Ltd) for the analysis.

Results: During the six-month follow-ups, six cases were unilateral TKA and two were treated bilaterally. Increase in step length was seen in the unilateral cases, and it decreased in the bilateral cases. Step width decreased in five cases, two cases showed no change, and increased in one case. Gait velocity had increased in all cases. Single-support phase was close to 1 for all the cases. Ratio of center of gravity maximum values, which indicates the movement of centroid during ambulation, the ratio went up for unilateral cases while it showed no change in the bilateral cases.

Discussion: Quantitative studies of gait analysis have reported that gait condition had improved after TKA. However, some reported that the gait impairment had remained. Unilateral TKA group showed gait restoration, whereas gait abnormality in either leg was seen in the bilateral group. Gait analysis is effective in determining whether surgeons should perform unilateral TKA or bilateral TKA to the patients with bilateral knee osteoarthritis. Among the gait analysis factors, we consider that Ratio of center of gravity maximum values shows effectively the improvement of the treated knee, gait, and the condition of contralateral knee.

Introduction: Trauma surgery creates enormous mental stress for operating surgeons, especially in trainees. This is responsible for sympathetic hyperactivity which can be measured by various cardio vascular variables. Air Traffic control is recognised as one of the most stressful occupations with accepted risks and incorporated remedies. We compared the stress during surgery with that experienced by air traffic controllers.

Materials & Methods: The study included 40 trainee doctors. We obtained multiple readings of heart rate, diastolic and systolic Blood Pressure with ambulatory monitoring methods when they operated. This was compared to their resting measurements obtained at home. Similar measurements were performed for Air Traffic controllers, while at work and at home.

Results: The heart rate and blood pressure were increased at the beginning and during surgery. Student t test was applied to compare the mean values obtained intra-operatively and in resting conditions. This suggested the increase to be statistically significant. This increase in autonomic function variables was compared with the values similarly obtained for Air Traffic Controllers. Operating surgeons manifested significant increase in comparison to the other group.

Discussion: Stress can not be eliminated but can be over come with experience. Recurrent sympathetic hyperactivity may contribute to various stress related ailments. As in Air Traffic controllers, stress should be accepted as integral part of occupation. Stress relieving manoeuvres should form an important part of surgeons’ occupational health and medical school/ foundation years curriculum.

Conclusions: Surgeons experience more emotional and mental stress than occupations accepted to be most stressful.

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil osteotomy.

Materials and Methods: A retrospective study of 75 feet (62 patients) with a mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires.

Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent meta-tarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography.

Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile.

Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy.We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intra-operative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile.

Introduction: The transverse metatarsal arch is the subject of some controversy as there isn’t a clear consensus as to whether there is a transverse arch (TMA) in stance phase. The current treatment options of forefoot pathology focus on the need to harmonise the TMA by the use of osteotomies such as the Weil’s.

Materials and Methods: A retrospective study of 75 feet (62 patients) with mean follow up of 19 months. Patients underwent clinical, pedobarographic and radiological assessment. ‘Metatarsal skyline Views’ (MSV) were procured to assess the plantar profile of the TMA following Weil osteotomy. The feet were assessed using AOFAS, Foot Function Index, SF-36 and Manchester-Oxford Foot Questionnaires.

Results: 69 feet showed good to excellent results with a normal MSV plantar profile. 6 feet had recurrent metatarsalgia with callosities and abnormal MSV profiles. These results correlated well with pedobarography.

Discussion: The angle of Weil osteotomy is usually referenced relative to the floor irrespective of the plantar angulation of metatarsal. As different metatarsals had varying plantar angulations, the weight bearing metatarsal skyline view was used to ascertain the plantar profile of the metatarsals before, during and after surgery. This was also used to determine the amount of dorsal displacement required in addition to shortening in order to harmonise both length and plantar profile.

Conclusion: The use of the Metatarsal skyline view has significantly improved our planning of the angles of the Weil osteotomy. We suggest that the reference for the osteotomy should be the plantar angulation of the metatarsal rather than the floor. It has made the intraoperative assessment of the osteotomy easier and has improved our understanding of the osteotomy and its influence on the forefoot plantar profile.

Aim: To identify reasons why surgical management of displaced supracondylar fractures of the humerus in children failed

Method: A retrospective analysis of 42 patients treated at our department over a 4 year period with case note and radiological review. Data was recorded with regards to mechanism of injury, operative method and technique with radiological assessment using Bauman’s angle and the Shaft-condylar angle. Using follow up information in case notes and radiologically, surgical “failures” were identified.

Results: Overall demographics were consistent with previous studies with a median age of 6.5 years. 95% of the case notes and 75% of the X-rays were reviewed. 80% of the injuries were Gartland 3 type fractures. We noted a 9% incidence each of preoperative neurological and vascular injury and ipsilateral fracture. Median time to surgery following admission to A+E was 3.5 hours with 90% performed before midnight. Overall early fracture displacement rate was 25% with a reoperation rate of 14%. 88% of the early displacement resulted from Gartland 3 fractures treated with manipulation only. The remainder was attributable to CRIF/ORIF using a crossed lateral wiring configuration.

We noted 1 case of iatrogenic ulnar nerve injury, 2 cases of cubitus varus @ 1 year associated with medial column comminution, 2 cases of hypertrophic scar formation and 3 cases of asymptomatic cubitus valgus. No deep infection. 2 superficial infections.

Conclusion: The management of displaced supracondylar fractures can potentially be fraught with problems therefore a standardisation of surgical management should be set for each hospital.

Aim: To identify factors which improved outcome following surgery. Method: Between 1994–2000, 28 patients with 30 displaced intra-articular fractures of the calcaneum were treated with open reduction and internal fix-ation at our hospital (mean, 45 years). We reviewed 20 patients within the Shropshire region over a 3.6 average follow-up period using 4 recognised hindfoot scoring systems. Patients were classified according to Sander’s classification with preoperative CT scans. The mechanism of injury and postoperative management was recorded. Clinical and radiographic assessments were also made. Results: Average follow up was 3.6 years. The overall surgical results were comparable of similar studies based upon the Maryland Foot Score (30% excellent, 35% good, 30% fair, 5% poor). 75% of our patients returned back to work within 6 months with an average of 5 months. 3 patients developed a superficial wound infection. Data analysis revealed that neither the age, energy of injury, time to surgery, time spent in plaster nor the time that physiotherapy was commenced had any significant bearing on functional outcome. However, early weightbearing at 6 weeks positively influenced outcome with all 4 scoring systems (p=0.01, 0.01, 0.02, 0.05) with a deterioration of outcome with delayed weightbearing. This was shown to be due to loss of sub-talar joint mobility (r=−0.74, p=0.001). Conclusions: We propose that good results can be obtained from internal fixation of intra-articular calcaneal fractures with a high probability of early return back to work. We recommend that patients be encouraged to weightbear at 6 weeks to optimise mobility at the subtalar joint.

Introduction

Considerable controversy exists with regard to the surgical management of displaced intra-articular calcaneal fractures. Protagonists for internal fixation would suggest there is sufficient evidence to expect better functional outcomes with surgery. However, this is not conclusive.

Aim

To identify factors which improved outcome following surgery.

Method

Between 1994–2000, 28 patients with 30 displaced intra-articular fractures of the calcaneum were treated with open reduction and internal fixation at our hospital (mean age 45 years). We reviewed 20 patients within the Shropshire region using four recognised hindfoot scoring systems. Patients were classified according to Sanders’ classification with pre-operative CT scans. The mechanism of injury and post-operative management were recorded. Clinical and radiographic assessments were also made.

Results

Average follow-up was 3.6 years. The overall surgical results were comparable with similar studies based upon the Maryland Foot Score (30% excellent, 35% good, 30% fair, 5% poor). Seventy-five percent of our patients returned to work within six months at an average of five months. Three patients developed a superficial wound infection. Age, energy of injury, time to surgery, time spent in plaster and time to commencing physiotherapy had no significant bearing on functional outcome. However, early weightbearing at six weeks positively influenced outcome with all four scoring systems (p=0.01, 0.01, 0.02, 0.05) with a deterioration of outcome with delayed weightbearing. This was shown to be due to loss of subtalar joint mobility (r=−0.74, p=0.001).

Conclusions

We propose that good results can be obtained from internal fixation of intra-articular calcaneal fractures with a high probability of early return to work. We recommend that patients be encouraged to weightbear at 6 weeks to optimise mobility at the subtalar joint.

We assessed the unloading effect of the patellar tendon-bearing (PTB) cast in five healthy volunteers using a new system for analysis of dynamic plantar pressure. We devised a method to improve the unloading effect of the PTB cast, and tested this using the same system.

Our findings showed that the conventional PTB cast only achieved unloading of 30% of the body-weight and that the part of the cast on the leg had a more important role in the unloading than that which was in contact with the patellar tendon. When the depth of the free space under the foot inside the PTB cast was 1, 2 and 3 cm, the unloading effect was 60%, 80% and 98%, respectively.

The unloading effect of the conventional PTB cast was disappointing at only 30% of body-weight. It was improved by producing a space between the sole of the foot and the cast, and was adjustable by altering the depth of this space.