The purpose of this study was to demonstrate the beneficial effects of elbow arthrolysis. This was a prospective study on 88 patients with post-traumatic elbow stiffness with a mean follow-up of 51 months (1 year - 11 years), who had failed to improve their range of movement at a mimimum period of 6 months after their injury. All patients had an open arthrolysis. Post-operatively patients received continuous passive movement (CPM) for 48 to 72 hours. This was facilitated by good analgesia afforded by a continuous brachial plexus block. All patients received no physiotherapy thereafter and were advised to actively mobilise their elbow. ROM was assessed using a goniometer and function assessed using the Mayo elbow performance index. The ROM improved from a mean of 56 degrees pre-operatively to 106 degrees post-operatively. This improvement in ROM was reflected in the improvement of pre-operative flexion from 107 to 138 degrees and improvement of extension from 60 to 31 degrees. Function improved from a mean of 65 to 85 on the Mayo elbow performance score. 95% of the patients were satisfied with the outcome. Complications included ulnar nerve paraesthesia in 3 patients, 1 triceps avulsion and 1 superficial infection. 3 patients required a manipulation of the elbow in the postoperative period. This was performed within 2 weeks of the operation. There were no cases of elbow instability or heterotopic ossification in this series.
Multiple threaded pins were used in 10 hips and a cannulated screw in 2 hips. Complications include revision surgery due to loss of fixation in 3 hips and a superficial wound infection. There were no cases of avascular necrosis and chondrolysis.
Stickler’s syndrome, also called Hereditary Progressive Arthro-Ophthalmopathy, is an autosomal dominant connective tissue disorder with strong expressivity, characterised by ocular, orofacial, skeletal, cardiac, and auditory features. We describe a case of valgus slipped capital femoral epiphysis in a 13 year-old boy with Stickler’s syndrome. He presented at routine rheumatology clinic follow-up with a 1-month history of progressively worsening right hip pain, which radiated to the knee. He underwent insitu cannulated screw fixation of the right slipped capital femoral epiphysis. Joint pains are a common manifestation in Stickler’s syndrome and this might delay the diagnosis of slipped capital femoral epiphysis. Valgus slipped capital femoral epiphysis is a rare entity. Obesity and the increased femoral anteversion are predisposing factors. Insitu fixation with a single cannulated screw is the treatment of choice.
Total hip arthroplasty (THA) patients often require peri-operative blood transfusion. Variables that predict transfusion requirement may allow us to target cross-matching of individual patients. 153 patients underwent primary unilateral THA for osteoarthritis or rheumatoid arthritis during 2002 in our institution. 75 casenotes from these subjects were reviewed. Age, sex, diagnosis, weight, height, pre-operative haemoglobin (Hb) and haematocrit (Hct), anticoagulation type and timing were recorded, along with post-operative Hb and timing and quantity of any blood transfusion. Potential predictors of transfusion were examined using logistic regression analysis. ROC analysis was used to compare the relative predictive value of significant variables. Mean (±SD) age at surgery was 67±11 years (53% females). Mean pre-operative Hb was 13.8±1.4g/dl, mean post-operative Hb was 10.2±1.0g/dl. 27 patients (36%) needed a transfusion; the most frequently given volume was 2 units and the mean number of units given was 0.85. The most common reason for transfusion was an asymptomatic low Hb (<
8.0g/dl). Pre-operative Hb and Hct were predictive of post-operative transfusion (logistic regression analysis P<
0.01). Age, gender, diagnosis and anticoagulation were not predictive. Using ROC analysis the optimal ‘cut-off’ value of pre-op Hb as a predictor was 12.7 g/dl, giving a sensitivity of 41% and a specificity of 88% for blood transfusion requirement. The optimal ‘cut-off’ for Hct was 0.41, sensitivity 74% and specificity 61%. There was no significant difference in the overall predictive value between these variables (comparison of area under ROC curves, P>
0.05). In summary, subjects with a pre-operative Hb<
12.7 or Hct <
0.41 are more likely to require a blood transfusion after unilateral primary THA than those with an Hb or Hct above these values. In treatment centres where cross-matched blood is not available at short notice on demand, pre-operative cross-match of patients with blood counts below these values may be appropriate.
Telephone interview is an important tool for patient follow-up after THR and a useful adjunct to life-long review.
The posterior capsule is variously incised and excised during total hip replacement (THR). There is no consensus on the direction of the capsulotomy and the need to repair the posterior capsule. The objective of this study was to determine the orientation of the collagen fibres and nerves in the posterior hip capsule in patients undergoing THR. Specimens from five patients with osteoarthrosis of the hip (with no fixed deformity) were obtained and fixed in 10% neutral buffered formalin. Sutures were placed to mark the head and trochanteric end before excising. A standard posterior approach was used. The samples were examined and reported by a pathologist. Samples were processed overnight in a VIP5 automatic tissue processor and embedded in paraffin wax, preserving the location of the suture sites on embedding. Sections were cut at 5 Ïm and routinely stained with haematoxylin and eosin. The van Gieson stain was used for collagen fibres. Nerve fibres were highlighted using immunohistochemistry for S100 protein and blood vessels using an antibody to CD34. The collagen bundles seen were predominantly parallel to the axis of the specimen. Dispersed within the collagen bundles were small vascular leashes that were parallel with the collagen fibres. The S100 staining revealed that these were neurovascular leashes, with small nerves running alongside the vessels and the collagen. Nerves that separate from the vessels were likely to serve proprioceptive and nociceptive functions. The direction of the capsulotomy during THR by posterior approach has been traditionally perpendicular to the direction of the capsular fibres. However, if possible, capsulotomy along the orientation of the collagen fibres may be advantageous. As this study demonstrates, it will result in less damage to the capsular collagen fibres, blood vessels and nerves resulting in better capsular repair and healing, and better conservation of pro-prioceptive and nociceptive functions.
All known shoulder surgeons in Scotland have made a voluntary registration of shoulder replacements since 1996. Information regarding diagnostic and demographic characteristics of the patients, rotator cuff status and type of procedure performed were collated. 20 surgeons have contributed to the register, performing a varied number of shoulder arthroplasties (2 to 79). By five years the total number of shoulder replacements performed was 451. 23. 2 % of patients were male and 76. 8% female. 397 patients had a hemiarthroplasty and 54 (12 %) had a total shoulder replacement. 204/451 (45 %) humeral components used were cemented. In comparison 48/54 (89%) glenoid components used were cemented. The most common condition requiring shoulder arthroplasty was inflammatory arthritis (184 cases), followed by trauma (128 cases), of which 60 % were for acute trauma and 40 % for old trauma. The remainder consisted of osteoarthritis (87 cases), avascular necrosis (27 cases), and others (25 cases). The consultant in 425 cases and the trainee in 26 cases performed the operation. In 85/451 (18. 9%) of the cases, associated procedures were performed which included cuff repair (26 cases), coracoacromial ligament excision (43 cases), coracoid osteotomy (14 cases) and acromioclavicular joint excision (2 cases). There were 24 intra-operative complications and 9 patients had a revision. Comparison with figures from the Information and statistics division in Scotland however indicated that our register collected only 53 % of all the arthroplasties performed. In addition it was noted that 30 % of shoulder replacements were performed by surgeons who performed three or fewer shoulder replacements a year. In an age of clinical governance we believe that a register can provide detailed and accurate information. It is useful for demonstrating current practice and can highlight future changes in practice. This register supports the need for a national register and surveillance of shoulder replacements. However, in addition to the voluntary data registration, it is proposed that dedicated data collection staff are employed to coordinate the data collection process.