Introduction. Computer hexapod assisted orthopaedic surgery (CHAOS) has previously been shown to provide a predictable and safe method for correcting multiplanar femoral deformity. We report the outcomes of tibial deformity correction using CHAOS, as well as a new cohort of femoral CHAOS procedures. Materials and Methods. Retrospective review of medical records and radiographs for patients who underwent CHAOS for lower limb deformity at our tertiary centre between 2012–2020. Results. There were 70 consecutive cases from 56 patients with no loss to follow-up. Mean age was 40 years (17 to 77); 59% male. There were 48 femoral and 22 tibial procedures. Method of fixation was intramedullary nailing in 47 cases and locking plates in 23. Multiplanar correction was required in 43 cases. The largest correction of rotation was 40 degrees, and angulation was 28 degrees. Mean mechanical axis deviation reduction per procedure was 17.2 mm, maximum 89 mm. Deformity correction was mechanically satisfactory in all patients bar one who was under-corrected, requiring revision. Complications from femoral surgery included one under-correction, two cases of non-union, and one pulmonary embolism. Complications from tibial surgery were one locking plate fatigue failure, one compartment syndrome, one pseudoaneurysm of the anterior tibial artery requiring stenting, and one transient neurapraxia of the common peroneal nerve. There were no deaths. Conclusions. CHAOS can be used for reliable correction of complex deformities of both the femur and tibia. The risk profile appears to differ between femoral and tibial surgeries

Percutaneous Achilles tenotomy is an integral part of the Ponseti technique. Though considered as a simple procedure, many authors have reported serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation. The authors describe the results of their new tenotomy technique, the ‘Posterior to Anterior Controlled’ (PAC) technique in an attempt to eliminate such complications. This is a prospective study. Infants < 1 year of age with idiopathic clubfoot were taken up for the Ponseti technique of correction. Tenotomy was performed by the ‘PAC’ technique under local anaesthesia if passive dorsiflexion was found to be < 15 degrees. Outcome measures included completeness of the tenotomy (by ultrasonography), improvement in the equinus angle and occurrence of neurovascular complications. 40 clubfeet in 22 patients underwent ‘PAC’ tenotomy. The mean age was 3.5 months. The tenotomy was found to be complete in all cases. The equinus angle improved by an average of 78.5 degrees (range 70–95 degrees), which was statistically significant (p < 0.05, students t test). Mild soakage of the cast with blood was noted in 21 (52.5%) cases. No neurovascular complication was noted. The average follow-up was 12.2 months (range 9–18 months). The ‘PAC’ tenotomy virtually eliminates the possibility of neurovascular damage, maintains the percutaneous nature of the procedure, is easy to learn and can be performed even by relatively inexperienced surgeons safely and effectively as an office procedure under local anaesthesia

A 55-year-old man developed a pseudoaneurysm of the popliteal artery after tibial valgization osteotomy performed for degenerative genu varum. A tourniquet was used for the procedure. A wedge osteotomy was performed two centimeters under the joint line; the correction angle was ten degrees. Immediately after the end of the procedure, the distal pulses disappeared for ten minutes. Doppler exploration of the arterial network did not demonstrate any anomaly. Ten days postoperatively, the patient complained of sudden onset pain in the knee and tension in the popliteal fossa. Arteriography demonstrated a pseudo-aneurysm of the popliteal artery. The lesion caused an interruption of arterial flow and was successfully treated by emergency resection and suture

Introduction. Anterior ankle arthroscopy currently provides the best chance of restricting local anatomy damage during ankle surgery. The anterior working area (AWA) of the ankle is restricted by the Dorsalis Pedis Artery (DPA) and the extensor muscle tendons when the procedure is conducted both in dorsiflexion and plantarflexion. During surgery, iatrogenic damage to the DPA can lead to the formation of a pseudoaneurysm, which can be difficult to identify intraoperatively. Our study investigates whether dorsiflexion or plantarflexion provides variability in the movement of the DPA to determine the positions at which anterior ankle arthroscopy provides the greatest anterior working area (AWA) without causing vascular damage. The current study expects the distance of the DPA from the inferior border of the medial malleolus (IBMM) (ankle joint) to be greater on ankle dorsiflexion than in ankle plantarflexion. Materials and Methods. Twelve cadaver ankles embalmed with a mixture of phenol and glycerol, allowing greater motion, were dissected to access the DPA. The ankles, while in a distracted position (in accordance with common surgical practice), were forced into dorsiflexion from a plantarflexion position at 5° intervals. The distance between the IBMM and the DPA was measured at the 5° intervals. Results. The mean amount of ankle flexion achieved was 24.58° (Range = 20–35). All twelve ankles showed positive range of movement (ROM) anteriorly from the IBMM with a mean ROM of 3.58mm (SE = 0.29mm) dorsiflexion. Discussion and Conclusion. Anterior movement of the Dorsalis Pedis Artery during dorsiflexion puts it at a lower risk of iatrogenic damage in a dorsiflexed position compared to plantarflexion. The increased AWA allows the surgeon more manoeuvrable space, possibly allowing the use of larger diameter surgical instruments

Introduction: Severe haemophilia affects 1 in 10,000 men. The ankle along with the hip and knee are commonly affected. Ankle fusion is the preferred surgery for end stage arthritis in the younger patient although debate exists as to the preferred technique. We conducted a retrospective review of the arthroscopic ankle fusions on haemophiliacs from Oxford and compared data with that of a specialist unit in London using an open technique. Materials and Methods: We reviewed 22 ankles (22 patients) from Oxford and 10 ankles (8 patients) from London. 90% had Type A haemophilia with similar regular monthly Factor VIII usage: 17941 U/month (Oxford) compared with 17992 (London). 73% of patients in the Oxford Group and 100% of the London group had Hepatitis C and/or HIV. Results: Union was achieved in all patients. The mean time to union in the open group was 9.1 weeks (Mode- 8 weeks, Range 7–14) compared to 12.2 weeks (Mode- 12 weeks, Range 8–24) in the arthroscopic group. Screw removal was required in 4 patients (3 arthroscopic v’s 1 open). 1 patient in the arthroscopic group suffered a pseudoaneurysm of the dorsalis pedis artery. The arthroscopic group spent less time in hospital- 5.7 days compared to 9.5. Factor VIII usage was less in the arthroscopic group- 32,882 Units compared to 40013. Discussion: Patients of this nature should be managed in centres used to dealing with their complex needs. Arthroscopic ankle fusion in haemophiliacs is safe for these patients. Although arthroscopic fusion may take slightly longer to unite, there are benefits in terms of reduced patient stay and factor VIII requirement and therefore costs

Introduction The aim of the study was to investigate the incidence, in Australia, of popliteal artery injury during knee surgery; to assess the distance from the popliteal artery to the posterior tibia in flexion and extension; and to investigate the influence of major trauma or surgery on the anatomy. Methods A questionnaire was sent to Australian members of the ANZ Society of Vascular Surgeons. Duplex ultrasound studies were obtained through the Vascular Laboratory University of Melbourne. Studies in extension and 90° of flexion assessed the distance from the popliteal artery to the posterior tibia. Twelve persons with normal knees were assessed bilaterally. Eight patients with a posterior cruciate ligament deficient knee were assessed bilaterally. Seventy vascular surgeons responded documenting 115 popliteal artery injuries occurring during knee surgery. There were 69 lacerations, 27 thromboses, 13 AV fistula and 19 false aneurysms. In 12 normal people (24 knees) the popliteal artery was 5.5 mm (2.9 to 9.9) from the tibia in extension and 5.7 mm (2.9 to 10.0) in 90° of flexion. In ten of 24 knees the artery moved closer in flexion. In the eight posterior cruciate ligament deficient knees the artery was 4.7 mm (2.7 to 6.9) from the tibia in extension and 3.8 mm (2.6 to 4.5) at 90° of flexion. In all eight PCL knees the artery moved closer in flexion. In normal knees the popliteal artery may move closer to the tibia in flexion, the average distance being about 5.5 mm. Conclusions The popliteal artery is closer to the knee joint following trauma or surgery and specifically closer in flex-ion than in extension. Risks of injury are significant

The author reviewed 10 patients with irreducible or unstable Total Hip Arthroplasty (THA) dislocation. After clinical and radiological assessment an attempt was made to classify these cases based on the radiological findings and anatomical derangement and review of the literature. The purpose of this study was to correlate the cause of dislocation and the treatment. The material consisted of ten cases of irreducible or unstable THA dislocation seen in the Healthcare Hawke’s Bay Hospital, Hastings, between 1995 and 2000. The mechanism of dislocation was either bending to put on socks or shoes, twisting injury pivoting on the leg or slipping in the shower. These patients had been treated by different surgeons and had various types of implants. All 10 were female and presented with pain, limp, shortening or deformity. Patients were categorised into:. Irreducible dislocation:. Dislodgement of the stem. Dislodgement of the cup. Disassociation of the liner or head in a modular system. Soft tissue interposition: Capsule, tendon. Miscellaneous: Cement interposition; Pseudoaneurysm, Myositis ossificans. Unstable Dislocation:. Subsidence of the stem. Cup migration. The incidence of dislocation, not an uncommon complication, has been reported to be 1.5% following primary THA. One-third may develop recurrent dislocation. Most of the reports in the literature are on the incidence and causes of dislocation. They include cup malposition, trochanteric migration, decreased femoral offset, inappropriate head size, leg length discrepancy, surgical approach and postoperative mobilization. Closed reduction can usually be easily achieved under sedation or general anesthesia. Very rarely, the hip joint cannot be reduced. The author discusses his experience with irreducible dislocation and tries to classify its different causes and to the best of his knowledge, there is no classification of irreducible dislocation according to the anatomic-radiological findings in the literature. The treatment depends on the type of dislocation and is discussed under the specific types of irreducible dislocation

Introduction: The surgical management for carpal tunnel syndrome is the release of pressure on the median nerve by dividing the transverse carpal ligament. There are different ways to release median nerve viz.extensive lazy ‘S’ incision from palm to forearm and the advanced arthroscopic release at wrist. We describe a simple, effective and minimally invasive surgery for C.T.S. to divide transverse carpal ligament. Material & method: We present 38cases of C.T.S. after clinical and Electro diagnosis confirmation underwent the minimal invasive surgery. A 1” transverse incision over the center of distal wrist crease placed exposing the palmeris longus (retracted/divided) and exposing transverse carpal ligament. These transverse fibers are cut in the line of skin incision and exposing the median nerve. With blunt curved scissors the transverse ligament is cut distally in the palm and proximally in the wrist separating from the median nerve thus relieving the compression. The wound is closed in layers over the drain and compression bandage applied. Post operatively hand elevated for 24hours, drain removed after 48hours and suture removed at 7th day. Results: In all the 38cases there was pain relief immediately after the surgery. There was progressive neurological recovery (sensory/motor) took place from 6months to 1year. One case developed a pulsatile swelling at the wrist (false A-V aneurysm). The false aneurysm was due to accidental nicking of superficial palmar branch of radial artery, which was ligated on second day. There was superficial marginal necrosis was observed in 6 cases, which healed in 12–16 days. Discussion: The technique is simple, short, safe, economic, effective and easily reproducible. The transverse incision gives better visualization of transverse carpal ligament; easy resection of the ligament and better exposion of median nerve at the wrist makes this procedure to have good results. This tiny incision is in the langhans line at wrist has early wound healing, a cosmetic scar and least morbidity

The February 2014 Knee Roundup³⁶⁰ looks at: whether sham surgery is as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether trans-tibial tunnel placement increases the risk of graft failure in ACL surgery; whether joint replacements prevent cardiac events; the size of the pulmonary embolism problem; tranexamic acid and knee replacement haemostasis; matching the demand for knee replacement and follow-up; predicting the length of stay after knee replacement; and popliteal artery injury in TKR.

Over recent years hip arthroscopic surgery has evolved into one of the most rapidly expanding fields in orthopaedic surgery. Complications are largely transient and incidences between 0.5% and 6.4% have been reported. However, major complications can and do occur. This article analyses the reported complications and makes recommendations based on the literature review and personal experience on how to minimise them.