Abstract

Abstract

Abstract

Abstract

Background

Recurrent patellar dislocation in combination with cartilage injures are difficult injuries to treat with confounding pathways of treatment. The aim of this study is to compare the clinical and functional outcomes of patients operated for patellofemoral instability with and without cartilage defects.

Introduction

Recurrent patellar dislocation is often reported in bilateral knees in young active individuals. The medial patellofemoral ligament (MPFL) tear is the attributable cause behind many of them and warrants reconstruction of the ligament to stabilize the patellofemoral joint. Besides, trochleoplasty and Fulkerson's osteotomy are some other procedures that are performed to treat this problem. This study aimed to compare the clinical and functional outcomes in a cohort of patients with single-stage bilateral realignment procedures vs staged procedures.

Introduction

Traditional Total Knee Arthpolasty (TKA) replaces all 3 compartments of the knee for patients diagnosed with OA. There might be functional benefit to replacing only damaged compartments, and retaining the normal ligamentous structures. There is a long history of performing multi-compartment arthroplasty with discrete components. Laskin reported in 1976 that good pain relief and acceptable clinical results were achieved at two years in patients with bi-unicondylar knee replacement [Laskin 1976]. Other authors also have reported on bi-unicompartmental knee arthroplasty achieving successful clinical outcomes [Stockley 1990; Confalonieri 2005]. Banks et al. reported that kinematics of bi-unicompartmental arthroplasties during gait demonstrated some of the basic features of normal knee kinematics [Banks 2005]. These reports suggest that a modular approach to resurfacing the knee can be successful and achieve satisfactory clinical and functional results.

Introduction

Many common fractures are inherently stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable fractures are advised that they need a cast, despite the potential for stiffness, skin problems and thromboembolism. Attempts to challenge this practice often meet the argument that patients prefer a cast for pain relief. We analysed five years of a single consultant's fracture clinic to see how many patients with stable foot and ankle fractures chose a cast after evidence-based counselling.

Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release. This was a prospective study of 28 consecutive patients with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon.

At surgery, arthroscopic joint assessment was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral and medial portals. The ECRB lesions were classified and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and 3 months using the DASH score.

Of the 28 elbows 21 were noted to have a Nirschl type I lesion (intact capsule), 6 had a type II lesion (linear capsular tear) and 1 a type III (capsular rent). Degenerative articular changes were noted in 19 elbows. If arthroscopic debridement was required it was undertaken. Three elbows were noted to have eccentric radial heads. Radial plicae which were impinging on the radial head were noted in three patients. 1 patient was lost to follow up.

There was a significant improvement in DASH scores (p< 0.002) at 2 weeks post operatively. This improvement was sustained at 3 months. This is a worst case scenario analysis using a paired t test. 1 patient had post operative stiffness and 6 failed to improve of which 2 were revisions.

The early results would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation.

Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic tennis elbow release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release.

This was a prospective study of 29 consecutive patients (30 elbows) with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon. At surgery, arthroscopic assessment of the elbow joint was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral, anteromedial and anterolateral portals. Associated intra-articular pathology was noted. The ECRB lesions were classified according to their gross morphology and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and at 3 months using the DASH score.

29 patients with tennis elbow were treated with arthroscopic release of the ECRB origin on the lateral epicondyle. Of the 30 elbows undergoing surgery, 22 were noted to have a Nirschl type I lesion (intact capsule), 7 had a type II lesion (linear capsular tear) and 1 had a type 3 lesion (capsular rent). Degenerative articular changes were noted in 18 elbows. Arthroscopic debridement was undertaken if appropriate. Three elbows had eccentric radial heads. Radial plicae which were impinging on the radial head were present in three patients.

Mean follow up is 9 months (1–23). 1 patient was lost to follow up.

There was a significant improvement in DASH scores (p< 0.05) at 2 weeks post operatively. This improvement became more significant at 3 months post operatively. This is a worst case scenario analysis using a paired t test. 6 patients failed to improve, 1 partially improved and 1 was revised and improved.

There were no surgical complications; however, one patient has post operative stiffness which required an arthroscopic release.

The early results of this study would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology if required. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation and return to normal activities.

Aim: Our aim was to find the effect of implementation of European working time directive on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: The audit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. We have analysed the results of the this and have identified a potential area of concern.

Results: An orthopaedic trainee of registrar level(Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. Overall, a trust grade surgeon (non-training grade) was the lead surgeon in 24% of cases. Comparing with the previous audits performed in the same hospitals, the number of hip fracture operations performed by trainees have reduced drastically. In 2003 and 2005 audits, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. There is a definite trend suggesting decrease in number of operations by trainees since the implementation of European working time directive as it has been introduced in a phased manner since 2004. In NHS, Current target is to achieve it fully by next year which may make the situation even worse from training point of view.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. On the other hand, the modernising medical curriculum (MMC) emphasises demonstration and record keeping of core competencies of surgical skills. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in England are mirrored elsewhere in Europe, the implications for orthopaedic training are significant. We are setting very high standards for training on one side but on practical grounds, not able to achieve the requirements set by educational bodies like OCAP and ISCP.

Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England.

Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant.

Background Bony or cartilaginous ossicles appear at the plantar aspect of the interphalangeal joint of the great toe. The variation in pattern, prevalence and anatomic relationships of these structures is not clearly established in the literature, especially in a Caucasian population. Without this knowledge, pathology at this joint may be underestimated and surgical approaches may be poorly planned particularly as radiographs underestimate the incidence of ossicles at this joint. The aims of this study were to determine the incidence and pattern of ossicles at this joint and to establish their anatomical relationships in order to aid planning the approach for their excision.

Method The left great toe interphalangeal joint was dissected in forty British Caucasian cadavers and the pattern of ossicles and their anatomic relationships were established.

Results In 27.5% of specimens, there was no identifiable ossicle and in these cases, the tendon of flexor hallucis longus was adherent to the joint capsule. In the remaining specimens (72.5%), a bursa separated the tendon of flexor hallucis longus from the plantar joint capsule and ossicles were found embedded within the joint capsule. Over a half (52.5%) of the specimens had a single ossicle located centrally within the plantar capsule and the remaining 20% had two ossicles lying within the capsule.

Conclusion This study shows that a large proportion of the population have either one or two bony or cartilaginous ossicles at this joint. In addition, the study has clarified the anatomy of this joint and shown that, when present, ossicles do not lie within the tendon of flexor hallucis longus and could be most safely approached from either a medial or lateral approach.