Since its first description, the pathology, natural history and treatment of lateral epicondylitis have remained controversial. For those who fail conservative management, surgery remains an option. The optimal method of surgery remains debatable and is further confounded by a relative lack of long-term follow up studies. This study describes a previously unpublished surgical technique and presents its long term results. Patients undergoing this open technique were reviewed using the HSS-1 and Mayo elbow performance assessment tools as well as having grip strength and subjective outcome recorded.Background
Material and methods
Primary arthroplasty of the hip and knee are amongst the most common elective surgical procedures carried out. Results are uniformly good with low complication rates. However, there is a subset of patients in whom a general malaise has been noted. Many of these patients have been seen to have elevated liver function tests. This study set out to examine the effects of primary arthroplasty on liver function and to establish differences between subsets of patients in a consecutive single surgeon series between June 2003 and September 2007 inclusive. In total, 374 procedures were carried out on 350 patients. There were 186 male and 164 female patients. The mean age of the patients was 64.97+/−10.02 years with no significant difference between sexes. Hip replacement accounted for 196 cases (69 cemented, 68 hybrid and 59 cementless) and there was 178 knee replacements. All 4 measurements (AST, ALT, Alk phos, Gamma GT) were significantly elevated at 1 week post-op compared to pre-op and 1 day post-op. All except Alk phos returned to normal at 6 weeks post-op. There were no differences recorded between males and females, hips and knees and the subsets of hips. It is clear from these results that liver function is affected by primary arthroplasty with no single subset providing a reason. Additional research is required to further evaluate these changes.
All neck of femur fractures are registered on a national hip database. Here a standardised proforma is used to ensure all relevant information is recorded. It is also essential all trauma admissions are thoroughly clerked and essential clinical information is recorded. Almost all trauma and orthopaedic units in the UK do not have any such proformas and admissions are written on standard headed paper. We describe a prospective study of all trauma admissions excluding neck of femur fractures. We analysed the comprehensiveness of orthopaedic patient clerking being admitted to a teaching hospital over 2 weeks. We aim to continue with data collection to a total of 100 patients. Here we describe our initial results. We further analysed the differences between levels of postgraduate experience of doctors against the completeness of clerkings. All orthopaedic trauma admissions were scrutinised for presence of demographic details including, name, number, consultant, date, time. We also considered patient details including presenting complaint, mechanism of injury, past medical history, social history, pulse, blood pressure (BP), respiratory rate (RR), temperature amongst others. Clerking doctor details included name, signature, bleep number. They were classified as either being present and documented or absent. We analysed 36 case notes in total. Of these 3 (8%) were clerked by a doctor of less than 12 months experience, 18 (50%) were clerked by a doctor with 12– 18 months experience, 8 (22%) were clerked by a doctor with 24– 30 months experience, 7 (20%) were clerked by a doctor with 30– 36 months experience. We found doctors 100% of the time included name, date, time, mechanism of injury and a plan. All doctors had very poor recording of mental score, allergies, oxygen saturations, temperature being recorded in 0%, 31%, 31% and 28% of cases respectively. Our results also revealed that doctors with less experience had more complete clerkings than more experienced trainees. In particular doctors with less than 18 months experience were better at recording patient details 30 % of the time. Less experienced doctors were also better at recording basic observations such as pulse, BP and temperature. These results are surprising as this would not be expected. More experience doctors may be taking ‘short cuts’ and thereby failing to document certain details. All doctors should ensure accurate and thorough clerkings including essential criteria such as allergies and basic observations, regardless of grade and experience. A standardised trauma proforma has been used by other hospitals with some success and should be considered to be implemented regionally and nationally. This would ensure essential clinical criteria would be included in all admissions.
Total hip and knee arthroplasty surgery has revolutionised the management of patients with arthritis. The musculoskeletal and cardiopulmonary complications of such surgery are well recognised, however hepatic complications are rare. Elevated liver function tests in the early post operative period were noted in a cohort of patients undergoing elective hip and knee arthroplasty. The aetiology and significance of this phenomenon is uncertain. A prospective study of all patients undergoing elective total hip and knee arthroplasty in one hospital by the senior author over a four year period was undertaken. All patients (over 300) had liver function tests (LFT’s), renal profile and haematological indices recorded pre operatively, one day, one week and six weeks post operatively. A standardised anaesthetic and post operative regime was followed. Significant elevation of the liver enzymes, ALT (from 59 to 120), AST (from 47 to 81) and GGT (from 39 to 50) was noted after one week. These values returned to normal after six weeks. The bilirubin levels were also raised at one day (from four to eight) and at one week (from four to ten). Alkaline phosphatase and globulin levels remained within normal parameters. There was a fall in albumin and total protein levels in the immediate post operative period. In conclusion, many patients undergoing elective total hip and knee arthroplasty experience significant hepatic enzyme dysfunction in the early post operative period. This elevation of liver function tests returns to normal after six weeks. The significance of these findings including likely causes is discussed.
We report early major complications encountered following TEN fixation of femoral fractures in children. A case series of four children aged 8– 16 years who had primary TEN fixation of isolated femoral diaphyseal fractures. Three of the four patients had major complications. These were: significant knee stiffness requiring manipulation, haemarthrosis requiring washout and nail removal, loss of position and refracture. Two required revision to locked intramedullary nails without early complication. In the skeletally immature child TEN fixation of femoral fractures has a significant major complication rate. This needs to be recognised when comparing TEN fixation with other treatment options.
Several surgical techniques have been described of resistant lateral epicondylitis or tennis elbow with variable results. This retrospective study presents the long-term outcome of a single surgeons experience with a modified surgical technique for the treatment of resistant lateral epicondylitis. Between 1986 and 2001, the senior author performed 171 surgical procedures in 158 patients for resistant lateral epicondylitis. 147 elbows in 136 patients (88%) were independently evaluated at a mean time to follow up of 9.8 years. Patients were assessed using a functional questionnaire and physical assessment. In addition to physical assessment, provocative testing of the extensor origin and grip strength was performed. Patients subjectively rated the result of surgery and these results were compared to objective elbow performance scores. Subjectively, 97% of patients assessed the result from surgery as good to excellent. Objectively, 97% results were good to excellent using elbow performance scores. Synovial fistulate developed in two patients by day ten postoperatively. One patient required further surgery for a synovial fistula which healed with no sequelae. There were no other complications following surgery. The postoperative range of motion improved in all patients but remained reduced in four patients. There was a significantly worse outcome for patients with Worker’s compensation claim and for cigarette smokers. There was no difference between grip strengths between the operated arm and the non-operated arm. The majority of patients returned to work by six weeks and were pain free by twelve weeks. Less than 5% of patients experienced lateral epicondylitis pain in their elbow post-operatively. A small group of patients altered their occupation or recreational activities due to tennis elbow symptoms. The surgical technique described produces excellent results in greater than 87% of patients in the treatment of resistant lateral epicondylitis. This procedure produces a low complication rate and is associated with a high rate of patient satisfaction. Patient selection is critical in the surgical treatment of resistant lateral epicondylitis.
Rapid bone turnover in Paget’s disease has been of concern to many surgeons performing hip arthroplasties. We present the case of a 71-year-old man with Paget’s disease affecting the proximal femur who fourteen years prior had undergone total hip arthroplasty. He sustained a fracture at the tip of the femoral component that was managed with revision total hip arthroplasty. His postoperative course was complicated by rapid and profound osteolysis of the femur distal to the fracture site, secondary to disease activity. This case highlights the need for awareness of Paget’s disease activity and this potential complication.
Eighty-one patients treated surgically for non-insertional Achilles’ tendinopathy between 1987 and 1999 by one surgeon were reviewed by a comprehensive postal questionnaire. Fifty-six patients (73 tendons) returned a questionnaire at an average of 58.7 months after surgery. The duration of preoperative symptoms averaged 24.6 months. In all cases, conservative treatment was first attempted but failed to alleviate symptoms. Twenty (35.7%) of these patients were involved in competitive or serious recreational sport. There were 34 men and 22 women with a mean age of 42.5 years (range: 23 to 66). All patients who had insertional tendinopathy or retrocalcaneal bursitis were excluded from this study. The surgical procedure consisted of excision of the paratenon circumferentially and early mobilisation. All patients had the same post operative treatment. There were 77.5% excellent, 6.4% good, 6.4% fair and 6.4% poor results. Eleven percent developed complications post operatively. We concluded that surgical decompression of the Achilles’ tendon is a very effective treatment for patients with non-insertional Achilles’ tendinopathy who have failed conservative treatment.
