Introduction and Objective

Continuous peripheral nerve blocks (cPNBs) have shown good results in pain management after orthopedic surgeries. However, the variation of performance between different subspecialities is unknown. The aim of this study is to describe our experience with cPNBs after lower limb orthopedic surgeries in different subspecialties.

Introduction

We present our experience of lower limb reconstruction for patients with obvious defects in the tibia, by bone transport using a stacked Taylor Spatial Frame.

Background

Correct positioning of the femoral component in resurfacing hip arthroplasty (RHA) is an important factor in successful long-term outcomes. The purpose of computer-assisted navigation (CAS) in resurfacing is to insert the femoral neck guide wire with greater accuracy and to help size the femoral component, thus reducing the risk of notching at the head and neck junction. Several recent studies reported satisfactory precision and accuracy of CAS. However, there is little evidence that CAS is useful in the presence of anatomical deformities of the proximal femur, which is frequently observed in young patients with secondary degenerative joint disease.

We present our experience of lower limb reconstruction for patients with obvious defects in the tibia, by bone transport using a stacked Taylor Spatial Frame.

A retrospective review of 40 patients treated between 2003 and 2009. There were 19 cases of infected non union, 9 cases of acute bone loss following fracture, 6 cases of chronic osteomyelitis, 4 cases of aseptic non union, 1 case of neurofibromatosis and 1 case of a loose and infected total ankle replacement.

Twenty-eight out of the 40 patients reviewed have completed their treatment. Of these 28 patients, bony union was achieved in 23 patients, of whom 22 were assessed at discharge to have regained good to excellent limb function, a functional assessment was not available for review in the remaining patient.

In 5 patients, docking site union failed, 3 of whom then underwent below knee amputation. Two patients required treatment with an intramedullary nail following frame treatment to achieve consolidated union of the docking site.

Anatomic sagittal and coronal alignment was achieved in 19 out of 23 patients.

The mean bone regenerate was 53.3 mm (range: 15-180mm), with a mean healing index of 9.2 days/mm (range: 4.4-25 days/mm)

The majority of patients experienced at least one complication, these included pin site and soft tissue infections, refracture, nerve palsy and joint stiffness. Surgical stimulation of the docking site was required in 12 of the 28 patients to promote union.

The use of a stacked Taylor Spatial Frame system is effective for restoring bone length and limb function in patients with bone loss following complex trauma and orthopaedic cases. The computer assisted nature of the spatial frame allows for predictable bone regenerate, minimal residual deformity and accurate bone docking

Open femoral fractures are uncommon, and there are very few reports in the literature which refer specifically to their management.

The results of the treatment of 31 open femoral fractures with significant bone loss in 29 patients treated in a single Orthopaedic Trauma Unit were reviewed. All fractures underwent wound and bony debridement before skeletal stabilisation at restored femoral length, using primary locked intramedullary nailing or dynamic condylar screw fixation for diaphyseal or metaphyseal fractures respectively. Soft tissue closure was performed at 48 hours in the majority of cases, followed by elective bone grafting procedures for 13 of the fractures.

All fractures achieved bony union at an average of 51 weeks (range 20-156 weeks). The time to fracture union and subsequent functional outcome were largely dependent upon the location, type and extent of the bone loss. Union was achieved more rapidly in fractures associated with wedge defects than those with segmental bone loss, and fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Metaphyseal wedge fractures did not require any further procedures to achieve union. Complications were more common in the fractures with greater bone loss, which included knee stiffness, delay to union, malunion and leg length discrepancy. One patient had a deep infection, treated by debridement.

We have produced an algorithm for the treatment of these injuries, based upon our findings. We feel that satisfactory results can be achieved in most femoral fractures with bone loss, using appropriate initial debridement and modern methods of primary skeletal fixation at a restored femoral length, followed by soft tissue coverage procedures and elective bone grafting, as required.

Early methods of treating high-energy tibial plateau fractures by open reduction and internal fixation led to high infection rates and complications. Alternative treatment methods include minimally invasive techniques and implants, external fixator stabilisation (monolateral and circular) and temporary external fixation followed by delayed definitive surgery. A clear understanding of the different fracture types is critical in achieving optimum results with minimally invasive techniques. The Chertsey classification system is based on the direction of force at the time of injury and helps with surgical planning. There are three groups: valgus, varus or axial fracture patterns.

124 tibial plateau fractures have been surgically treated in our hospital since 1995; there were 62 valgus, 14 varus and 48 axial type fracture patterns. Seventy-nine underwent open reduction with internal fixation, and forty-five had an Ilizarov frame. For valgus fractures the average IOWA knee score was 88 if internally fixed or 86 with an Ilizarov frame, range of motion was 140 and 131 degrees and time to union was 81 versus 126 days respectively. Varus fractures had an IOWA score of 83 (ORIF) and 95 (Ilizarov), ROM of 138 and 130 degrees and time to union of 95 versus 82 days. For axial fractures the average IOWA knee score was 85 (ORIF) compared to 82 (Ilizarov), the ROM was 124 degrees for both groups and time to union was 102 days and 141 days respectively.

Deep vein thrombosis occurred in 9% of cases with an Ilizarov and one patient required a total knee replacement for painful post-traumatic osteoarthritis. The infection rate for those internally fixed was 2.5%, three patients required a total knee replacement and 2.5% suffered a DVT.

Our results are comparable to the literature and the Chertsey classification of tibial plateau fractures helps with surgical planning.

Background

Autologous chondrocyte implantation (ACI) and mosaicplasty (MP) are two methods of repair of symptomatic articular cartilage defects in the adult knee. This study represents the only long-term comparative clinical trial of the two methods.

Introduction

Getting the distal locking screw lengths right in volar locking plate fixation of distal radius is crucial. Long screws can lead to extensor tendon ruptures whereas short screws can lead to failure of fixation, especially if there is dorsal comminution of the fracture. The aim of our study was to determine the distal radius anatomy in relation to sagittal lengths and distance between dorsal bone edge and extensor tendons based on MRI scan.

Autologous chondrocyte implantation is now a recognised treatment for patients with knee pain secondary to articular cartilage defects. The initial technique involving periosteum as the cover for the implanted cells (ACI-P) has been modified to the use of a type I/III collagen membrane (ACI-C). Matrix-induced Autologous Chondrocyte Implantation (MACI) is a technique in which autologous donor chondrocytes are implanted onto the collagen membrane and then fixed into the defect with fibrin glue.

We performed a prospective randomised comparison of 247 patients (126 ACI and 121 MACI). Patients' pain and function were assessed with mean follow-up of 42 months. Function was measured using the Modified Cincinnati and Stanmore Scoring systems. Arthroscopic assessment was by the ICRS classification. The influence of the size and site of the lesion, sex, age and previous knee surgery on the results was analysed.

The Modified Cincinnati score showed a mean 17.5 point rise from pre-operative scores in the ACI group and 19.6 point rise in the MACI group. Pain, measured using the Visual Analogue Score, showed an improvement in both arms of the trial.

Both chondrocyte implantation methods showed improvement in 86% of patients clinically and arthroscopically, with excellent and good results in 50% and fair results in 30% of patients. 20% of patients showed no improvement in function but none were worse. There were no serious complications. Limited histological analysis showed hyaline cartilage in a higher but non-significant proportion of ACI-C cases.

With over 11 years' experience in the use of both forms of cartilage implantation we have established more precisely the indications for chondrocyte implantation. Although MACI is technically a more attractive option in most cases, because of ease and speed of the procedure, longer term follow-up is required to assess the longevity of ACI-C and MACI and the effect on prevention of ‘early-onset’ Osteoarthritis.

Introduction

Total elbow arthroplasty (TEA) is a widely accepted for the treatment for damaged rheumatoid elbows to achieve sufficient joint function. The current prospective study reports the long term follow-up of TEA with an unlinked stem type (Stemmed Kyocera type I, SKC-I) with a solid trochlea on patients who have rheumatoid arthritis (RA). SKC-1 is derived from an unlinked surface replacement prosthesis using polycrystalline alumina ceramics on high-density polyethylene (Kyocera type I), which was developed in 1979, based on the measurement study on the cadaveric elbows.

Materials and Methods

57 elbows (Larsen’s grade IV and V) from 45 RA patients replaced by SKC-1 were investigated. Cement fixation was used in all cases. The duration of follow-up ranged from 36 to 154 (average 73. 7) months. The clinical condition of each elbow before and after operation was assessed according to the scoring system of Japanese Orthopaedic Association (JOA) elbow scoring system (maximum 100 points), which is composed of scores for pain, activity of daily life, muscle strength, range of motion, instability, and deformity of the joint. On the basis of this system, the results are defined as excellent (90–100 points), good (75–89), fair (60–74), and poor (< 60). Radiographic loosening was defined as a progressive radiolucent line of more than two millimeters that completely surrounded the prosthesis.

Results

The average postoperative JOA score improved from 43. 5±10. 2^° to 81. 0±}10. 3^°, with marked pain relief. The mean range of motion (ROM) of extension/flexion before the surgery was –35. 7±}22. 4/117. 1±}19. 1^° and at last follow-up was −17 5±}12. 7/136. 3±}11. 4^°. The mean ROM of pronation /supination improved from 51. 1±}23. 4/56. 5±}28. 5^° to 78. 3±}16. 8/82. 3±}16. 5^°. Of the 57 elbows, 9 elbows were judged to have excellent results, 37 had good results, 8 had fair results, and 3 had poor results.

There were no instances of ulnar nerve palsy, triceps avulsion, or postoperative infection. Medial or lateral epicondylar fracture occurred in 2 cases during the operation, and union was achieved 3 months later. Massive instability with joint dislocation was seen in 3 cases of mutilans arthritis, resulting in poor results. Aseptic loosening was seen in 3 elbows. Revision surgery was performed in 1 case of accidental post-operative distal humerus fracture, and in another of olecranon fracture with the breakage of the ulnar component. With loosening defined as the end point, Kaplan-Meier curve of the cumulative probability of survivorship demonstrates the likelihood of survival of the prosthesis at 93. 8 percent for as long as 10 years.

Discussion

The results of the current study showed a high reliability of the SKC-1 prosthesis with the novel alumina ceramic component over a long period when implanted with cement. However, the use of non-constrained devices is limited by the amount of bone and by the need for ligamentous stability. If soft tissues are damaged along with marked bone loss or inflammatory changes, the ligament should be repaired or a semiconstrained type of prosthesis is indicated. It is important to note that a high level of surgical technique is required for TEA in RA elbows to avoid typical postoperative complications.