Background

RHF nail is an important tool for simultaneous ankle and subtalar joint stabilisation +/− fusion. Straight and curved RHF nails are available to use, but both seem to endanger plantar structures, especially the lateral plantar artery and nerve and Baxter's nerve.

There is a paucity of literature on the structures at risk with a straight RHF nail inserted along a line bisecting the heel pad and the second toe (after Stephenson et al). In this study, plantar structures ‘at risk’ were studied in relation to a straight nail inserted as above.

Increasing expectations from arthroscopic anterior cruciate ligament (ACL) reconstructions require precise knowledge of technical details such as minimum intra-femoral tunnel graft lengths. A common belief of having ≥20mm of grafts within the femoral tunnel is backed mostly by hearsay rather than scientific proof.

We examined clinico-radiological outcomes in patients with intra-femoral tunnel graft lengths <20 and ≥20mm. Primary outcomes were knee scores at 1-year. Secondarily, graft revascularization was compared using magnetic resonance imaging (MRI). We hypothesized that outcomes would be independent of intra-femoral tunnel graft lengths.

This prospective, single-surgeon, cohort study was conducted at a tertiary care teaching centre between 2015–2018 after obtaining ethical clearances and consents. Eligible arthroscopic ACL reconstruction patients were sequentially divided into 2 groups based on the intra-femoral tunnel graft lengths (A: < 20 mm, n = 27; and B: ≥ 20 mm, n = 25). Exclusions were made for those > 45 years of age, with chondral and/or multi-ligamentous injuries and with systemic pathologies. All patients were postoperatively examined and scored (Lysholm and modified Cincinnati scores) at 3, 6 and 12 months. Graft vascularity was assessed by signal-to-noise quotient ratio (SNQR) using MRI. Statistical significance was set at p<0.05.

Age and sex-matched patients of both groups were followed to 1 year (1 dropout in each). Mean femoral and tibial tunnel diameters (P =0.225 and 0.595) were comparable. Groups A (<20mm) and B (≥20mm) had 27 and 25 patients respectively. At 3 months, 2 group A patients and 1 group B patient had grade 1 Lachman (increased at 12 months to 4 and 3 patients respectively). Pivot shift was negative in all patients. Lysholm scores at 3 and 6 months were comparable (P3= 0.195 and P6= 0.133). At 1 year both groups showed comparable Cincinnati scores. Mean ROM was satisfactory (≥130 degrees) in all but 2 patients of each group (125–130 degrees). MRI scans at 3 months and 1 year observed anatomical tunnels in all without any complications. Femoral tunnel signals in both groups showed a fall from 3–12 months indicating onset of maturation of graft at femoral tunnel.

Our hypothesis, clinical and radiological outcomes would be independent of intra-tunnel graft lengths on the femoral aspect, did therefore prove correct. Intra-femoral tunnel graft lengths of <20 mm did not compromise early clinical and functional outcomes of ACL reconstructions. There seems to be no minimum length of graft within the tunnel below which suboptimal results should be expected.

Abstract

In cerebral palsy patients, while upper limb function is acknowledged as being important, it has traditionally taken a back seat to lower limb function. This is partly due to inexperience and partly due to difficulty deciding on the best way of improving upper limb function.

In Swansea since June 2008 we have been offering a multi-disciplinary service for the assessment and treatment of upper limb problems in cerebral palsy. The core team consists of a consultant orthopaedic surgeon, a consultant plastic surgeon with a special interest in CP upper limb problems, a consultant paediatric neurologist, a community paediatric physiotherapist and a community paediatric occupational therapist.

Upon referral, the physiotherapist and occupational therapist carry out initial functional assessment of the patient. This is followed by a joint assessment by the whole team in a special clinic held every 3 months. If required, the child is offered surgery, botox injections or both. Further follow-up is in the special clinic until the child is suitable for follow-up in a normal clinic.

We present our initial experience with this multi-disciplinary approach, the problems encountered in setting up the service and our plans for the future.

To assess the effect on knee motion of gradual femoral lengthening using an intramedullary nail, between 1994 and 2003, 27 non-achondroplastic patients had bilateral femoral lengthening using the Albizzia nail. Vigorous post-operative physiotherapy was the norm. Knee motion recorded at various stages pre and post-operatively was compared.

For an average gain of 6 cm the mean flexion during lengthening was 119. By final follow-up all patients had regained pre-operative range of motion. No tenotomies or joint manipulations were required. Good knee motion can be maintained during femoral lengthening using an intramedullary lengthening device.

Background: Knee prosthesis design is being constantly altered in a bid to imitate kinematics of the normal knee. It is hoped that this will improve the wear characteristics and performance of the implant. The ‘Medial Pivot’ knee has a characteristic geometry and is expected to lower contact stresses on the tibial surface and ease rehabilitation while providing greater stability.

We conducted a study comparing the midterm outcome of the Medial Pivot knee (MP) to the Posterior Stabilised (PS) knee.

Materials and Methods: Over a 3 year period, 312 knee replacements were carried out of which 124 were MP and 188 were PS. 100 patients from each of the 2 groups were called for review. Demographic data, age at operation, time since surgery and ASA grading were noted. Postoperative knee function was assessed using the American Knee Society (AKS) and Oxford Knee (OK) scores and the scores were compared between the 2 groups. Individual functional parameters were also compared.

Results: 38 patients with 42 replaced knees in the MP group and 43 patients with 52 replaced knees in the PS group were reviewed. The 2 groups were comparable in terms of gender of patients and age at operation and were followed up to a mean 31 months. For the MP group the mean AKS knee assessment score was 77/100, AKS function score was 75/100 and OK Score was 23/60. For the PS group the corresponding values were 81/100, 77/100 and 22/60. The differences in scores between the groups were not statistically significant. Only active and passive knee extension was better following MP Arthroplasty than PS arthroplasty (p< 0.05). Although the mean flexion was better following the PS arthroplasty, this was not statistically significant.

Conclusion: Our study has shown that the midterm outcome for the Medial Pivot knee system did not show any distinct advantage over the Posterior Stabilised knee system in terms of knee pain & function.

Introduction: Restoring normal mechanical axis is one of the key goals of the total knee arthroplasty (TKA). The majority of the surgeons resect the tibia perpendicular to its axis in the coronal plane, then use an intra-medullary jig inserted through the centre of the knee or slightly medial to centre of the knee to resect the distal femur at a 6 or 7degree valgus angle. The aim was to establish the safety of using a predetermined valgus angle (VA) and entry point (EP) in the primary TKA. We also studied the relationship between the VA and EP to the height, weight and BMI of the patient.

Materials and Methods: We studied 125 long leg radiographs of 125 patients who underwent TKA under the care of senior author. All the radiographs were taken in the preoperative clinic with knee in full extension and patella facing forward. The radiographs were used to measure the valgus angle and entry point of the femur. The patients with VA between 6–7 degrees and EP at the centre were defined as normal group and rest were defined as outliers.

Results: The VA ranged from 4 to 9.5 degrees (with a mean of 6.8 and SD 1.11). Only 66 (53%) knees had the VA between 6 and 7 degrees. The EP ranged from 30mm medial to 18mm lateral to the centre of the knee with a mean of 7.7mm medial to the centre of the knee (SD 6.1). The EP was at the centre of the knee in 31 (24.8%) knees and lateral to the centre in 19 (15.2%) knees. Only 14 (11.2%) knees were in the normal group. Overall there was no significant relationship between the EP and VA to the height, weight or BMI of the patient at p-value > 0.001.

Conclusions: The resection of distal femur using the predetermined valgus angle, the predetermined entry point is not a safe practice in TKA. The long leg radiographs of the knee should be studied to identify the outliers. In future computer-assisted surgery and digitalisation of the images may obviate the need for this. However, it may be prudent though to use pre-operative templating of long leg radiographs during the learning curve of computer assisted surgery as well.

Vast amount of literature is available on mechanical properties of PMMA, but not about the composite specimens of old and new cement. This is important, as in cement revision has become established technique with good clinical results. Originally Greenwald and later Li described properties of such specimens. However in these studies the old samples were only few days old, unlike clinical situation, where the old cement is a few years old.

We therefore decided to test short-term mechanical properties of composite specimens and compare these with new uniform specimens. We choose specimens of cement 3–17 years old (median 11.8) for the manufacturing of the composite specimens.

Material and Methods: Uniform and composite specimens were fabricated and were tested for bending, tensile and shear strength. Beam shaped specimens were fabricated for bending and tensile tests, cylindrical for shear. Seventeen beams and eight cylindrical specimens fabricated earlier (1988–2002) using the same moulds were available to form composite specimens. Old specimens were placed into the moulds and new cement was injected next to these. Specimens were allowed to polymerize at room temperature for 30 minutes and stored in saline at 37 °C for 6 weeks before testing. Specimens were tested in Lloyds EZ 20 machine with customized jig so that the junction was subjected to bending, tensile or shear force.

Results: Bending tests: The load and bending stress for new specimen was 80N and 47MPa as compared with 72N and 38MPa for composite specimens. 4 composite specimens failed though old cement, 3 through the junction and 1 through the new cement. There was no statistical difference in maximum load between uniform and composite specimens (p=.29). However there was a difference in the stress between uniform and composite specimens.

Tensile tests: The load and tensile stress for new specimen was 916N and 29MPa as compared with 795N and 24MPa for composite specimens. 7 composites failed through old cement, 1 through new cement and 1 at junction. There was difference in the load and stress of uniform specimens as compared with composite specimens.

Shear tests: The load and shear stress for new specimen was 2718N and 35MPa as compared with 2055N and 26MPa for composite specimens. There was significant difference in load as well as stress in uniform specimens as compared with composite specimens.

Discussion: This study demonstrates that composite specimens fail at 89.6% of bending load, 77.2% of tensile and 74.6% of shear load as compared with uniform new cement specimens. They have 81.4% of bending stress, 74.9% of tensile stress and 73.3% of shear stress at failure as compared with uniform specimens. Of more importance is the fact that only four of these composite specimens (23.5%) failed at the junction and the rest thirteen failed either through old cement (64.7%) or through new cement (11.8%).

Objective: Prolonged waiting time after being referred for a specialist opinion has plagued the NHS despite pressures to deliver optimum healthcare. We have assessed changes in clinical situation in patients referred to a spinal service while awaiting the first assessment.

Materials & Results: 89 patients were referred to our unit between Jan 2001 and December 2004. The gender distribution in this cohort was equal and the mean age was 50.7 yrs. The mean delay for being seen in the clinic was 28.4 mo (16–58 mo). Significant changes in the symptom pattern were noted in 46 patients, of which 8 patients reported radicular symptoms on a different side. In addition, 7 patients experienced an increased severity in the existing symptoms. 43 patients had been referred to us with an MRI. However due to the delay, 20 of these patients required re-scanning. Following the clinical assessment 25 patients were referred for Physiotherapy, 4 patients required a further clinical review and 44 patients were referred for further imaging.

Conclusion: The problem of excessive out-patient waiting time results in changes in symptom patterns and an increase in the severity of existing symptoms. The changes frequently results in an increased requirement of re-imaging.

The aim of this study was to evaluate whether using a predetermined entry point and standard value for valgus cut could restore normal mechanical axis of the TKA.

The study included 125 consecutive patients, who underwent TKA under care of the senior author (NJD). Details of height, weight, BMI were noted. All the radiographs were taken with the patient standing, with the knees in maximum extension, with the patella facing forward. The long leg radiographs were evaluated and the mechanical axis and anatomical axis were marked. The entry point (EP) and the angle between the anatomical and the mechanical axis of the femur ware measured, which is valgus angle of distal femoral cut (VA). Statistical analysis was done using SPSS (Table 1). Proportion of the cases with VA less than 6 degrees or more than 7 degrees were identified. Similarly cases with EP distance less than 0 and more than 5mms were also identified. Cases with VA of 6–7 degrees and EP 0–5mms were identified as one group. Correlation was performed using nonparametric tests.

The results revealed the angle between the anatomical and the mechanical axis ranges from 4 to 9.5 degrees (mean 6.8 degree and standard deviation 1.11 degree). Only 53% had an angle of between 6 and 7 degrees, with 7% of knees having an angle of less than 5 degree or greater than 8 degrees.

The site of entry of the jig showed variation from 30mms medial to the centre to 18mms lateral to the centre with the mean entry point of 5.04mms medial to centre of the notch, with a standard deviation of 8.5mms.

Overall only 33% of the knees templated would have an optimal femoral jig placement and distal femoral angle cut with an entry point in the centre of the notch or up to 5mms medial to centre and a distal valgus cut of between 6 and 7 degrees. The author feel this study gives evidence that if the mechanical axis is to be restored then long leg pre-operative radiographs should be performed and used as a key component to the pre-operative plan.

Table 1. Spearman’s rho correlations, between the valgus angle and entry point to the height, weight and BMI of the patients.

Stem dissociation in modular revision knee replacement due to failure of the frictional lock of the Morse taper has been reported in the literature. However, the medium and long-term implications of stem dissociation are unknown, as clinical outcomes have not been reported. We report a series of 10 cases in which there was intra-operative dissociation of the tibial stem.

Between 1994 and 1999, 98 patients underwent revision total knee replacement for aseptic loosening at our institution. Ten of these patients were noted to have tibial stem dissociation, apparent on the immediate post-operative radiographs. The senior author (RWP) performed all procedures and used a standardized operative technique. The Co-ordinate modular knee revision system was used in all cases. The quality of the bone was noted in all the cases intra-operatively; and was graded as 1) sound bone, 2) soft but intact, 3) soft and fractured cortex.

Our study demonstrates that the tibial stem dissociation did not cause any significant detriment to the clinical outcome on minimum follow-up of six years in nine cases where the tibial metaphyseal cortical rim was intact. In one case, where the medial tibial plateau had a cortical defect, the prosthesis drifted into varus mal-alignment and the patient required a further revision for aseptic loosening. We therefore question whether long canal filling tibial stems are necessary in all revision total knee replacements particularly when the cortical rim is intact and a non-constrained poly-ethylene insert is used.

Introduction: The purpose of this study was to evaluate the predictors of outcome of hip reconstruction in cerebral palsy and to review the trend in recovery over five years following operations.

Methods: 39 reconstructions in 22 patients [mean age 9.9 SD 2.1] with a mean follow up of 4.7 years were reviewed retrospectively. Information regarding diagnosis, preoperative function and symptoms, details of operation and the postoperative status were retrieved from the clinical records. Preoperative, postoperative and yearly follow up radiographs were reviewed to document acetabular index, Rimmer’s migration percentage (MP) and CE angle. 17 patients underwent simultaneous bilateral hip reconstruction. Femoral osteotomy was performed in all cases in the primary hip and in 17 cases in second hip. Acetabuloplasty was performed in 18 patients in the worst hip and only in 5 cases in the second hips.

Results: The mean preoperative MP in the worst hip was 81%. This improved to 30.7%. In the second hip it improved from 38% to 12.2%. The follow up measurements of the acetabular indices, MP and CE angle had a significant correlation with the postoperative measurements (p< 0.05). In 18 patients hip pain improved and in 14 patients sitting tolerance improved. Perineal hygiene improved in 7 patients following the operation. Graphs of trends in the MP and CE angle are presented. There was no correlation between preoperative presence of pelvic obliquity and post operative outcome. There was no significant difference in outcome in the groups of patients based on open reduction at the time of surgery.

Discussion and Conclusions: The final outcome of the reconstruction can be predicted consistently from the first postoperative radiograph. The quality of reduction at the time of operation is of paramount significance in ensuring long-term survival of the reconstruction.

Purpose of study : – To highlight possible complications following Philos plating of proximal humeral fractures.

Methods : – 10 patients with proximal humeral fractures operated upon in period 2003–2004 were reviewed. Analysis was undertaken with observer xray review and using radiograph analysis software.

Results : – In 3 cases the fracture had collapsed significantly resulting in cut out of the proximal screws. One case required implant removal within a month following initial surgery. In another case the radiographs were not standardised views to compare the amount of collapse. The other cases went onto healing without any complication.

Conclusions : – As the Philos plate is a fixed angle implant the degree of collapse expected must be accounted for when fixing the implant this is especially important in osteoporotic patients or in those with a high degree of comminution. In these circumstances high placement of the plate and long proximal screws should be avoided.

Introduction We have reviewed the clinical outcome and complications of Monofocal and Bifocal Callotasis for lower limb lengthening in children with Achondroplasia.

Methods Between August 1986 and January 1999, 57 children with Achondroplasia had lower limb lengthening. Monofocal callotasis had been carried out in 147 Segments of 44 children and bifocal callotasis in 38 segments of 17 children. Complications were noted and final outcomes recorded.

Results The 29 children who completed the programme gained an average of 20 cms in height. For all patients, the mean length gained per segment was roughly nine centimetres. Average Bone Healing Index in the mono-focal lengthening group was 39.9 days/cm and in the bifocal lengthening group 33.6 days/cm. Complications were staged and graded and the average was 2.8 complications per lengthened segment. Most were pin-site related and occurred during stage of distraction. Twenty percent of the segments required further axis corrections. Most patients regained their pre-operative range of motion. Serious irreversible complications were seen in only two patients and included a physeal bar and psychological disturbances. Functional outcome analyses are planned.

Conclusions Limb lengthening for short stature due to Achondroplasia can be confidently undertaken with favourable results in most cases. Bifocal lengthening is an alternative technique with quicker consolidation time.

Introduction Chronic venous insufficiency can be a disabling complication following otherwise successful arthroplasty. The objectives of this study were 1) To evaluate correlation between the CIVIQ (questionnaire) score and the clinical score in a cohort of patients with lower limb arthroplasty. 2) To evaluate if CIVIQ score can predict post-phlebitic syndrome.

Methods A cohort of 44 patients at least three years following primary lower limb arthroplasty was selected. The control group included 22 patients who did not have DVT. The study group included 22 age matched patients who had DVT following the index procedure. CIVIQ score and clinical score was obtained. Statistical analysis included correlations, linear regression analysis and independent sample t-test.

Results The CIVIQ and clinical scores showed significant correlations, with r=0.66 (p 0.01). The linear regression yielded the formula; CIVIQ score equals 32 plus 1.7 (clinical score) with power of 0.9. There was statistically significant difference in the CIVIQ score in the study and control groups (p 0.013, power 0.9).

Conclusions CIVIQ is an effective tool to predict post-phlebitic syndrome in patients with arthroplasty. This is especially useful as it is self administered and hence can be done as a postal or telephone survey.

Introduction Intermediate and long-term results following extracapsular fracture neck of femur have been evaluated in the past. However the precise effect of the type and the stability of the fracture on the early outcome is not known. This study evaluates the correlations between type and stability of the fracture, length of stay and predictors of early functional outcome.

Methods Ninety-five consecutive cases admitted with intertrochanteric fractures were reviewed retrospectively. Eight patients died during the hospital stay and were excluded from the study. Revision surgery for implant failure was excluded from the study. The medical records were reviewed to determine the pre-operative functional status and the outcome. Radiographs were reviewed by one of the authors to classify the fracture according to AO and Tronzo classification. Statistical analysis was performed using bivariate analysis and multistep logistic regression analysis.

Results The factors influencing the post-operative length of stay most were age and AO classification. The factors influencing post-operative mobility were pre-operative mobility, accommodation and presence of complications. The factors predicting post-operative accommodation were pre-injury accommodation and mobility. The mean difference in the pre and post-operative mobility grade was 1.9. The mean difference in the pre and postoperative accommodation grade was 1.31.

Conclusions One of the reasons for classification is to predict the prognosis. Our study showed that age and AO classification can predict length of stay in hospital. This can be used to pre-empt the discharge strategy.