In arthritic knees with severe valgus deformity Total Knee Arthroplasty (TKA) can be performed through medial or lateral parapatellar approaches. Many orthopaedic surgeons are apprehensive of using the lateral parapatellar approach due to lack of familiarity and concerns about complications related to soft tissue coverage and vascularity of the patella and the overlying skin. However surgeons who use this approach report good outcomes and no added complications. The purpose of our study was to compare outcomes following TKA performed through a medial parapatellar approach with those performed through a lateral parapatellar approach in arthritic knees with severe valgus deformity.

We conducted a retrospective review of patients from two consultants using computer navigation for all their TKAs. All patients with severe valgus deformities (Ranawat 2 & 3 grades) operated on between January 2005 and December 2011 were included. 66 patients with 67 TKAs fulfilled the inclusion criteria. Patients were group by approach; Medial = 34TKAs (34 patients) or Lateral = 33 TKAs (32 patients). Details were collected from patients' records, AP hip-knee-ankle (HKA) radiographs and computer navigation files. Outcome measures included lateral release rates, post-operative range of knee movements, long leg mechanical alignment measurements, post-operative Oxford scores at six weeks and one year, patient satisfaction and any complications. Comparisons were made between groups using t-tests.

The total cohort had a mean age of 69 years [42–82] and mean BMI of 29 [19–46]. The two groups had comparable pre-operative Oxford scores (Medial 41[27–56], Lateral 44 [31–60]) and pre-operative valgus deformity measured on HKA radiographs (Medial 13° [10°–27.6°], Lateral 12° [6°–22°]). Three patients in the Medial group underwent intra-operative lateral patellar release to improve patellar tracking. Seven patients in the Lateral group had a lateral condyle osteotomy for soft tissue balancing (one bilateral). There was no statistically significant difference between groups at one year follow up for maximum flexion (Medial 100° [78°–122°], Lateral 100° [85°–125°], p=0.42), fixed flexion deformity (Medial 1.2° [0°–10°], Lateral 0.9° [0°–10°], p=0.31) or Oxford score (Medial 23 [12–37], Lateral 23 [16–41], p=0.49). Similarly there was no difference in the patient satisfaction rates between the two groups at one year follow up. However there was a statistically significant difference in the mean radiographic post-operative alignment angle measurement (Medial 1.8° valgus [4° varus to 10° valgus], Lateral 0.3° valgus [5° varus to 7° valgus], p=0.02). One patient in the Medial group had a revision to hinged knee prosthesis for post-operative instability. There was no wound breakdown or patellar avascular necrosis noted in either of the groups.

The lateral parapatellar approach resulted in slightly better valgus correction on radiographs taken six weeks post-operatively. We found no major complications in the Lateral parapatellar approach group. Specifically we did not encounter any difficulties in closing the deep soft tissue envelope around the knee and there were no cases of patellar avascular necrosis or skin necrosis. Hence we conclude that lateral parapatellar approach is a safe and reliable alternative to the medial parapatellar approach for correction of severe valgus deformity in TKA.

INTRODUCTION

Leg length discrepancy following total hip arthroplasty (THA) can be functionally disabling for affected patients and can lead on to litigation issues. Assessment of limb length discrepancy during THA using traditional methods has been shown to produce inconsistent results. The aim of our study was to compare the accuracy of navigated vs. non navigated techniques in limb length restoration in THA.

Distal femur resection for correction of flexion contractures in total knee arthroplasty (TKA) can lead to joint line elevation, abnormal knee kinematics and patellofemoral problems. The aim of this retrospective study was to establish the contribution of soft tissue releases and bony cuts in the change in maximum knee extension in TKA.

Data were available for 211 TKAs performed by a single surgeon using a medial approach. Intra-operatively pre- and post-implant extension angles and the size of bone resection were collected using a commercial navigation system. The thickness of polyethylene insert and the extent of soft tissue release performed (no release, moderate and extensive release) were collected from the patient record. A linear model was used to predict change in maximum extension from pre- to post-implant.

The analysis showed that bone cuts (p<0.001), soft tissue release (p=0.001) and insert thickness (p=0.010) were all significant terms in the model (r²_adj=0.170). This model predicted that carrying out a TKA with 19 mm bone cuts, 10 mm insert and no soft tissue release would give 4.2° increase in extension. It predicted that a moderate release would give a further 2.8° increase in extension with an extensive release giving 3.9°. For each mm increase in bone cuts the model predicted an 0.8° increase in extension and for each mm increase in insert size a decrease extension by 1.1°.

The modelling results show that in general to increase maximum extension by the same as an extensive soft tissue release that bone cuts would have to be increased by 4–5 mm. However this model only accounted for 17% of the variation in change in extension pre- to post-implant so may not be accurate at predicting outcomes for specific patients.

Introduction

Aseptic loosening is the most common mode of failure of massive endoprostheses. Introduction of Hydroxyapatite coated collars have reduced the incidence of aseptic loosening. However bone growth is not always seen on these collars.

Introduction

We aimed to determine the extent of osseous integration of the hydroxyapatite collars of tumour endoprostheses implanted in our unit.

Purpose

The aim of this prospective study was to determine the usefulness of a gravity stress view in detecting instability in isolated Weber B fractures of the fibula.

Introduction: Distal third fractures of the clavicle account for approximately 10–15% of clavicle fractures. Non union rates following conservative management can be as high as 30%. Many techniques have been described, including external fixation, k-wire fixation, and most recently, hook plate fixation. Non-absorbable sutures, and slings have also been utilised. All of these techniques are associated with complications. In addition, Hook plates require a second operation to remove the plate. This study reports the results of a simple technique using a PDS loop in the fixation of Neer type 2 fractures of the clavicle, performed in our institution.

Methods: Twelve patients with Neer type 2 fractures operated by a single surgeon over three years were included in the study. The mean age was 45 (14 to 63). There were 7 male and 5 female patients. Standard postoperative protocols were followed in all patients. A 1.5 PDS cord looped around the coracoid was used to hold the reduced medial clavicular shaft fragment. Patients were followed up postoperatively at two, six and twelve weeks. Final outcomes were assessed using radiographs and the Oxford and DASH scoring systems at twelve months.

Results: Ten fractures united within twelve weeks. All of these patients returned to their pre-injury activity level. There were two non unions, both in non compliant patients. One of these non unions remained asymptomatic and one patient was lost to follow up. The mean Oxford score at 12 months was 14.25 (range 12 to 16) and the mean DASH score was 5 (4–7).

Conclusion: We conclude that this technique is safe, simple and cost effective. It achieves high rates of union without the need for implant removal. As with other techniques, proper patient selection is essential. We recommend this technique as an excellent treatment option when dealing with these notoriously difficult fractures.

Percutaneous fixation is a well recognised technique in the treatment of three-part and four-part fractures of the proximal humerus. Minimal fixation of these fractures do show good functional outcome and may further reduce the incidence of avascular complications. We report a preliminary series of 11 patients who underwent percutaneous minimal fixation of such complex humeral fractures using a new technique. 11 consecutive patients (7 with three-part fractures and 4 with four-part fractures) treated by percutaneous limited fixation in our Hospital were involved in this retrospective study. There were 7 fractures with valgus displacement. Percutaneous technique was employed using small incisions and the fracture was reduced under image guidance. The three-part and the four-part fractures were essentially converted into two part fractures, i.e. only the greater and the lesser tuberosities were re-attached to head with AO cancellous screws after realignment of the fragments. The shaft of the humerus was not fixed to the head in any of the cases. All of these cases had a minimum follow-up of at least 6 months. The results were evaluated using the Constant -Murley Shoulder score. 1 out of 11 cases had to be converted to hemi-arthroplasty due to secondary redisplacement of the fracture. The remaining 10 cases showed good bony union although the greater tuberosity in 2 cases showed a residual superior displacement of 3mm and a residual valgus displacement in 2 out of 7 cases. There were no complications of avascular necrosis in any of the cases. Clinically, compared to the uninjured side the average constant score was 93.7% (range- 68.7% – 100%). 7 patients were very satisfied and 4 were satisfied with the operation. Percutaneous minimal fixation achieves good to very good functional outcome comparable to the conventional methods and theoretically reduces the incidence of infection, avascular necrosis and neurological complications.

Purpose: To evaluate the objective outcomes in patients who had undergone hardware removal after ORIF of calcaneus fractures.

Materials and Methods: Between 1994 and 2002, 31 cases of hardware removal was performed in 30 patients (25 male, 5 female) with an average age at operation of 47 years (31 to 65 years) were reviewed. Patients’ demographic details were recorded including smoking habit. Fracture patterns were graded according to the Sanders’ classification with preoperative CT scans. The clinical result was assessed using Bristol hind foot scoring system. Serial radiographs assessments were also recorded.

Results: Average follow-up was 4.5 years. Average delay from time of injury to surgery was 12.4 days (range 5 to 24 days). 7 (23%)fractures were Sanders’ type 2A, 8 (26%)fractures were type 2B, 6 (19%)fractures were type 2C, 2 (6%) fractures were type 3AB and 8 (26%) fractures were type 3AC. Average time from surgery to hardware removal was 27 months (range 11 to 45 months). There were 16 smokers and 14 non-smokers. There were 5 deep infections and 3 superficial wound infections after ORIF of calcaneus fractures. 84% of the patients shown objective improvement following hardware removal at the latest follow-up. 2 patients had unsuccessful hardware removal due to dense scarring. No wound infections were recorded. Smoking habit had no significant bearing on the objective outcome improvement following hardware removal (p= 0.891), time from surgery to hardware removal (p=0.53) and wound morbidity (p= 0.4882). Objective improvement showed a statistically significant improvement in the Sanders’ type 2 compared with Sanders’ type 3 (p=0.015).

Conclusion: Removal of hardware is justified in symptomatic patients following ORIF calcaneus fractures. It results in an improved objective outcome and has a low complication rate. Hardware removal may be considered in cases of Sanders’ type 2 calcaneus fractures which are refractory to improvement.

Introduction: Stainsby’s procedure for correction of severe claw toe deformity is a relatively new procedure in foot and ankle surgery. The purpose of this study is to evaluate our early experience in a single institution.

Method: Between 1998 and 2002 we reviewed retrospectively 17 patients who had severe claw toe deformity who had undergone Stainsby’s procedure. All patients had lesser toe involvement. The records and radiographs were reviewed and the subjective assessment by telephone interview.

Results: Eleven females and six males were included. There were 21 feet and 42 toes with four bilateral feet involvement. Mean age of 56.7 years (range 40–78) and median follow-up was 28 months (range 8–48). Ten feet in nine patients undergone single lesser toe correction and 11 feet in eight patients undergone multiple toe correction were reviewed. Five patients (29.4%) with six feet suffered rheumatoid arthritis (RA); four patients (23.5%) with six feet suffered cavus deformity and the remaining eight patients (47.1%) with nine feet had isolated toe pathology. All patients were presented with shoe wear problem with 16 (94.1%) patients had pain related to callosities. Sixteen (94.1%) patients were satisfied with the results; two patients had persistent metatarsalgia. Forty (95.2%) toes had good alignment and two (4.8%) toes had recurrent asymptomatic clawing. Fifteen (88.2%) patients had unlimited daily activities. Eleven (64.7%) patients are able to have normal foot wear, four (23.5%) require insole support and two (11.8%) required soft padding only. Complications included sensory alteration in two patients who had multiple lesser toe correction and seven patients had superficial wound infection. There was no statistical difference in results related to number of toes operated on and association with RA.

Conclusion: Stainsby’s procedure remains a versatile surgical technique when dealing with severe claw toe deformity. It gives very good correction with high patients’ satisfaction rate and a low complication rate. We recommend this surgical technique, as one of the armamentarium foot and ankle surgeons should acquire.