Fractures of the distal third of the adult tibia pose a management problem. Conservative treatment often results in delayed and non-union, mal union or sub optimal functional results in terms of joint motion. Closed reduction and intramedullary fixation may not be possible where the fracture line traverses or lies distal to the level of the locking screws and open reduction and internal fixation at this level has a high soft tissue complication rate. Percutaneous plating provides a safe and minimally invasive procedure for fixation of these fractures. In our unit, over an eighteen month period from September 1999 to March 2001, fourteen patients (ten male and four female) with an average age of forty five (range sixteen to sixty nine years) with fractures of the distal third of the tibia underwent percutaneous plating. Thirteen cases were isolated limb injuries and one occurred in a polytrauma patient with bilateral lower limb injuries. Eight were A1.2, four A1.3 and two B1.3 fractures according to the OTA classification. Only one injury was compound. All patients had a general anaesthetic and antibiotic prophylaxis. The procedure was carried out under tourniquet control and fluoroscopy. Except for the polytrauma patient, all procedures were carried out within seventy two hours of the injury. All fractures were reduced closed and fixed percutaneously with either a semi tubular or DCP plate. The average tourniquet time was 50 minutes. A below knee plaster slab was used in the initial postoperative period and patients were mobilised non weight bearing in a below knee cast at forty eight hours. Patients were followed up in the out patients at two weeks for suture removal and cast change. The average period of non weight bearing was ten weeks. There were no cases of wound infection and union was achieved in all cases with an average time to union of fourteen weeks. After union, three patients underwent a further procedure to remove symptomatic metalwork. On clinical review, all patients had an excellent range of knee and ankle motion. One patient with an associated subtalar dislocation developed marked stiffness at that joint. Percutaneous plating is a quick and relatively easy way of achieving biological fixation of distal tibial fractures. In our study, there was a very low complication rate with predictable union and excellent functional results

Aim. Dissolvable antibiotic-loaded calcium sulphate beads have been utilized for management of periprosthetic joint infection (PJI) and for aseptic revision arthroplasty. However, wound drainage and toxic reactive synovitis have been substantial problems in prior studies. Currently a commercially pure, physiologic product has been introduced that may reduce complications associated with this treatment modality. We aim to answer the question: does a commercially pure, physiologic version of antibiotic-loaded calcium sulfate beads reduce wound drainage and provide efficacious treatment for PJI and aseptic revision arthroplasty?. Method. Starting January 2010, 756 consecutive procedures were performed utilizing a set protocol of Vancomycin and Tobramycin antibiotics in commercially pure dissolvable antibiotic beads. There were 8 designated study groups:. Aseptic Revision TKA. N = 216. Aseptic Revision THA. N = 185. DECRA. *. TKA. N = 44. DECRA. *. THA. N = 16. 1. st. Stage Resection TKA. N = 103. 1. st. Stage Resection THA. N = 62. Reimplant TKA. N = 81. Reimplant THA. N = 49. *. DECRA = Debridement, modular Exchange, Component Retention, iv Antibiotics for acute PJI. Results. Wound drainage in the entire series was 4.2%. Wound drainage was generally seen in cases using higher bead volumes (≥30cc). The rate of heterotopic ossification was 1.6%. With bead volumes of ≥30cc, we did notice transient hypercalcemia in 12% of the study group (14% hips, 10% knees). The overall rate of infection failure was 2.5%. In the DECRA groups, reinfection failure rate was encouraging, measuring 9.1% in knees and 6.3% in hips. The non-DECRA group with the highest infection rate was Reimplant TKA (6.2%). Conclusions. We utilized a large series of commercially pure dissolvable antibiotic-loaded beads in a wide variety of clinical scenarios in patients with substantial comorbidities. Our rate of wound drainage, compared to prior studies utilizing gypsum products, was reasonably good. Additionally, our infection failure rates were encouraging. Over-stuffing knee joints with too many beads, in our clinical review, does affect wound drainage rates. By removing impurities from calcium sulfate, we do not see the substantial toxic synovial reaction compared to the traditional gypsum-washed products. We feel that commercially pure, physiologic antibiotic-loaded dissolvable beads are an acceptable delivery tool for local antibiotic delivery in aseptic and septic revision joint arthroplasty of the hip and knee. In our opinion, further study is warranted. We advocate future randomized studies to examine the potential of improving outcomes of PJI and aseptic revision arthroplasty

For patients suffering from osteoarthritis confined to one compartment of the knee joint, a successful unicondylar knee arthroplasty (UKA) has demonstrated an ability to provide pain relief and restore function while preserving bone and cruciate ligaments that a total knee arthroplasty (TKA) would sacrifice. Long-term survival of UKA has traditionally been inconsistent, leading to decreased utilisation in favour of alternative surgical treatment. Robot-assisted UKA has demonstrated an ability to provide more consistent implantation of UKA prosthesis, with the potential to increase long-term survivorship.

This study reports on 65 patients undergoing UKA using an image-free, handheld robotic assistive navigation system. The condylar surface was mapped by the surgeon intra-operatively using a probe to capture a 3-dimensional representation of the area of the knee joint to be replaced. The intra operative planning phase allows the surgeon to determine the size and orientation of the femoral and tibial implant to suit the patients’ anatomy. The plan sets the boundaries of the bone to be removed by the robotic hand piece. The system dynamically adjusts the depth of bone being cut by the bur to achieve the desired result. The planned mechanical axis alignment was compared with the system's post-surgical alignment and to post-operative mechanical axis alignment using long leg, double stance, weight bearing radiographs.

All 65 knees had knee osteoarthritis confined to the medial compartment and UKA procedures were completed using the handheld robotic assistive navigation system. The average age and BMI of the patient group was 63 years (range 45–82 years) and 29 kg/m² (range 21–37 kg/m²) respectively. The average pre-operative deformity was 4.5° (SD 2.9°, Range 0–12° varus). The average post-operative mechanical axis deformity was corrected to 2.1° (range 0–7° varus). The post-operative mechanical axis alignment in the coronal plane measured by the system was within 1° of intra-operative plan in 91% of the cases. 3 out of 6 of the cases where the post-operative alignment was greater than 1° resulted due to an increase in the thickness of the tibia prosthesis implanted. The average difference between the ‘planned’ mechanical axis alignment and the post-operative long leg, weight bearing mechanical axis alignment was 1.8°. The average Oxford Knee Score (old version) pre and post operation was 38 and 24 respectively, showing a clinical and functional improvement in the patient group at 6 weeks post-surgery.

The surgical system allowed the surgeons to precisely plan a UKA and then accurately execute their intra operative plan using a hand held robotically assisted tool. It is accepted that navigation and robotic systems have a system error of about 1° and 1mm. Therefore, this novel device recorded accurate post-operative alignment compared to the ‘planned’ post-operative alignment. The patients in this group have shown clinical and functional improvement in the short term follow up. The importance of precision of component alignments while balancing existing soft-tissue structures in UKA has been documented. Utilisation of robotic-assisted devices may improve the accuracy and long-term survivorship UKA procedure.

Objectives and Material: The authors have evaluated 78 patients with fractures of the proximal humerus that have been interned in the Orthopedics’ Service at Hospital de Santa Maria since the 1st January of 1995 until the 31st December of 1999 with the objective of evaluating different factors influencing the final results and concluding to the best therapeutic conduct in the different cases. Method: The following parameters have been evaluated: sex, age, accident type (low/high energy), associated injuries, fracture’s classification, type of treatment and results achieved. The Constant score have been used for the functional evaluation. Due to reduced number of patients in each class a non-parametric test has been used – Qui-square test (X2). SPSS program has been used to run the calculations.

Results: It has been verified that sixty four percent of the cases happened due to low energy accidents and the three-part fractures prevailed (46%), followed by four-part fractures (34%). The fracture of the proximal humerus occurred isolated and prevailed in women above 60 years old. Patients’ age was not a factor of bad prognostic. The number of bad results depended on the fracture’s type. Open reduction and internal fixation has been the most frequently used technique in all fracture types and the one with the best results. Open reduction and Kirschner pinning should be used only in very specific cases and with limited functional objectives. Humeral head reconstruction has not been a valid option to four-part fractures treatment, allowing concluding that, in many cases of very fragmented fractures, the option for the humeral head substitution by prosthesis should be better than trying its reconstruction.

This paper describes the development, operative technique and results of an unconstrained total elbow arthroplasty. Forty-seven elbow replacements were carried out in 44 patients between 1974 and 1982. There was a high rate of loosening in the early condylar replacements. The results in patients with post-traumatic arthritis were poor. The later design employs an ulnar stem, with a humeral stem if the distal humeral bone stock is poor. When used in carefully selected patients with rheumatoid arthritis, pain is reduced significantly, stability and movement are preserved and function is improved.

High myelomeningocele lesions do not preclude an acceptable level of functional walking provided that an integrated programme of surgical treatment and bracing is adopted. Clinical analysis of 100 patients with myelomeningocele shows that the development of the "swivel walker" and "hip guidance orthosis" has been associated with an improved level of function. Over 30 per cent of patients with thoracic lesions and 68 per cent of those with lumbar lesions achieved independent walking. For this reason the criteria used at present by paediatricians to govern the selection of infants for non-active treatment may require reconsideration.

Electromyographic and clinical studies were performed on patients undergoing total hip replacement by the modified direct lateral (29 hips), the direct lateral (29 hips) and the posterior approaches (21 hips). Assessments were made three months after operation. The Trendelenburg test was positive (Grade II) in eight cases operated upon by the direct lateral route, but in only one of each of the other two groups. Denervation occurred in only five of the 28 hips with abductor weakness without statistical difference between the groups. In the modified direct lateral group, radiological evidence of union of the trochanteric sliver was associated with significantly better abductor function than in those with malunion or non-union.

The early results of revision osteoarticular allografts in weight-bearing joints are reported. Sixteen consecutive patients underwent surgery over a six-year period between 1982 and 1988. At the time of review eight patients (50%) had surviving second allografts with an average follow-up time of 48 months (range 12 to 87). Five patients were graded excellent according to the Mankin scale, one good and two fair. Eight patients (50%) required further surgery, but only two patients came to amputation.

Aim

The purpose of this clinical series is to prospectively review the mid-term clinical and radiographic outcomes of the Scandinavian Total Ankle Replacement (STAR) performed at two academic Canadian University centres.

Total Hip Replacement (THR) in proximal, posterior iliac dislocation of the hip often represents a problematic issue. Reviewing their selected cases (70 patients between 3700 THR from 1986 to 2001), authors focalized some key points for this demanding surgery. The most important steps are acetabular positioning, implant decisioning and surgical approach (exposure and release).

Acetabular cup positioning. The natural site (Paleoacetabulum), the ideal place to restore biomechanical and dynamic properties of the joint, many times gives few chances to achieve primary stability. So one site, at least the nearest possible to the natural site must be reached. A CT or MRI study is necessary to assess preoperative planning for cup positioning. We used two different cups, the Zweymuller and the Wagner cup, with good primary stability. A Conus stem (Wagner) or an Alloclassic stem (in less displastic femoral shape) was used.

We always performed this surgery as a one step procedure. No preventing traction or release surgery was performed. An anatomic and wide (medial and lateral) exposure of the joint must be performed. We used the Smith-Petersen approach modified by Wagner. A meticulous periarticular release of soft tissue was performed. In same cases a shortening femoral osteotomy was performed to allow refractory reduction. Possible complications are discussed. Good clinical outcomes at more than ten years are shown.

Introduction: There is little dispute that flexion and extension spaces should be rectangular and equal in a knee replacement and that rotation of the femoral component has a bearing on function and outcome. However, there is dispute over what is the ‘correct’ rotation and how best to achieve it. Transepicondylar line, computer navigation, 3 degrees external rotation have all been tried with a similar lack of reliability (Siston et al, JBJS Am, 2005 Oct; 87(10):2276–80) Insall and Scuderi recommended placing a tensor in the knee in flexion and rotating the femoral cutting block so that its posterior edge is parallel to the top of the tibia (Scuderi et al, Orthop Clinc. North. America, 20:70–78, 1989)

We feel the Equiflex instrumentation designed by Mr Lennox will reliably achieve Insall and Scuderi’s recommendation and reduce the incidence of lateral retinacular release

Purpose of Study: To evaluate early clinical results and lateral retinacular release rates using Equiflex instrumentation to do TKR

Method: We evaluated 209 consecutive knees done with this technique at Basildon from 4 April 05 – 19 September 06. Pre and postop American Knee Society and Oxford scores, deformity, ROM were recorded for the 152 cases with 6 week follow-up. Lateral retinacular release rates and complications are presented for the entire cohort of 209 cases.

Results: Average inpatient stay −4.9 days (20% discharged in −3 days) if we exclude complications. There were 31 Valgus knees, 178 varus knees with an average alignment of 5.95 (23 degree varus − 25 degree valgus). 38 uncemented knees.

At 6 weeks, Knee score improved from 34.5 to 78.5, function score improved from 47.5 to 49.8, oxford score improved from 43.4 to 30.06. Average preop flexion was 105 degrees (65–130) and average postop flexion was 98 (40–130)

We could correct alignment and achieve our technical goals in 99% of cases

A lateral retinacular release was required in only 5 out 31 valgus knees (16%) and 0 out of 178 varus knees (a total lateral release rate of 2.4%)

Complications: Wound or ipsilateral skin problems – 10 (4.7%) all of which settled rapidly with antibiotics. Thromboembolic phenomena – 13 cases (6.2%) – 9DVTs, 5 PE. MUA – 3 (2.3%). Hairline crack of tibial cortex in soft porotic bone– 3 (1.4 %). MI – 2 (1 postop, 1 at 4 weeks). CVA – 4 (1 postop, 1 at 6 weeks). Confusion – 2. GI bleed -2 . Bleeding PR, Ca Rectum -1.

Discussion: Perioperative complications probably under-reported in studies with> 1 year follow up. Callahan et al in their metaanalysis of literature from 1966–1992 did not include delayed wound healing, wound drainage, haematoma, urinary retention etc. They found a weighted mean complication rate of 18.1 % with a mortality per year of followup of 1.5%. Studies which have specifically looked at complications have reported an average of 3.9% superficial infections, 1.7% deep infections, 6.5% DVTs and 2.1% peripheral nerve damage (9).

Our complication rates were well within published data and we could correct alignment and achieve our technical goals in 99% of cases. We required to do a lateral retinacular release only in 5 valgus knees with subluxed patellae and contracted lateral structures for an overall release rate of 2.4%.

Conclusions:

This is a safe, effective and reproducible procedure with complications comparable to published data

Much controversy surrounds synovial sarcomas, including prognostic indicators and optimal treatment. This paper reviews these subjects on the 65 cases of synovial sarcoma on the hospital’s database.

At 40 months 3 cases were excluded. 2 on review of the diagnosis and 1 had definitive treatment elsewhere. At 80 months 5 additional patients were lost to follow up.

The Kaplan-Meier 5 year survival rate for all patients in this review was 52.1%. Excluding patients who presented with metastases, this figure rose to 60.1%. All deaths were due to metastatic disease. Univariate analysis showed age of patient and size of tumour to be significant prognostic indicators for survival. Size of tumour only, was a significant predictor of metastatic spread using univariate analysis. Multivariate analysis showed only tumour size to be a significant indicator of survival and metastatic spread.

The local recurrence rate at 5 years was 22.3%. No convincing clinical features were shown to influence the local recurrence rate.

Adjuvant therapy was not shown to influence outcome significantly.

At 80 months follow up the 5 year survival rate increased to 54.9% (SE = 6.9%) and without metastases 61.7% (SE = 7.2%). The significance of established prognostic indicators did not change at final follow up.

The amputation rate was 21%. 3 patients had limb preserving surgery using an endoprosthetic replacement.

Tumour size and metastases appear to be the only consistent prognostic indicators of survival. Endoprosthetic replacement surgery should be considered a surgical option for synovial sarcomas involving bone. Doubling the follow up did not statistically affect survivorship data.

Aims: The objective of this study was to clinically assess the outcome of CADCAM femoral components in the revision hip replacement. Methods: Between 1991 and 2000, 125 revision total hip replacements using CAD-CAM femoral components were performed. Clinical assessment was performed using the Harris Hip score, by direct patient consultation, and telephone or postal questionnaire. Survivorship was defined as the requirement for revision. Results: The patients were reviewed at a mean of 5.2 yrs (1 to 10)

The mean Harris hip score increased from 44 points (range, 27 to 71 points) preoperatively to 71 points (range, 21 to 98 points) at the time of the most recent follow-up. 9 patients required subsequent revision; 4 for aseptic loosening, 1 for septic loosening and 4 for fracture of the femoral component. Conclusions: CAD-CAM technology provides a viable alternative to the challenge of revision hip surgery, with results comparable to other cementless techniques.

Purpose of study: To evaluate the clinical outcome of operative intervention for chronic patellar instability for patients treated by a single paediatric orthopaedic surgeon over a 74-month period

Method: There were 11 patients (16 knees) with a mean age at operation of 11.9 years (5 to 17 years). Patients were treated with combined proximal and distal patellar realignment. Mean follow-up was 44.6 months (11–86 months). All patients were assessed post-operatively with satisfaction scores, the Trillat grading system and the Activity Scale for Kids (ASK). They were also questioned specifically for patellofemoral symptoms and examined for signs of mal-tracking.

Results: Subjective patient rating of all procedures revealed 10 (62.5%) responses of excellent or very good, 4 (25%) good, 1 (6.25%) fair and 1 poor (6.25%). Formal Trillat grading revealed 9 (56.3%) excellent, 6 (37.5%) good, 1 (6.2%) fair and no poor outcomes. The mean ASK score was 82% (39–100%). All except one patient felt that they would choose to undergo the surgery again. There was one complication of a superficial wound infection.

Conclusions: These results show improvement in symptoms and function as judged by Trillat grading and a majority of patients satisfied with the results of the procedure. We feel that the advantage of appropriate surgical intervention at a young age is not only the improvement in symptoms, but also that successful realignment of patellar tracking may reduce subsequent degenerative problems associated with chronic instability and allow better rehabilitation of the dynamic stabilisers of the patellofemoral joint.

Objectives: Background: In 1999 all General Practitioners (GPs) in the UK were sent guidelines about the criteria for urgent referral of patients with suspected sarcoma. In addition, the receiving specialist centre was given a set of targets to meet in relation to referral, diagnosis and treatment of these cancers. These targets have now been updated for 2008 in the Cancer Reform strategy.

Aim: To compare the clinical information on two-week wait referrals with imaging clinical assessment within a specialist centre to confirm a malignant diagnosis; to review sarcoma diagnosis hit-rate and to establish whether early diagnosis has been improved.

Methods: All two-week wait referrals direct into our department were studied from June 2007 to June 2008 to determine whether a sarcoma was diagnosed, whether the GP criteria were met, and whether the targets were achieved.

Results: A total of 166 referrals received as two-week referrals to the specialist unit. One hundred and thirty six were diagnosed with benign lesions. Thirty patients had a malignant diagnosis and of those 10 patients had surgery as their first definitive treatment.

Conclusions: Detailed analysis is still being undertaken but initial conclusions drawn seem to suggest that there are still a large number of inappropriate referrals being made under the two week wait. This may be due to the GPs not following the criteria on the referral form.

Introduction. A key outcome measured by national joint registries are revision events. This informs best practice and identifies poor-performing surgical devices. Although registry data often record reasons for revision arthroplasty, interpretation is limited by lack of standardised definitions of revision reasons and objective assessment of radiologic and laboratory parameters. Our study aim was to compare reasons for unicompartmental knee arthroplasty (UKA) revision reported to the New Zealand Joint Registry (NZJR) with reasons identified by independent clinical review. Methods. A total of 2,272 patients undergoing primary medial and lateral UKA at four large tertiary hospitals between 2000 and 2017 were included. A total of 158 patients underwent subsequent revision with mean follow-up of 8 years. A systematic review of clinical findings, radiographs and operative data was performed to identify revision cases and to determine the reasons for revision using a standardised protocol. These were compared to reasons reported to the NZJR using Chi-squared and Fisher exact tests. Results. Osteoarthritis progression was the most common reason for revision on systematic clinical review (30%), however this was underreported to the registry (4%, p<0.001). A larger proportion of revisions reported to the registry were for ‘unexplained pain’ (30% of cases vs. 4% on clinical review, p<0.001). A reason for revision was not reported to the registry for 24 (15%) of cases. Discussion and Conclusion. We found significant inaccuracies in registry-reported reasons for revision following UKA. These included over-reporting of ‘unexplained pain’, under-reporting of osteoarthritis progression, and failure to identify a reason for revision. Efforts to improve registry capture of revision reasons for UKA should focus on increasing accuracy in these three areas. This could be addressed through standardised recording methods and tailored revision reason options for UKA for surgeons to select when recording the reasons

Aims. Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation. Methods. We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic. Results. From February 2018 to January 2019, there were 442 patients diagnosed as clinical scaphoid fractures. 122 patients (28%) self-referred back to the emergency department at two weeks. Following clinical review, 53 patients were discharged; MRI was booked for 69 patients (16%). Overall, six patients (< 2% of total; 10% of those scanned) had positive scans for a scaphoid fracture. There were no known missed fractures, long-term non-unions or malunions resulting from this pathway. Costs were saved by avoiding face-to-face clinical review and MRI scanning. Conclusion. A patient-focused opt-in approach is safe and effective to managing the suspected occult (clinical) scaphoid fracture. Cite this article: Bone Jt Open 2024;5(2):117–122