We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs. In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intra-operatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years). There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029). We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support. Cite this article: Bone Joint J 2015;97-B:192–6

Introduction: One of the complications of first metatatarsal osteotomies is metatarsalgia secondary to shortening of the first metatarsal. Conservative treatment with insoles is not acceptable to all patients and the traditional treatment of this condition is by shortening osteotomies of the lesser metatarsals (eg Weil, Helal)- the latter osteotomies themselves have complications of causing pain or stiffness in the lesser toes. Purpose: The aim of this work is to report our results of step cut metatarsal lengthening of iatrogenic first brachymetatarsia. Patients and Methods: 16 female patients had metatarsal lengthening of iatrogenic first brachymetatarsia. A typical Scarf type osteotomy was used in the first 4 cases and a simple step cut of equal thicknesses along the axis of the first metatarsal was performed in the next 12 procedures. Results: When 10mm lengthening was done, the metatarsalgia was relieved in all of the 6 patients, in contrary to only 50% relief of symptoms in the patients when less then 8mm lengthening was achieved. Conclusions: One stage step cut lengthening osteotomy of the iatrogenic short first metatarsal, when over 8mm length is achieved, is safe with good results and is a preferable alternative to shortening osteotomies of the lesser metarsals in the treatment of metarsalgia due to inappropriate shortening of the first metatarsal

Supracondylar humeral fractures are the most common elbow injury in children, usually sustained from a fall on the outstretched hand. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring. NNH is the number of cases needed to treat in order to have one adverse outcome. A systemic review was undertaken to calculate relative risks, risk difference and number needed to harm following management of supracon-dylar fractures with cross or lateral K wires. It was found that there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires. The aim of this study was to calculate the number of cross K wiring of supracondylar fractures of the humerus that would need to be performed for one iatrogenic ulnar nerve injury to occur. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring of supracondylar fractures of the humerus. To date there are no clinical trials showing the benefit of cross K wiring over lateral K wiring in the management of supracondylar fractures of the humerus in children. If it can be confirmed that lateral K wiring is as effective as crossed K wiring, iatrogenic ulnar nerve injury can be avoided. A systematic review of iatrogenic ulnar nerve injuries following management of supracondylar fractures was conducted. The databases MEDLINE 1966 – present, EMBASE 1980 – present, CINAHL 1982 – present, CDSR, and DARE were searched along with a meticulous search of the Journal of Paediatric Orthopaedics from 1998 to 2004. Of the two hundred and forty-eight papers identified, only thirty-six met the inclusion criteria. The papers where both lateral crossed K wires were used as treatment were identified for calculating relative rates, risk difference and number needed to harm. NNH was 7.69. When a sensitivity analysis removing two studies that had five subjects or fewer and a 100% ulnar nerve injury rate was peformed, the NNH was 27.7. In other words, there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires

Introduction. Iatrogenic spondylolisthesis occurs infrequently after posterior decompression. Posterior surgery is challenging due to altered anatomy and scarring. Anterior lumbar interbody fusion (ALIF) allows indirect decompression, restoration of lordosis and fusion. Material and Methods. Retrospective review of 6 patients (5 female, 1 male, mean age 64±5.8 years) with iatrogenic spondylolisthesis (5 L4/L5; 1 L4/L5) treated with stand-alone ALIF (Synfix, BMP2). Assessment of pelvic incidence, listhesis, pre- and post-operative ODI, VAS, global lumbar lordosis and segmental lordosis as outcome measurements. Results. The slippage was grade II at L4/L5 in 3 patients and grade I in 2 patients at L4/L5 and 1 patient at L5/S1. Average ODI dropped from 49±11% pre-operatively to 30±9% at 6 and to 25±6% at 12 months follow-up. VAS average dropped from 7±1 to 3±1 at 6 and 12 months follow-up. Average pelvic incidence was 54.6±8.0°. Global lordosis of 44.6±5.2° increased to 49.0±8.6°; Segmental lordosis in L4/5 was increased from 12.1±8.2° to 22.4±3.7° at 6 and 20.5±7.9° at 12 months. Cage migration due to severe osteoporosis occurred in 1 case after 5 months. Conclusion. Anterior interbody fusion offers good stabilization and restoration of lordosis in iatrogenic spondylolisthesis. In our group, ODI and VAS scores were improved. These early results encourage further investigations regarding long-term follow-ups and prospective studies in larger patient groups

Several studies have evaluated the risk of peroneal nerve (PN) injuries in all-inside lateral meniscal repair using standard knee magnetic resonance imaging (MRI) with the 30 degrees flexed knee position which is different from the knee position during actual arthroscopic lateral meniscal repair. The point of concern is “Can the risk of PN injury using standard knee MRIs be accurately determined”. To evaluate and compare the risk of PN injury in all-inside lateral meniscal repair in relation to both borders of the popliteus tendon (PT) using MRIs of the two knee positions in the same patients. Using axial MRI studies with standard knee MRIs and figure-of-4 with joint fluid dilatation actual arthroscopic lateral meniscal repair position MRIs, direct lines were drawn simulating a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the PT. The distance from the tip of each line to the PN was measured. If a line touched or passed the PN, a potential risk of iatrogenic injury was noted and a new line was drawn from the same portal to the border of the PN. The danger area was measured from the first line to the new direct line along the joint capsule. In 28 adult patients, the closest distances from each line to the PN in standard knee MRI images were significantly shorter than arthroscopic position MRI images (all p-values < 0.05). All danger areas assessed in the actual arthroscopic position MRIs were included within the danger areas as assessed by the standard knee MRIs. We found that the standard knee MRIs can be used to determine the risk of peroneal nerve injury in arthroscopic lateral meniscal repair, although the risks are slightly overestimated

Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of iatrogenic injury at shoulder surgery has not, to date, been fully appreciated. Patients: Four female patients aged 59 and over who suffered iatrogenic injury to the axillary artery at the time of shoulder surgery are reported. Two occurred during surgery for planned elective shoulder arthroplasty, while two occurred while treating elderly patients who had previously sustained a 3 part proximal humeral fracture. In all 4 cases the injury probably started as an avulsion of the anterior or posterior humeral circumflex vessels. Results: Vascular surgeons were called in urgently to help with the management of all 4 cases. In two cases the axillary artery was found to have extensive atheroma, was frail and, after initial attempts at end-to-end repair, it became clear that a reversed vein graft was required. Three patients had a satisfactory outcome after reconstruction, while one patient who had previously had local radiotherapy for malignancy, but was now disease free, developed a completely ischaemic upper limb and required a forequarter amputation to save her life. Message: The axillary artery can be very frail in the elderly, is often diseased with atheroma, and is vulnerable to iatrogenic injury at surgery. If injury occurs at surgery, small bulldog clamps should be applied to the cut ends and a vascular surgeon should be called immediately. A temporary arterial shunt should be considered urgently to provide an early return of vascularisation to the limb and to prevent serious complications. The axillary artery is very difficult to repair, and, in our experience may require a vein graft. In addition, distal clearance of the main brachial artery with a Fogarty catheter which is an essential part of the management

Purpose: The aim of this retrospective study was to assess the correlation between the occurance of iatrogenic ulnar nerve injury and frontal and saggital angular insertion of the medial pin in pediatric type 3 supracondylar humerus fractures treated with closed reduction and percutaneous fixation using a crossed-pin configuration. Method: Among 164 patients with type 3 supracondylar humerus fractures, treated with closed reduction and percutaneous fixation using a crossed-pin configuration while the elbow was in hyperflexion, between 1999 and 2003, ninety patients (54 male and 36 female, mean age 6.1 years) with complete clinical and radiological records and follow-up period of at least 6 months were included the study. Frontal humerus-pin angle (FHPA) was the angle between the long axis of humerus and the axis of the medial pin measured on an anteroposterior radiograph. Saggital humerus-pin angle (SHPA) was the angle between the long axis of humerus and the axis of the medial pin measured on a lateral radiograph and expressed as a positive value if the medial pin direction was anteroposterior and as a negative value if the direction was posteroanterior. All the mesurements were made by the same observer blinded to the clinical records of the patients. Results: Postoperative ulnar nerve injury was observed in 18 patients. The ulnar nerve injury group and control group were similar with respect to age and gender. Mean FHPA was 36.6 and 33.8 degrees in ulnar nerve injury and control groups respectively (p=0.270). Mean SHPA was 12.1 and 1.6 degrees in ulnar nerve injury and control groups respectively, and the difference was significant (p=0.001). All the patients with ulnar nerve injury had complete recovery within 3 months following surgery. Conclusion: There are several methods to avoid iatrogenic ulnar nerve injury in supracondylar fractures such as insertion of two or three lateral pins, insertion of the medial pin while the elbow is less than 90 degrees of flexion. The findings of this retrospective study revealed that there was a considerable correlation between the occurence of iatrogenic ulnar nerve injury and sagittal angular insertion of the medial pin. We suggest that if a crossed-pin figuration is desired, it is better to insert the medial pin neutral or posteroanterior direction in the sagittal plane if the elbow is in hyperflexion

Background: Iatrogenic hallux varus is a very disappointing potential complication following hallux valgus surgery. Depending on its clinical and radiological form, a possible surgical technique is the reconstruction of the lateral components of the first metatarsophalangeal joint. Methods: A new surgical technique of ligamentoplasty based upon the use of the abductor hallucis tendon is described. The new method was applied in 5 patients (6 feet) with a mean follow-up of 25.8 months. Four hallux varus deformities were operated by only the transplant of the abductor hallucis tendon and two were associated with the use of an osseous buttress. Results: We found a radiographic correction of most of the factors considered as being at the origin of the iatrogenically induced deformity. All of our patients considered the result as very good and no complications were noticed. Conclusion: This new technique is a reliable, anatomic reconstruction with the use of the tendon participating in the physiopathology of the hallux varus deformity. No other functional tendon is harvested

Introduction: Operations inside the spinal canal are afflicted with a certain number of iatrogenic dural lesions. Incidence figures in the literature vary from 1 to 17% and are mainly based on retrospective studies. The Swedish Spine Register, SweSpine, provides a good possibility to study the incidence in a prospective patient material. Patients and Methods: During 5 years more than 9 000 patients had surgical treatment for lumbar disc herniation or lumbar spinal stenosis and were registered according to the protocol of the Swedish Spine Register. One year follow-up data were present for 74 % of the patients. Pre- and postoperative data are entirely based on questionnaires answered by the patient whereas surgical data are completed by the surgeon. Complication and re-operation registration is included. Mean patient age for LDH was 45 (12–88) years, for spinal stenosis 68 (27–93) years and 56% of the disc herniation patients and 43% of the spinal stenosis patients were males. Most common level for LDH operation was L5/S1 followed by L4/L5 and for spinal stenosis L4/L5 followed by L3/L4. The one-year result was studied. Results: The incidence of dural lesion in lumbar disc herniation surgery was 2.7% and in spinal stenosis decompression 7.3%. The risk for dural lesion was more than doubled in patients with previous surgery which, thus, was a significant but also the only risk factor. At one year after surgery the result was similar for patients with and without dural lesion when VAS pain, ODI, SF-36 and patient graded global assessment were studied. Correlation between previous surgery and inferior outcome was seen but was not affected by the dural lesion as such. Three and 5% respectively in the groups were subjected to repeat surgery before discharge from the hospital. The lost-to follow-up group (26%) had similar pre-operative demographics and the same incidence of dural lesion as those followed-up. Conclusion: In a large prospectively studied material, the incidence of dural lesion in lumbar disc herniation surgery was 2.7% and in decompressive spinal stenosis surgery 7.3%. Previous surgery was a significant risk factor for dural lesion. The dural lesion as such did not negatively influence the one-year outcome

We report seven cases in which open or closed reduction of a shoulder dislocation associated with a fracture of the humeral neck led to displacement of the neck fracture. Avascular necrosis of the humeral head developed in all six patients with anatomical neck fractures. All five anterior dislocations also had a fracture of the greater tuberosity and both posterior dislocations had a fracture of the lesser tuberosity. The neck fracture had not initially been recognised in three of the seven cases. In five cases attempted shoulder reduction led to complete displacement of the head segment, which was treated by open reduction and minimal internal fixation. In the other two cases, shoulder reduction caused only mild to moderate displacement which was accepted and the fracture was treated conservatively. We conclude that biplane radiography is essential before reduction of a shoulder dislocation. Neck fractures must always be ruled out, especially where there are tuberosity fractures. In our series, careful closed reduction under general anaesthesia with optimal relaxation and fluoroscopic control did not prevent iatrogenic displacement. Prophylactic stabilisation of the neck fracture should be considered before reduction of such a fracture-dislocation. It may be, however, that the prevention of displacement by prophylactic stabilisation does not always prevent late avascular necrosis; we observed this in one case

We have reviewed our experience of four iatrogenic femoral neck fractures in 315 consecutive closed intramedullary nailings with the AO/ASIF universal femoral nail. The average neck-shaft angle in the bones that fractured was 139.3 degrees +/- 1.2 degrees SD (136 to 141); in the whole series the average neck-shaft angle was 125.3 degrees +/- 8.6 degrees and only 11 had angles of more than 135 degrees. The upper ends of the nails in the four which fractured were 17 mm, 5 mm, 3 mm, and 1 mm below the tip of the greater trochanter. In the seven patients with neck-shaft angles greater than 135 degrees but with no fracture, none of the nails had been inserted beyond the tip of the greater trochanter. We nailed six cadaver femora to simulate the forces produced by intramedullary nailing. Despite deep insertion, only one of the six sustained a neck fracture. This specimen had a radiographic neck-shaft angle of 140 degrees against an average of 127.3 degrees +/- 4.0 degrees for the other five. We believe that the medial prong of the AO insertion jig, with its medial overhang of 2 to 3 mm, may impinge on the superior aspect of a valgus femoral neck during final impaction, causing a neck fracture. This may be avoided by leaving the end of the nail above the tip of the trochanter in such cases

Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open exploration and repair, but more recently there has been a trend towards percutaneous endovascular management.

We performed a systematic review of the literature to assess if this change in trend has led to an improvement in the overall reported rates of morbidity and mortality during the last 22 years in comparison with the reviews of the literature published previously.

We found a total of 61 articles describing 138 vascular injuries in 124 patients. Injuries because of a laceration were the most prevalent (n = 51, 44%) and the most common presenting feature, when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis was associated with the type of vascular lesion (p < 0.001) and the clinical presentation (p = 0.002).

Open exploration and repair was the most common form of management, however percutaneous endovascular intervention was used in one third of the injuries and more constantly during the last 13 years.

The main overall reported complications included death (n = 9, 7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9, 7.3%). When compared with previous reviews there was a similar rate of mortality but lower rates of amputation and permanent disability, especially in patients managed by endovascular strategies.

Cite this article: Bone Joint J 2015;97-B:1447–55.

Objectives

The use of the haptically bounded saw blades in robotic-assisted total knee arthroplasty (RTKA) can potentially help to limit surrounding soft-tissue injuries. However, there are limited data characterizing these injuries for cruciate-retaining (CR) TKA with the use of this technique. The objective of this cadaver study was to compare the extent of soft-tissue damage sustained through a robotic-assisted, haptically guided TKA (RATKA) versus a manual TKA (MTKA) approach.

Introduction. Iatrogenic proximal femur hoop-stress fracture is a recognised complication of uncemented hip arthroplasty. It has a reported incidence of two to three percent and increases patient morbidity. We describe a novel technology that predicts fracture in real-time by less than one minute. Method. Four proximal femora from red deer (Cervus elaphus), similar size to human proximal femora, were prepared to accept an uncemented hip arthroplasty femoral rasp (Finsbury Orthopaedics) and then mounted in a loading machine. The femora were fresh-frozen, defrosted and kept at room temperature in 0.9% saline swabs. The rasp was forced into each femur in repeated loading cycles every 10 seconds, in steps of 100N increasing from 200N to over 2000N until fracture, in a manner to simulate surgery. One sensor was attached to the surface of the proximal femur and one to the femoral rasp. The sensor outputs were recorded, analysed and displayed on a PC using a software algorithm to show signal energy (joules) and amplitude (decibels). The proximal femur was coated with specular marking paint to permit real-time 3-D digital image correlation (DIC) analysis. DIC is an established tool in engineering fracture analysis and utilises two spatially orientated video cameras to measure surface strain and fracture. The femur was observed by the human eye and loaded in cycles until a fracture was seen. The moment of fracture was marked in the recording timeline. DIC was used to confirm fracture. Results. All femora fractured in the anterior proximal cortex. Signals from both sensors were identical in form and differed by less than five percent in strength during loading. Both signals demonstrated significant increases in energy and amplitude shortly prior to fracture. Early during loading cycles the femoral rasp subsided and became well-fixed within the femur; this was associated with signals of 60-70dB. During later loading cycles the rasp ceased to subside in the femur and was well-fixed in a press-fit; subsequent loading caused fracture and this was preceded by a greater number of stronger signals of over 90dB. The increase occurred 1 to 3 loading cycles prior to fracture, or less than 30 seconds. DIC was used to confirm the presence of a fracture visible to the human eye. At the time of the first significant increase in signal there was no crack visible to the eye or to DIC analysis and the femoral rasp did not subside further into the femur. Conclusions. During press-fitting of an uncemented femoral rasp in a deer femur a significant change in signal characteristics occurs shortly prior to a fracture being visible to the eye and detectable by DIC analysis. The almost identical signal output from both sensors suggests that one single sensor mounted on a femoral rasp will suffice, thereby removing the need to expose more of the proximal femur during surgery. This technology may be able to predict and therefore prevent femur fracture during uncemented hip arthroplasty. Further research is necessary in animal and human cadavers to explore and validate this research

Introduction: This study highlights the occurrence of significant post operative scoliosis associated with en-bloc resection of pancoast or superior sulcus tumours. We observed the rapid onset of high thoracic scoliosis following en-bloc resections. The Magnitude of the scoliosis, and predisposing surgical factors were reviewed in each of the cases implicating the role of the transverse process or its associated structures in the stabilization of the spine.

Methods: Sixteen patients undergoing en-bloc resection for pancoast tumour were retrospectively reviewed. This was a single surgeon series where all patients had tumour resection over a 3 year period. The number of upper ribs and transverse processes resected were analysed and compared with the magnitude of scoliosis that developed over a follow up period of 2 years.

Results: Four patients had significant resection of the transverse processes of T1 to T3. All of these patients developed scoliosis of rapid onset, convex to the side of the resection. Of the remaining 12 patients either no scoliosis developed, (6 of 12), or scoliosis of less than 12 degrees.

Discussion: We observed rapid development of thoracogenic scoliosis in patients following lung tumour and chest wall resection. Our study shows that excision of the transverse processes is associated with subsequent development of an upper thoracic scoliosis. Preservation of the transverse process appears to be protective. Large resections can be performed with no subsequent scoliosis provided the transverse processes remain intact.

This suggests that the transverse process or its associated structures have an important stabilizing function on the spine.

Introduction

While manual total knee arthroplasty (MTKA) procedures have demonstrated excellent clinical success, occasionally intraoperative damage to soft tissues can occur. Robotic-arm assisted technology is designed to constrain a sawblade in a haptic zone to help ensure that only the desired bone cuts are made. The objective of this cadaver study was to quantify the extent of soft tissue damage sustained during TKA through a robotic-arm assisted (RATKA) haptically guided approach and conventional MTKA approach.

In this study, we discuss 68 cases in which peripheral nerve trunks were inadvertently divided by surgeons. Most of these accidents occurred in the course of planned operations. Delay in diagnosis and in effecting repair was common. We list the nerves particularly at risk and the operations in which special care is needed. We recommend steps to secure prompt diagnosis and early treatment.

I never considered this to be a significant problem if it is noticed. (back to that later)

Aaron Rosenberg's report seems to have agreed, but at the last members meeting of the Knee Society, Boston, September 2009, others had experience that contradicted my view.

With their experience, ultimately the results were very substantially compromised. This video and presentation show you how to avoid a bad result, actually obtain a perfect result, if you or your student assistant, resident or fellow, bags the MCL.

There are three important points. (1) One needs to recognise the occurrence. (2) The setting is usually varus and so direct end-to-end repair cannot be depended upon. (3) Use of a semitendinosis tenodesis, together with an imperfect, distracted direct repair works perfectly well!

(1) Recognition: The setting is usually varus, but I have had one case in which the chief resident, working with the fellow succeeded in getting the MCL in a valgus knee! In this usually tight varus setting the key feature is that at some point in the case, before component placement, one notices that the exposure is all of a sudden better! Now, the guilty resident or just a passive assisting resident/fellow will usually disagree. The extension space is not so obviously lax, but the flexion space is. Secondly, you do not feel an intact ligament in flexion. And, to prove it I have had to do a little more exposure of the superficial MCL to show the tear. There are at least three mechanisms. Most common is a saw cut. Next is possibly injury with the scalpel or cutting cautery during exposure, and last is damage essentially pre-operatively by a very sharp medial osteophyte which has thoroughly abraded the ligament.

Laxity in full flexion is not necessarily obvious as the posterior capsular integrity helps hide the instability. Again, the really intact ligament is well felt, and in the situation of laceration, the tibia pulls forward more on the medial side, the medial flexion space opens, and what was usually a tight exposure gets suddenly better.

(2) When varus is the setting, I have found it impossible or at least uncomfortable to depend upon direct repair. When the soft tissues are needing to be released or simply undergoing more stress than usual and a lot more than on the lateral side, I see it as unwise to expect or depend upon only a medial repair to hold.

(3) The semitendinosis tenodesis has worked essentially perfectly in every one of my cases. These patients have had no post-operative instability and they have had better than average to extremely good ROM.

A presumably key point is not to alter the patient's post-operative regimen! And, to avoid some passive alteration of PT, I advise specifically that the surgeon or those in his/her team do not mention the occurrence to the patient, the family or the PT! I put the whole story in the op-note, and weeks later I will specifically tell the patient what the staple in place is all about.