Introduction:. Distal humerus fractures as well as elbow fracture dislocation are often accompanied by soft tissue damage that warrants early fixation with an external fixator. The distal humerus is a hazardous area for placement of an external fixator due to the close proximity of the radial nerve to the humerus in this area. No known safe zone has been identified on the lateral border of the humerus to avoid radial nerve damage. The aim of this study was to record the incidence of radial nerve damage by placing two 4 mm pins into the humerus and to note the relation of the nerve to the pins. Methods:. Two 4 mm pins used to fix an external fixator were drilled into the lateral border of the humerus at points 100 mm and 70 mm proximal to the lateral epicondyle of both arms of 39 cadavers. The 30 mm interval between the pins is the interval between the pins in a pinblock of a commonly-used external fixator. The arms were dissected by medical students and the incidence of radial nerve damage was recorded. Statistical analysis was done using a Fischer's exact test to identify the incidence of nerve damage relative to pin insertion. The number of damaged nerves was compared to the number of non-damaged nerves. A design based Chi Square test was carried out to test left and right arms. The proportions of interest were estimated along a 95% confidence interval. Results:. The radial nerve was hit (damaged) by 56.4% of the proximal and 20.5% of the distal pins. The radial nerve ran posterior to the proximal pin in 2.57% of arms and 0% to the distal pin. Conclusion:. Although no clear safe zone could be established, pins should be placed closer than 100 mm from the lateral epicondyle and as posterior on the humerus as possible to minimize the risk for radial nerve damage. Keywords: Radial nerve, external fixation, humerus fractures

To evaluate the short-term clinical outcomes of patients treated arthroscopically with chitin-based scaffolding for acetabular chondral defects in conjunction with microfracture compared to microfracture alone. This study is a retrospective analysis of prospectively collected data. A review of charts was performed (2014–2016) on all patients who underwent hip arthroscopy and had microfracture +/− scaffolding for acetabular chondral defects, intraoperative details (lesion size, grade, labral repair/reconstruction) and postoperative complications were recorded with a minimum follow-up of 2 years. Clinical outcomes were assessed by analysing iHOT and HOS scores which were obtained pre-operatively, at six months, one year and two years post-surgery. Plain radiographs were assessed for hip osteoarthritis by Kellgren & Lawrence grading. A total of 60 patients (microfracture=25, scaffolding=35) were included. Patients had a mean age of 36.2 years at the time of the index operation. There were no major adverse events of deep vein 36.2 years at the time of the index operation. There were no major adverse events of deep vein thrombosis, blood vessel or nerve damage, hemarthrosis or device related adverse events in both groups. Two patients were readmitted due to pain as a result of an inflammatory reaction in the scaffolding group. Both treatments of microfracture and scaffolding showed significant improvement in outcome score (iHOT) (p < 0 .001) when compared postoperative to preoperative. Both the arthroscopic treatment of chondral acetabular defects with chitin based scaffolding and microfracture demonstrated significant improvement from their pre-operative outcomes

We reported the first single surgeon series comparing outcome of microscopic and open primary single level unilateral lumbar decompression or discectomy. We aimed to determine any difference in outcomes between the two techniques. Forty-six decompressions were performed with use of an operating microscope (microscopic), and forty without (open) at two different hospitals. All procedures were performed by the senior author. Information was obtained by analysis of the patients' notes. The average age of the patients in both groups was comparable. Operating time was shorter in the microscopic group (68min, range 30-130) compared to the open group (83 mins, range 30-180). Dural tear rate was 4.3% with use of a microscope (0% symptomatic dural tear rate) and 7.5% without (2.5% symptomatic dural tear rate). Nerve damage incidence was 0% with use of a microscope and 5% (two patients) without. One of these was a neurapraxia and the patient made a full recovery. Wound infection rates, diagnosed on grounds of clinical suspicion, were 4.3% and 2.5% for microscopic and open respectively. There were no incidences of deep infection or post-operative discitis. Average inpatient stay was under 48 hours in both groups. Using the modified Macnab criteria, results using the microscope were 0% poor, 14% fair, 32% good, and 55% excellent. The results for the open group were 0% poor, 10% fair, 37% good and 53% excellent. Average follow-up was six months (1-19) for the microscope group, and seven months (2-16) for the open group. We conclude that primary single level unilateral lumbar decompressive surgery, performed without the use of a microscope, has a higher dural tear rate than the same surgery performed with the benefit of an operating microscope. Surgical time and incidence of nerve damage are also reduced by use of the microscope

A total of 38 patients with leprosy and localised nerve damage (11 median at the wrist and 37 posterior tibial at the ankle) were treated by 48 freeze-thawed skeletal muscle autografts ranging between 2.5 cm and 14 cm in length. Sensory recovery was noted in 34 patients (89%) and was maintained during a mean period of follow-up of 12.6 years (4 to 14). After grafting the median nerve all patients remained free of ulcers and blisters, ten demonstrated perception of texture and eight recognised weighted pins. In the posterior tibial nerve group, 24 of 30 repairs (80%) resulted in improved healing of the ulcers and 26 (87%) demonstrated discrimination of texture. Quality of life and hand and foot questionnaires showed improvement; the activities of daily living scores improved in six of seven after operations on the hand, and in 14 of 22 after procedures on the foot. Another benefit was subjective improvement in the opposite limb, probably because of the protective effect of better function in the operated side. This study demonstrates that nerve/muscle interposition grafting in leprosy results in consistent sensory recovery and high levels of patient satisfaction. Ten of 11 patients with hand operations and 22 of 25 with procedures to the foot showed sensory recovery in at least one modality

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement-bone interface for fixation. The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic: Nerve damage, Altered hemodynamics with limb exsanguinations (15–20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain), Delay in recovery of muscle function, Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes, A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles, Vascular injury with higher risk in atherosclerotic, calcified arteries, Increase in wound healing disturbances, Obese patients TKA with tourniquet show impaired endothelial function and more DVTs. Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last 14 years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, cement penetration/ fixation, less postoperative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation. The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic: Nerve damage; Altered hemodynamics with limb exsanguinations (15–20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3× greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances. Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-operative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation. The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic - Nerve damage; Altered hemodynamics with limb exsanguinations (15‐20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain); Delay in recovery of muscle function; Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes; A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles; Vascular injury with higher risk in atherosclerotic, calcified arteries; Increase in wound healing disturbances. Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less postoperative pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Aims

As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach.

The major benefit of TKA with tourniquet is operating in a bloodless field. A possible secondary benefit is a better cement bone interface for fixation. The disadvantages of tourniquet use for TKA include multiple risk factors both local and systemic. . Nerve damage. Altered hemodynamics with limb exsanguinations (15–20% increase in circulatory volume) and reactive hyperemia with tourniquet release (10% increase in limb size increasing soft tissue tension and secondary pain). Delay in recovery of muscle function. Increased risk of DVT with direct trauma to vessel walls and increased levels of thrombin-antithrombin complexes. A 5.3x greater risk for large venous emboli propagation and transesophageal echogenic particles. Vascular injury with higher risk in atherosclerotic, calcified arteries. Increase in wound healing disturbances. Our initial experience with TKA without tourniquet was in high risk patients with previous DVT or PE, multiple scarring, or compromised cardiovascular status. We have used this method on all patients for the last eight years. The protocol includes regional anesthesia, incision and approach made with 90-degree knee flexion, meticulous hemostasis, jet lavage and filtered carbon dioxide delivered to dry and prepare bone beds for cementation, application of topical tranexamic acid and routine closure. We have encountered no differences in blood loss or transfusion rates, less post-op pain, faster straight leg raise and knee flexion gains, and fewer wound healing disturbances. We recommend TKA sans tourniquet. Let it bleed!

Acute scaphoid fractures are commonly treated with cast for 8–12 weeks. With this prolonged period of immobilisation patients can encounter joint stiffness and muscle wasting requiring extensive physiotherapy. Despite best practice, these fractures also pose a risk of non-union and suboptimal function. Fracture location, duration of time lost from work and impairment in activities of daily living are key factors in scaphoid fracture management. The aim of our study was to compare percutaneous screw fixation of the scaphoid with other operative fixation techniques. Parameters documented were length of conservative treatment, mechanism of injury, post-op complications and patient satisfaction levels with each technique using a standardised questionnaire. Economic benefit was also measured by examining time to return to work, number of x-rays and outpatient visits required per treatment group. In this study, 76 patients requiring operative scaphoid fixation were evaluated. 27 patients underwent percutaneous fixation. Waist fractures accounted for 66% (n= 18), proximal pole fractures 33% (n=8) and distal pole fractures 4% (n=1). There were 16 non-displaced fractures (59%) and 11 displaced fractures (41%). The average length of conservative treatment was 77 days (range: 2–256 days). Within the percutaneous group 2 patients developed non-union. We did not encounter any wound infection or superficial radial nerve damage. Patients treated with early percutaneous fixation had highest satisfaction levels, returned to work earlier and required less follow-up (P< 0.001). In conclusion percutaneous screw fixation provides earlier bone union and avoids the need for prolonged immobilisation when compared to other treatment modalities. The economic benefit of early percutaneous fixation must also be considered when managing patients with scaphoid fractures

Background. Recent meta-analyses have shown reduced re-rupture rates for the surgical management of Achilles ruptures. However percutaneous repair has been demonstrated to lead to improved function, patient satisfaction but greater complications than open repair. In the current economic climate, we believe it is reasonable to consider the financial cost of rupture management for both the patient and the provider. We aimed to determine the cost effectiveness of operative treatment of ruptures of the Achilles tendon based upon theatre occupancy, clinic attendance and cast changes, operative complications and functional assessment score. Methods. We audited the cost effectiveness of the surgical management of Achilles tendon ruptures between 2005–2011 in our unit by comparing 49 patients receiving percutaneous repair to 35 patients whom had open repairs (Retrospective cohort study level 3). Results. There was no significant difference in complications between the two surgical techniques: (Open vs. Pc) overall rates 14.3% vs. 10.4%: infection; 2.7% vs. 2.0%, transient sural nerve damage: 5.6% vs. 8.1%, wound breakdown: 2.8% vs. 0.0%, re-rupture: 2.8% vs. 2.0%. Achilles Total Rupture Scores (ATRS) were comparable (Open 89 (65–100) at 49 months vs. Pc 88.8 (33–100) at 12 months (P=0.9). Theatre occupancy (P< 0.00) and hospital stay (P< 0.00) were significantly longer with open repair (43 mins (26–70) and 2.9 days (0–4)) compared to Pc repair (15 mins (12–43) and 1.2 days (0–2)). Excluding the costs of running the operating theatre we have estimated the costs of surgery for open repair to be £935.36 and percutaneous repair to be £574.04. Conclusions. This study suggests that percutaneous repair of the Achilles tendon resulted in reduced costs and yet had comparable outcome and complications rates to open repair in surgical management of the Achilles tendon. We recommend that percutaneous repair should be considered as the primary method of cost effective surgical management of Achilles tendon rupture

Background:. Total hip arthroplasty (THA) has been proven to be successful in achieving adequate pain relief and favorable outcomes in patients suffering from hip osteoarthritis (OA). However, leg length discrepancy (LLD) is still a significant cause of morbidities such as nerve damage, low back pain and abnormal gait. Despite most of the reported values of LLD in the literature being within the acceptable threshold of < 10 mm, some patients still report dissatisfaction, leading to litigation against orthopedic surgeons. However, lower extremity lengthening is sometimes necessary to achieve adequate hip joint stability and prevent dislocations. The purpose of this study was to compare LLD in patients undergoing THA using three different techniques: conventional anterior-approach THA (ATHA), conventional posterior-approach THA (PTHA), and robotic-assisted posterior-approach THA (RTHA) using the MAKO™ robotic hip system. Materials and Methods:. All cases of RTHA, ATHA and PTHA that were performed by the senior surgeon between Sep 2008 and Dec 2012 were reviewed. Patients included in this study had a primary diagnosis of hip osteoarthritis, with available and proper post-operative antero-posterior pelvis radiographs. All radiographs were calibrated and measurements done twice by two blinded observers. Results:. After exclusions, 67 RTHA cases, 29 ATHA cases and 59 PTHA cases were included in this study. There was a strong inter- and intra-observer correlation for all LLD measurements (r > 0.9, p < 0.001 in all). Mean LLD in the RTHA, ATHA and PTHA groups was 2.7 ± 1.8 mm (CI. 95. : 2.3, 3.2), 1.8 ± 1.6 mm (CI. 95. : 1.2, 2.4) and 1.9 ± 1.6 mm (CI. 95. : 1.5, 2.4) respectively (p = 0.01). When LLD > 3 mm was set as an outlier, the percentage of patients in the RTHA, ATHA and PTHA groups was 37.3%, 17.2% and 22% respectively (p value range, 0.06–0.78). When LLD > 5 mm was set as an outlier, the percentage of patients in the RTHA, ATHA and PTHA groups was 10.4%, 6.9% and 8.5% respectively (p value range, 0.72–1.0). None of the patients in all three groups had LLD ≥ 10 mm (Figure 1). Conclusion:. The results of the current study demonstrate the accuracy of the MAKO™ system in obtaining minimal LLD compared to the conventional anterior-approach and conventional posterior-approach THA, with no cases having LLD > 10 mm

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet). Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years. Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient. Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique

Aims

Despite the increase in the surgical repair of proximal hamstring tears, there exists a lack of consensus in the optimal timing for surgery. There is also disagreement on how partial tears managed surgically compare with complete tears repaired surgically. This study aims to compare the mid-term functional outcomes in, and operating time required for, complete and partial proximal hamstring avulsions, that are repaired both acutely and chronically.

External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such as necrotising fasciitis (NF) and toxic shock syndrome (TSS) may occur.

We retrospectively reviewed all patients who underwent external fixation between 1997 and 2012 in our limb lengthening and reconstruction programme. A total of eight patients (seven female and one male) with a mean age of 20 years (5 to 45) in which pin/wire track infections became limb- or life-threatening were identified. Of these, four were due to TSS and four to NF. Their management is described. A satisfactory outcome was obtained with early diagnosis and aggressive medical and surgical treatment.

Clinicians caring for patients who have external fixation and in whom infection has developed should be aware of the possibility of these more serious complications. Early diagnosis and aggressive treatment are required in order to obtain a satisfactory outcome.

Cite this article: Bone Joint J 2015;97-B:1296–1300.

Over a two-year period, 265 Norwegian orthopaedic surgeons working at 71 institutions performed 63 484 operations under a tourniquet. Their replies to a questionnaire revealed that they mostly followed modern guidelines in their use of the tourniquet. Most felt that the tourniquet could be left on for two hours, and that it could be re-applied after 15 minutes. A total of 26 complications (one in 2442 operations) that might have been due to the tourniquet were reported, of which 15 were neurological. Three were in the upper limb (one in 6155 operations) and 12 in the lower limb (one in 3752 operations). Two were permanent (one in 31742 operations), but the remainder resolved within six months. One permanent and one transient complication occurred after tourniquet times of three hours. The incidence of tourniquet complications is still at least as high as that estimated in the 1970s.

Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries.

Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome.

At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years.