To determine in skeletally mature patients with a traumatic, first-time, patellar dislocation, the effect of early MPFL reconstruction versus rehabilitation on the rate of recurrent patellar dislocations and functional outcomes.

Three online databases MEDLINE, EMBASE and PubMed were searched from database inception (1946, 1974, 1966 respectively), to August 20th, 2021, for literature addressing the management of patients sustaining acute first-time patellar dislocations. Data on redislocation rates, functional outcomes using the Kujala score, and complication rates were recorded. A meta-analysis was used to pool the mean postoperative kujala score as well as calculate the proportion of patients sustaining redislocation episodes using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS and Detsky scores.

Overall, there were a total of 22 studies and 1705 patients included in this review. The pooled mean redislocation rate in 18 studies comprising 1409 patients in the rehabilitation group was 31% (95% CI 25%-36%, I2 = 65%). Moreover, the pooled mean redislocation rate in five studies comprising 318 patients undergoing early MPFL reconstruction was 7% (95% CI 2%-17%, I2 = 70%). The pooled mean postoperative Kujala anterior knee pain score in three studies comprising 67 patients in the reconstructive group was 91 (95% CI 84-97, I2 = 86%), compared to a score of 81 (95% CI 78-85, I2 = 78%) in 7 studies comprising 332 patients in the rehabilitation group. The reoperation rate was 9.0% in 936 patients in the rehabilitation group and 2.2% in 322 patients in the reconstruction group.

Management of acute first-time patellar dislocations with MPFL reconstruction resulted in a lower rate of redislocation and a higher Kujala score, as well as noninferiority with respect to complication rates compared to nonoperative treatment. The paucity of high-level evidence warrants further investigation in this topic in the form of well-designed and high-powered RCTs to determine the optimal management option in these patients.

Aims

To systematically review the outcomes and complications of cosmetic stature lengthening.

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be difficult. Clinical prediction algorithms have been devised to distinguish septic arthritis (SA) from transient synovitis (TS). Within Europe measurement of the Erythrocyte Sedimentation Rate (ESR) has largely been replaced with assessment of C-Reactive Protein (CRP) as an acute phase protein. We produce a prediction algorithm to determine the significance of CRP in distinguishing between TS and SA.

Purpose

To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure.

Background

Establishing the diagnosis in a child presenting with an atraumatic limp can be challenging. There is particular difficulty distinguishing septic arthritis (SA) from transient synovitis (TS) and consequently clinical prediction algorithms have been devised to differentiate the conditions using the presence of fever, raised erythrocyte sedimentation rate (ESR), raised white cell count (WCC) and inability to weight bear. Within Europe measurement of the ESR has largely been replaced with assessment of C-reactive protein (CRP) as an acute phase protein. We have evaluated the utility of including CRP in a clinical prediction algorithm to distinguish TS from SA.

Purpose

To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure.

Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm.

The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient.

A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.

Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87). We prospectively reviewed the medication of such patients who were admitted to our Trauma Unit to identify if the NICE guidance was being followed.

Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture. We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one. 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded.

Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate. 6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner.

Nice guidance from 2005 is clearly not being implemented in our area. A minority of patients will have contraindications or allergies to bisphosphonates (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society). Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care. This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service.

Introduction: Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. In 2005, the National Institute for Health & Clinical Excellence (NICE) recommended bisphosphonates as a treatment option in women over 75 years without the need for prior DEXA scanning (Technology Appraisal Guidance 87).

We prospectively reviewed the medication of such patients who were discharged from our Trauma Unit to identify if the NICE guidance was being followed.

Method: Over a three month period between May and July 2007, 54 women over 75 years old were discharged from our Trauma Unit having sustained an osteoporotic fracture.

We prospectively reviewed their medication to identify if a bisphosphonate had been commenced by the General Practitioner and their discharge letters to their General Practitioners to see if it had been suggested to start one.

Results: 7 of the 54 women (13%) were already on a bisphosphonate and were therefore excluded.

Only one (2%) of the discharge letters (written by the Orthopaedic doctor to the General Practitioner) recommended commencing a bisphosphonate.

6 of the 47 patients (13%) had been started on a bisphosphonate by the General Practitioner.

Conclusions: Nice guidance from 2005 is clearly not being implemented in our area. Some patients will have contraindications or allergies to bisphosphonates, however, they will be a minority (up to 1 in 4 patients as highlighted recently by the National Osteoporosis Society).

We believe the results demonstrate a lack of health promotion opportunities to prevent future fracture. Although there is clear focus and impetus for developing falls prevention services nationwide, this enthusiasm has not been translated across to bone health, despite the potential savings in terms of morbidity, mortality and healthcare costs.

Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care.

This study lead to an education initiative to ensure the Trauma department and our local General Practitioners were aware of the NICE guidance. A second prospective audit is currently being undertaken to assess the effect on our service.

Introduction: We present a double blinded prospective randomized controlled trial between viscoseal and intraarticular diamorphine injection in shoulder arthroscopy.

Materials & Methods: Twenty adult patients undergoing arthroscopic subacromial decompression were randomised into two groups. The Viscoseal group received 10ml of Viscoseal and 10ml of 0.5% bupivacaine injected into the subacromial bursa at completion of the procedure (n=10). The matched control group received 10mg diamorphine and 10mls of 0.5% bupivacaine (n=10). All procedures were performed by the senior author. The patients were blinded to the injections given. Post-operative regimes were standardised and all patients were assessed by visual analogue pain scores at recovery and 1, 2, 6, 12 & 24 hours post-operative. The presence or absence of nausea and time to discharge were also noted.

Results: The mean age of the Viscoseal group was 53 (range 34–70) years and in the control group 59 (32–85) years. In the Viscoseal group 40% of patients were discharged on the same day, while there were no early discharges in the diamorphine group this difference did not reach statistical significance (P=0.054 by Fisher’s exact test). There were no significant differences in post-operative pain score or the fraction pain-free between the two groups or in supplementary analgesic drug doses given (all P> 0.08). Only 10% of the Viscoseal group were nauseous post-operatively compared to 60% of the control group (P=0.03 by Fisher’s exact test).

Discussion: Arthroscopic surgery has never been more popular. Patients like smaller scars, early discharge and quick return to daily life and work; for surgeons arthroscopic surgery is skilful, satisfying and digitally recordable; and the NHS benefits from reduced hospital stay and post-operative complications.

Review of the literature involving the use of viscoseal in shoulder surgery revealed no direct comparison with diamorphine, but only to bupivacaine alone.

Many methods of post-arthroscopic pain relief are available. In our hospital diamorphine with bupivacaine is standard, at £2.57 per treatment. In the present study nausea was significantly lower in the Vicoseal group, but no significant intervention was required and oral anti-emetics sufficed. Pain was not significantly different, and there were no significant differences in supplementary analgesia or in early discharge. In our opinion, the significant improvement in nausea alone is not enough to justify the high price of £52.88 per Vicoseal treatment. We believe that the benefits for routine use have not been demonstrated.

Background: In times of blood shortage, the department of health plan to cancel elective surgery requiring more than 2 units of blood cross matching preoperatively. We assessed the use of blood products in scoliosis surgery and identified factors increasing the need for post operative blood transfusion.

Methods: Prospective data collection. Forty four patients underwent corrective spinal surgery between January 2003 and June 2004. Numbers of units of blood cross matched pre operatively and transfused post operatively were calculated. Subtype of scoliosis and surgical approach were also identified.

Results: All patients were cross matched 6 units of blood pre operatively, total of 264 units. Only 133 units were actually transfused, giving an overall 50.4 % product use rate. All syndromic patients were transfused blood irrespective of surgical approach. Idiopathic patients who had a one stage anterior approach did not require transfusion. Idiopathic patients were transfused a mean of 2.4 units and 2.9 units for one stage posterior and 2 stage approaches respectively. Syndromic patients were transfused a mean of 2.5 units, 5.8 units and 4.2 units for one stage anterior, one stage posterior and 2 stage procedures respectively.

Conclusion: The department of health published a paper on contingency planning for the shortage of blood products (1). In times of shortage, those surgeries requiring preoperative cross matching of more than 2 units will be cancelled first. Therefore, not only is it important to reduce the waste of blood products from a cost perspective, but also to cross match appropriately to avoid unnecessary cancellation if blood shortages occur. Surgical approach and underlying diagnosis need to be identified when cross matching patients for corrective scoliosis surgery. Idiopathic scoliosis patients only require 2 units of blood cross matching preoperatively. Patients with syndromes require 2–6 units depending on the surgical approach. A prospective validation trial has been implemented to validate our retrospective findings.

Introduction and Aims: Although PD has characteristic findings and stages of progression, neither the nature of operative spine problems occurring in patients with PD, nor their peri-operative complications, have been presented previously.

Method: In this retrospective observational case series, we describe the nature of operative spine problems in patients with Parkinson’s disease (PD), and evaluate the incidence and types of peri-operative complications in spine surgery for patients with PD. A retrospective chart review was performed on 24 consecutive PD patients undergoing spine surgery in a six-year span at one institution. Nineteen were first surgeries, and five were first seen as failed back syndrome from surgery done elsewhere.

Results: The mean patient age was 69 years. Spinal stenosis (10 patients) and cervical myelopathy (4 patients) were the predominant pre-operative diagnoses for the primary surgeries, with three patients operated upon for kyphoscoliosis (16%) and two for other conditions. Minor or transient complications were common, including delirium, arrhythmia, deep vein thrombosis, and dural tear; there were also two significant PD-specific complications, including aspiration pneumonia and global motor paresis post-operatively. Four of 19 primary cases were revised for recurrent stenosis (two patients) or pseudarthrosis (two patients). The overall number of poor patient-reported outcomes was only two of 14 primary cases (five patients had inadequate outcome measures) and zero of seven revisions (two had inadequate outcome measures), at a mean follow-up of 19 months.

Conclusion: Symptoms and functional deficits of spinal disease were often masked by PD, posing diagnostic difficulty. However, outcomes and complications of spine surgery were similar to those of non-PD patients at the same institution. Spine symptoms improved concomitantly with successful surgery unless the PD progressed or significant complications ensued.

The risk of articular penetration during tibial nailing is well known, but the incidence of unrecognised damage to joint cartilage has not been described. We have identified this complication in the treatment of tibial fractures, described the anatomical structures at risk and examined the most appropriate site of entry for tibial nailing in relation to the shape of the bone, the design of the nail and the surgical approach.

We studied the relationship between the intra-articular structures of the knee and the entry point used for nailing in 54 tibiae from cadavers. The results showed that the safe zone in some bones is smaller than the size of standard reamers and the proximal part of some nails. The structures at risk are the anterior horns of the medial and lateral menisci, the anterior part of the medial and lateral plateaux and the ligamentum transversum. This was confirmed by observations made after nailing 12 pairs of cadaver knees. A retrospective radiological analysis of 30 patients who had undergone tibial nailing identified eight at risk according to the entry point and the size of the nail. Unrecognised articular penetration and damage during surgery were confirmed in four.

Although intramedullary nailing has been shown to be a successful method for treating fractures of the tibia, one of the most common problems after bony union is pain in the knee. Unrecognised intra-articular injury of the knee may be one cause of this.