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Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_7 | Pages 8 - 8
1 Jul 2022
Dalal S Guro R Kotwal R Chandratreya A
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Abstract

Methodology

Prospective single-surgeon case-series evaluating patients undergoing surgery by this technique. 76 cases (mean age of 33.2 years) who had primary ACL reconstruction with BTB or quadriceps tendon with bone block, were divided into 2 matched groups (age, sex and type of graft) of 38 each based on the method of femoral fixation used (interference screw or adjustable cortical suspension). Patients were followed up clinically and using PROMS from NLR with EQ-5D, KOOS, IKDC and Tegner scores. Complications and return to theatre were noted. Paired two-tailed student t-tests and Chi-square tests were employed for statistical analysis.

Results

At a mean follow-up of 82 months, peri-operative mean EQ-5D VAS, EQ-5D Index, KOOS, IKDC and Tegner activity scores showed significant improvement (p<0.05), but no significant difference between the two groups (p>0.05). Mean graft length and diameter was 77mm and 9.3 respectively. Mean interval from injury to surgery was 10.5 months. 18(23.7%) patients had associated meniscal tear with 73.3 % undergoing repair. 10 cases (13.2 %) returned to theatre including, MUA for arthrofibrosis (n=2) and intra-substance graft failure (n=2). 3 cases had to be converted to interference screw fixation due to the tightrope cutting through from the femoral bone block as a result of a technical pitfall.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_7 | Pages 64 - 64
1 Jul 2022
Dayananda K Dalal S Thomas E Chandratreya A Kotwal R
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Abstract

INTRODUCTION

A paucity of literature exists regarding efficacy of lateral unloader bracing in treatment for pathologies effecting the lateral compartment of the knee.

We evaluate patient outcomes following customised lateral unloader bracing (cLUB) in treatment of lateral compartment osteoarthritis (LCOA), lateral tibial plateau fractures (LTPF) and spontaneous osteonecrosis of knee (SONK).

METHODS

Institutional study approval was obtained. All patients undergoing cLUB between January 2013 and January 2021 were included, and prospectively followed-up. Visual Analogue Scales (VAS), Oxford Knee Scores (OKS) and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were assessed at brace fitting and final follow-up. Brace compliance, complications and surgical interventions were also collected. Statistical analysis utilised paired t-test.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_2 | Pages 15 - 15
1 Mar 2021
Dalal S Setia P Debnath A Guro R Kotwal R Chandratreya A
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Abstract

Background

Recurrent patellar dislocation in combination with cartilage injures are difficult injuries to treat with confounding pathways of treatment. The aim of this study is to compare the clinical and functional outcomes of patients operated for patellofemoral instability with and without cartilage defects.

Methods

82 patients (mean age-28.8 years) with recurrent patellar dislocations, who underwent soft-tissue or bony procedures, were divided into 2 matched groups (age, sex, follow-up and type of procedure) of 41 each based on the presence or absence of cartilage defects in patella. Chondroplasty, microfracture, osteochondral fixation or AMIC-type procedures were done depending on the nature of cartilage injury. Lysholm, Kujala, Tegner and Subjective Knee scores of both groups were compared and analysed. Complications and return to theatre were noted.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_2 | Pages 29 - 29
1 Mar 2021
Dalal S Aminake G Chandratreya A Kotwal R
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Abstract

Introduction

Long term survivorship in Total Knee Arthroplasty is significantly dependent on prosthesis alignment. The aim of this study was to determine, compare and analyse the coronal alignment of the tibial component of a single implant system using 3 different techniques.

Method

Retrospective study of cases from a prospectively collected database. Radiological assessment included measurement of the coronal alignment of tibial components of total knee arthroplasties, and its deviation from the mechanical axis. A comparison study of intramedullary, extramedullary and tibial crest alignment methods was performed.


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_11 | Pages 45 - 45
1 Dec 2020
Dalal S Setia P Debnath A Guro R Kotwal R Chandratreya A
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Background

Recurrent patellar dislocation in combination with cartilage injures are difficult injuries to treat with confounding pathways of treatment. The aim of this study is to compare the clinical and functional outcomes of patients operated for patellofemoral instability with and without cartilage defects.

Methods

82 patients (mean age-28.8 years) with recurrent patellar dislocations, who underwent soft-tissue or bony procedures, were divided into 2 matched groups (age, sex, follow-up and type of procedure) of 41 each based on the presence or absence of cartilage defects in patella. Chondroplasty, microfracture, osteochondral fixation or Autologous Matrix-Induced Chondrogenesis(AMIC)-type procedures were done depending on the nature of cartilage injury. Lysholm, Kujala, Tegner and Subjective Knee scores of both groups were compared and analysed. Complications and return to theatre were noted.


Orthopaedic Proceedings
Vol. 102-B, Issue SUPP_11 | Pages 63 - 63
1 Dec 2020
Debnath A Dalal S Setia P Guro R Kotwal RS Chandratreya AP
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Introduction

Recurrent patellar dislocation is often reported in bilateral knees in young active individuals. The medial patellofemoral ligament (MPFL) tear is the attributable cause behind many of them and warrants reconstruction of the ligament to stabilize the patellofemoral joint. Besides, trochleoplasty and Fulkerson's osteotomy are some other procedures that are performed to treat this problem. This study aimed to compare the clinical and functional outcomes in a cohort of patients with single-stage bilateral realignment procedures vs staged procedures.

Methods

It was a retrospective matched cohort study with prospectively collected data. A total of 36 patients (mean age-26.9 years, range 13 years to 47 years) with recurrent patellar dislocations, who underwent a surgical correction in both the knees, were divided into two matched groups (age, sex, follow-up, and type of procedure). Among them, 18 patients had surgeries in one knee done at least six months later than the other knee. The remaining 18 patients had surgical interventions for both knees done in a single stage. Lysholm, Kujala, Tegner, and subjective knee scores of both groups were compared and analyzed. The rate of complications and return to the theatre were noted in both groups.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_15 | Pages 104 - 104
1 Mar 2013
Conditt M Kreuzer S Jones J Dalal S
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Introduction

Traditional Total Knee Arthpolasty (TKA) replaces all 3 compartments of the knee for patients diagnosed with OA. There might be functional benefit to replacing only damaged compartments, and retaining the normal ligamentous structures. There is a long history of performing multi-compartment arthroplasty with discrete components. Laskin reported in 1976 that good pain relief and acceptable clinical results were achieved at two years in patients with bi-unicondylar knee replacement [Laskin 1976]. Other authors also have reported on bi-unicompartmental knee arthroplasty achieving successful clinical outcomes [Stockley 1990; Confalonieri 2005]. Banks et al. reported that kinematics of bi-unicompartmental arthroplasties during gait demonstrated some of the basic features of normal knee kinematics [Banks 2005]. These reports suggest that a modular approach to resurfacing the knee can be successful and achieve satisfactory clinical and functional results.

Objective

The primary objective of this study is to compare the functional outcomes of three patient groups treated for osteoarthritis.


The Bone & Joint Journal
Vol. 95-B, Issue 2 | Pages 199 - 205
1 Feb 2013
Robinson PM Wilson J Dalal S Parker RA Norburn P Roy BR

This study reports the clinical and sonographic outcome of arthroscopic rotator cuff repair in patients aged ≥ 70 years and aimed to determine factors associated with re-tear. A total of 69 consecutive repairs were performed in 68 patients with a mean age of 77 years (70 to 86). Constant-Murley scores were collected pre-operatively and at one year post-operatively. The integrity of the repair was assessed using ultrasound. Re-tear was detected in 20 of 62 patients (32%) assessed with ultrasound. Age at operation was significantly associated with re-tear free survival (p = 0.016). The mean pre-operative Constant score was 23 (sd 14), which increased to 58 (sd 20) at one year post-operatively (paired t-test, p < 0.001). Male gender was significantly associated with a higher score at one year (p = 0.019).

We conclude that arthroscopic rotator cuff repair in patients aged ≥ 70 years is a successful procedure. The gender and age of the patient are important factors to consider when planning management.

Cite this article: Bone Joint J 2013;95-B:199–205.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXII | Pages 52 - 52
1 May 2012
Dalal S Barrie J
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Introduction

Many common fractures are inherently stable, will not displace and do not require plaster casting to achieve union in a good position. Nevertheless, many patients with stable fractures are advised that they need a cast, despite the potential for stiffness, skin problems and thromboembolism. Attempts to challenge this practice often meet the argument that patients prefer a cast for pain relief. We analysed five years of a single consultant's fracture clinic to see how many patients with stable foot and ankle fractures chose a cast after evidence-based counselling.

Materials and methods

All patients with stable fractures of the ankle or metatarsals seen between 1st June 2005 and 31st May 2010 were included. Displaced or potentially unstable ankle fractures, Jones fractures and fractures involving the Lisfranc joint were excluded. Patients were advised functional treatment but offered a cast if they wished. Patients were documented prospectively as part of a larger audit, including demographics, diagnosis and treatment in the emergency department and fracture clinic.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 43 - 44
1 Jan 2011
Parmar R Dalal S Roy B
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Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release. This was a prospective study of 28 consecutive patients with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon.

At surgery, arthroscopic joint assessment was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral and medial portals. The ECRB lesions were classified and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and 3 months using the DASH score.

Of the 28 elbows 21 were noted to have a Nirschl type I lesion (intact capsule), 6 had a type II lesion (linear capsular tear) and 1 a type III (capsular rent). Degenerative articular changes were noted in 19 elbows. If arthroscopic debridement was required it was undertaken. Three elbows were noted to have eccentric radial heads. Radial plicae which were impinging on the radial head were noted in three patients. 1 patient was lost to follow up.

There was a significant improvement in DASH scores (p< 0.002) at 2 weeks post operatively. This improvement was sustained at 3 months. This is a worst case scenario analysis using a paired t test. 1 patient had post operative stiffness and 6 failed to improve of which 2 were revisions.

The early results would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 574 - 574
1 Oct 2010
Parmar R Dalal S Roy B
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Many procedures have been described for the operative treatment of tennis elbow (lateral epicondylitis). Arthroscopic tennis elbow release is a relatively recent development. The aim of this study was to review our early results of arthroscopic tennis elbow release.

This was a prospective study of 29 consecutive patients (30 elbows) with tennis elbow refractory to conservative management, who underwent arthroscopic tennis elbow release performed by one surgeon. At surgery, arthroscopic assessment of the elbow joint was performed followed by capsulectomy and debridement of the Extensor Carpi Radialis Brevis (ECRB) tendon origin using the proximal lateral, anteromedial and anterolateral portals. Associated intra-articular pathology was noted. The ECRB lesions were classified according to their gross morphology and resected with a shaver but the insertion site was not decorticated. Patients were assessed preoperatively, at 2 weeks and at 3 months using the DASH score.

29 patients with tennis elbow were treated with arthroscopic release of the ECRB origin on the lateral epicondyle. Of the 30 elbows undergoing surgery, 22 were noted to have a Nirschl type I lesion (intact capsule), 7 had a type II lesion (linear capsular tear) and 1 had a type 3 lesion (capsular rent). Degenerative articular changes were noted in 18 elbows. Arthroscopic debridement was undertaken if appropriate. Three elbows had eccentric radial heads. Radial plicae which were impinging on the radial head were present in three patients.

Mean follow up is 9 months (1–23). 1 patient was lost to follow up.

There was a significant improvement in DASH scores (p< 0.05) at 2 weeks post operatively. This improvement became more significant at 3 months post operatively. This is a worst case scenario analysis using a paired t test. 6 patients failed to improve, 1 partially improved and 1 was revised and improved.

There were no surgical complications; however, one patient has post operative stiffness which required an arthroscopic release.

The early results of this study would suggest arthroscopic tennis elbow release is an effective treatment for tennis elbow, which in addition also allows assessment of the elbow joint and the potential to address associated intra-articular pathology if required. This minimally invasive technique has been demonstrated to be safe and affords early post operative rehabilitation and return to normal activities.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 558 - 558
1 Oct 2010
Sahu A Dalal S Jain N Mahajan R Todd B
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Aim: Our aim was to find the effect of implementation of European working time directive on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: The audit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England. We have analysed the results of the this and have identified a potential area of concern.

Results: An orthopaedic trainee of registrar level(Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. Overall, a trust grade surgeon (non-training grade) was the lead surgeon in 24% of cases. Comparing with the previous audits performed in the same hospitals, the number of hip fracture operations performed by trainees have reduced drastically. In 2003 and 2005 audits, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively. There is a definite trend suggesting decrease in number of operations by trainees since the implementation of European working time directive as it has been introduced in a phased manner since 2004. In NHS, Current target is to achieve it fully by next year which may make the situation even worse from training point of view.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. On the other hand, the modernising medical curriculum (MMC) emphasises demonstration and record keeping of core competencies of surgical skills. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in England are mirrored elsewhere in Europe, the implications for orthopaedic training are significant. We are setting very high standards for training on one side but on practical grounds, not able to achieve the requirements set by educational bodies like OCAP and ISCP.


Aim: Our aim was to find the effect of implementation of European working time directive (EWTD) on current Orthopaedic training in England. Hip fracture surgery is one of the most frequently performed operation on the trauma lists and hence it is considered mandatory to independently able to perform hip fracture surgery in the registrar training curriculum.

Methods: This reaudit was performed over four month period in 2007 (1st April to 31st July) collating information on 1010 hip fracture patients undergoing surgery in 14 NHS hospitals in the North Western deanery of England.

Results: An orthopaedic trainee of registrar level (Speciality trainee year 3–6) was the lead surgeon in 37% of cases while only 4% of operations were performed by a Speciality trainee year 1–2 or Foundation year 2 (senior house officer grade) in 2007. These findings varied amongst the audited hospitals but in one hospital, trainees operated on only 12% of hip fractures. In previous audits done in 2003 and 2005, Orthopaedic registrar’s operated on 52 % and 50% of hip fractures respectively. Similarily senior house officers had hands on experience on 11% and 9% of hip fractures in 2003 and 2005 respectively.

Discussion: European working time directive has reduced the working hours, leading to decreased hours of surgical training. The Orthopaedic Competence Assessment Project (OCAP) and the Intercollegiate Surgical Curriculum Project (ISCP) expects trainees to achieve core competencies in key procedures such as hip fracture surgery. In the context of shorter training and reduced working hours, to achieve these core competencies it is imperative to maximise operative exposure and experience for trainees. If the findings of this reaudit in Northwest of England are mirrored elsewhere in United Kingdom, the implications for orthopaedic training are significant.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 375 - 375
1 Sep 2005
Davies M Dalal S
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Background Bony or cartilaginous ossicles appear at the plantar aspect of the interphalangeal joint of the great toe. The variation in pattern, prevalence and anatomic relationships of these structures is not clearly established in the literature, especially in a Caucasian population. Without this knowledge, pathology at this joint may be underestimated and surgical approaches may be poorly planned particularly as radiographs underestimate the incidence of ossicles at this joint. The aims of this study were to determine the incidence and pattern of ossicles at this joint and to establish their anatomical relationships in order to aid planning the approach for their excision.

Method The left great toe interphalangeal joint was dissected in forty British Caucasian cadavers and the pattern of ossicles and their anatomic relationships were established.

Results In 27.5% of specimens, there was no identifiable ossicle and in these cases, the tendon of flexor hallucis longus was adherent to the joint capsule. In the remaining specimens (72.5%), a bursa separated the tendon of flexor hallucis longus from the plantar joint capsule and ossicles were found embedded within the joint capsule. Over a half (52.5%) of the specimens had a single ossicle located centrally within the plantar capsule and the remaining 20% had two ossicles lying within the capsule.

Conclusion This study shows that a large proportion of the population have either one or two bony or cartilaginous ossicles at this joint. In addition, the study has clarified the anatomy of this joint and shown that, when present, ossicles do not lie within the tendon of flexor hallucis longus and could be most safely approached from either a medial or lateral approach.