Abstract

Abstract

Objective

To assess the long term functional and objective outcomes for 2 stage Dupuytrens contracture correction.

We used an atomic layer deposition (ALD) approach to create titanium oxide nanolayers on ultra high molecular weight polyethylene (UHMWPE) surfaces. These materials were then characterised in terms of rat osteoblast adhesion, morphology and differentiation.

UHMWPE discs produced from a machined cylinder or impact moulded discs were coated with titanium oxide by ALD. Light, atomic force microscopy and scanning electron microscopy with EDX were used to characterise the coated surfaces. These approaches showed 1-1.5 micron tooling grooves with a periodicity of 40 microns on the machined discs whilst the moulded discs exhibited nanotopographical features. The titanium oxide coating was successfully deposited on discs from both sources but was not uniform across the surfaces, with vein-like ‘creases’ clearly visible. We believe that these features are due to the thermal expansion of the UHMWPE discs during the ALD process and their subsequent cooling.

Coated and uncoated discs were seeded with osteoblasts for 24 hours, then fixed. Immunofluorescence microscopy and computer-based image processing enabled determination of osteoblast numbers, size and shape. A trend of larger average cell area was associated with the coated discs and P<0.01 for an H0 of no difference in cell area between coated and uncoated grooved discs.

Osteoblasts were also cultured on the discs in osteogenic medium to promote bone nodule formation. After a few weeks, von Kossa staining and computer-based image processing allowed calculation of surface area covered with bone nodules for each of the discs. Based on results from three of each type of disc, a significantly greater proportion of the surface area of coated discs was covered with calcified deposits compared to uncoated discs (P<0.025 for grooved discs and P<0.005 for smooth discs). On average, the coated discs had bone nodules on 1.4 times the surface area as compared to their uncoated counterparts.

The hypothesis for our study was that TiO2 coating of a polymer might better promote osteoblast interaction with the biomaterial surface leading to enhanced osteogenesis. Our preliminary data support this view and suggest that this approach could likely be exploited in the fabrication of implant materials with tailored biological activity.

There is a difference of opinion regarding the usefulness of MR Imaging as a diagnostic tool for triangular fibrocartilage complex (TFCC) tears in the wrist. Our aim was to determine the accuracy of direct magnetic resonance arthrography (MRA) in the diagnosis of triangular fibrocartilage complex (TFCC) tears of the wrist in a district general hospital setting.

In a retrospective review of 21 patients who presented with complains of wrist pain and following a clinical examination, all had direct MR arthrography of the wrist in our hospital in a 1.5Tesla scanner. All had a diagnostic arthroscopy within 2-4 months of the MR scan. All patients had chronic ulnar sided wrist pain, although only two had a definite history of trauma. The findings of each diagnostic method were compared, with arthroscopy considered the gold standard.

Twenty-one patients were studied (10 male: 11 female), mean age 42 years (range 27-71) years). Seventeen TFCC tears were diagnosed on arthroscopy. For the diagnosis of TFCC tears MRA had a sensitivity, specificity and accuracy of 67%.

Our results echoed the opinion of some of the previous investigators with an unacceptable sensitivity or specificity for a diagnostic tool. MR arthrography needs to be further refined as a technique before it can be considered to be accurate enough to replace wrist arthroscopy for the diagnosis of TFCC tears. Other centres have reported better accuracy, using more advanced MRI technology. Until this iswidely available at all levels of healthcare the results of MRI for the diagnosis of TFCC tears should be interpreted with caution.

Background

Fracture non-union is still a major challenge to the orthopaedic surgeon and established non-union has zero probability of achieving union without intervention.

Introduction: Fracture of cortical long bone can be treated with open reduction and internal fixation. Although the lag-screw technique would provide a stronger compression across the fracture site, this may not translate directly into a significantly better mechanical stability of the construct. In narrow long bone such as the metacarpus, it may be technically difficult to over-drill the near cortex. In addition, the fracture configuration as well as the presence of soft tissue attachment and neurovascular bundle in such smaller bones may give rise to technical difficulty in fixation with all the screws from the same side.

Hypothesis: We therefore propose to test the hypothesis that there is no difference in the mechanical stability of the construct, in terms of three points bending and axial loading, between fixation with lag screw (L) and cortical screw (1C) in long bone oblique fracture.

Secondly, we proposed that fixation with alternate cortical screws from both sides of the cortices (2C) may confer a stronger mechanical stability than fixation with all screws from one side (1C).

Method: A 12 cm long oblique osteotomy was created along the shaft of tibial saw bone to produce an artificial long oblique fracture. The two fragments were held together and precompressed similarly with reduction clamp. Lag screw technique (L), unilateral (1C) and bilateral (2C) simple cortical screws techniques were used to fix the fracture with a total of four 4.5mm cortical screw in each construct. The test piece was placed into position and compressed under displacement control using a Bose ElectroForce^® 3300 Series test instrument (Bose Corporation ElectroForce Systems Group, Minnesota USA). The displacement was applied at a rate of 0.42mm/s. The displacement and load were measured every 0.0586 seconds and recorded using Win-Test Software (Bose Corporation ElectroForce Systems Group, Minnesota USA).

Result: In three-points bending, fixation with unilateral cortical screws (1C) provided the highest mean stiffness values of the three techniques with an average of 27.72 N/mm (standard deviation STD 4.90 N/mm). The lag screw technique (L) had slightly lower mean stiffness values with an average of 26.29 N/mm (STD 3.46 N/ mm). Fixation with opposing screws (2C) had a lowest mean stiffness averaging 18.31 N/mm (STD 14.49 N/ mm). In axial compression, unilateral cortical screws (1C) provided the highest average stiffness at 290.33 N/mm (STD 89.84 N/mm) The opposing pre-compression technique had an average stiffness of 241.24 N/ mm (STD 121.30 N/mm) and the lag screw technique 198.94 N/mm (STD 58.33N/mm).

Conclusion: In conclusion, fixation with unilateral cortical screws (1C) provided a better mechanical stability than lag screw. Fixation with bilateral cortical screws (2C) did not provide a more stable construct than unilateral screw fixation.

Purpose: This study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap.

Materials and Method: Sixty-eight patients (72 breasts) had this operation between September 1999 and June 2002. fifty-four patients (58 breasts) were assessed. The average age was 50 year (range 30 – 66 year). Average follow up was 38 month (range 24 – 54 month). DASH and Constant-Murley were used for clinical assessment.

Results: Twenty-nine (50%) shoulders found to have a normal function; whereas, 11 (19%) shoulders had mild disability, 10 (17%) shoulders had moderate disability and 8 (14%) shoulders had severe disability. Only 6 (10%) patients reported being unsatisfied with their outcome; these were, from a shoulder function point view, 4 patients with sever disability, 1 patient with moderate disability and 1 patient with normal shoulder function. However, all these 6 patients were not satisfied with their breast reconstruction outcome.

Conclusion: This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients.

The purpose of this study was to investigate the effect of the degree of abduction on shoulder abduction strength.

Thirty healthy volunteers with no history of shoulder complaint participated in this study. A modified Nottingham Mecmesin Myometer was used. The modification allowed the Myometer to be attached to a clinic table at different angles in order to be at 90°to the arm in varying degrees of abduction. Abduction strength of both shoulders was measured on four occasions at two-week intervals. On each occasion, a different abduction position was adopted at 90°, 60°, 30°and 0°.

The results showed that shoulder abduction strength varies according to the degree of abduction. In comparison with that at 90° of abduction, shoulder abduction strength showed an increase by 12.5% and of 31.3% at 60° and 30° of abduction respectively. However, it was decreased by 18.8% at 0° of abduction. The Student’s T-test showed significant difference between shoulder abduction strength at 90° abduction and all other three abduction positions.

Purpose: Management of unstable or comminuted displaced fractures of the distal radius is difficult. We report our experience treating these fractures with AO volar plate fixation applying the principle of a volarulnar tension band platting. An attempt to introduce a new radiological classification for the accuracy of reduction is made. The classification includes 10 criteria.

Materials and Method: We reviewed clinically and radiologically 99 patients (101 fractures); 60 were type C and 41 were type A. The average follow up was 37 months (24 – 57). The average age was 46 years (19 – 81). Sarmiento’s modification of Gartland and Werley and Cooney’s modification of Green and O’Brien were used for clinical assessment. Lidstorm and Frykman used for radiological assessment.

Results: At final follow up the means of distal radius parameters were: volar tilt of 9°, radial inclination of 22°, radial height of 11mm and palmer cortical angle of 32°. The mean dorsiflexion was 61°, palmer flexion was 59°, pronation was 80° and supination was 76°. Grip strength was 86% of the opposite side. The average DASH score was 13.6. There was 13 poor results, 6 of them had a significant loss the initial reduction. There was significant correlation between our classification outcome and the clinical outcome.

Conclusion: AO volar plate fixation of unstable distal radius fractures provides a strong fixation that maintains reduction and allows early mobilisation.

Aim: Osteoarthritis of the wrist is a well recognised cause of secondary carpal tunnel syndrome. The aim of the study is to compare the outcome following carpal tunnel decompression with regard to patient satisfaction. We compared the outcome of carpal tunnel decompression between patients with and with out osteoarthritis of the wrist.

Patients and Methods: The study was done retrospectively. Clinical notes of all the patients who underwent carpal tunnel decompression over a period of 8 years were verified. Twenty four patients who underwent surgical decompression for carpal tunnel syndrome secondary to osteoarthritis were identified by reviewing the notes and the radiographs. Control group consisted of 24 patients who under went carpal tunnel decompression but without osteoarthritis of the wrist. The control group was matched for age, sex, side, and neuro-physiological severity of the nerve compression. Clinical notes were verified to find whether the patients were satisfied with the symptom relief at the first post-operative follow up visit.

Results: There were 24 patients in the group with osteoarthritis of the wrist. The mean age of the patients was 71 years (range 33–89 years). There were 19 females and five males. The right hand was involved in 17 patients and the left was involved in 7 patients. The control group with out osteoarthritis also had similar distribution regarding age sex side, and neuro-physiological severity of nerve conduction. In the group with osteoarthritis of the wrist 17(71%) patients reported the their symptom relief as satisfactory and the rest seven(29%) reported the results as unsatisfactory. In the control group 23(96%) patients reported their symptom relief as satisfactory and one (4%) reported their results as unsatisfactory (P= 0.0325).

Conclusions: Patient satisfaction following surgical decompression in patients with secondary carpal tunnel syndrome due to osteoarthritis is significantly lower compared to patients with out osteoarthritis of the wrist. Patients with osteoarthritis of the wrist should be warned about the higher incidence of poor outcome prior to decompression.

The purpose of this study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap.

Sixty-eight patients (72 breasts) had this operation. Average follow up was 38 months (range 24 to 54 months). DASH and Constant-Murley were used for clinical assessment. Twenty-nine shoulders found to have a normal function; whereas, 11 shoulders had mild disability, 10 shoulders had moderate disability and 8 shoulders had severe disability. However, only 6 patients reported being unsatisfied with their outcome. Furthermore, all these 6 patients were not satisfied with their breast reconstruction outcome.

This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients.

Purpose: Management of the unstable or comminuted displaced fractures of the distal radius is difficult. We report our experience treating these fractures with AO volar plate fixation. An attempt to introduce a new radiological classification for the accuracy of surgical reduction is made. The classification includes 10 criteria and 100 points.

Methods: 124 patients had volar plate fixation performed between June 2000 and May 2003 using AO volar plate. We reviewed clinically and radiologically 101 patients; 60 were type C and 41 were type A (after failed conservative treatment). The average follow up is 37 months (24 – 57). The average age is 46 years (19 – 81). Postoperative regimen consisted of immediate physiotherapy and a wrist splint for three weeks. Cooney’s modification of Green and O’Brien and Sarmiento’s modification of Gartland and Werley were used for clinical assessment. Lidstorm and Frykman used for radiological assessment.

Results: At final follow up the means of distal radius parameters were: volar tilt of 9 degrees, radial inclination of 22 degrees, radial height is 11mm and palmer cortical angle of 32 degrees. The mean dorsiflexion was 61 degrees, palmer flexion was 59 degrees, pronation was 80 degrees and supination was 76 degrees. Grip strength was 86 percent of the opposite side. The average DASH score was 13.6. There was 14 poor results, 6 of them had significant loss the initial reduction. There was significant correlation between our classification and the clinical outcome.

Conclusion: AO volar plate fixation of unstable distal radius fractures provides strong fixation that maintains reduction and allows early mobilisation.

Displaced comminuted intra-and extra-articular fractures of distal radius require anatomical reduction for optimum results.

To assess clinical, functional and radiological results of volar-ulnar tension band plating of dorsally displaced comminuted fractures of distal radius, we used volar-ulnar tension band plating technique (without bone grafting) and early mobilisation to treat dorsally displaced and comminuted fractures of distal radius in 47 patients with an average age of 48 years (range, 19–76 years).

Volar tilt, radial height, ulnar inclination and volar cortical angles were measured on the unaffected side. AO volar plate was pre-contoured to match the volar cortical angle of the unaffected side. The horizontal arm of the plate was fixed to the distal fragment first. When the longitudinal arm of the plate was brought onto the radial shaft, the displaced distal fragment was levered out anteriorly to restore the normal volar tilt. Adjustment in ulnar inclination and radial height can be made by medio-lateral and cephalo-caudal movement of the longitudinal arm of the plate.

The average follow-up was 26 months (range 12–41 months). According to Gartland and Werley’s system 25 patients had excellent, 15 had good, 7 had fair functional results. The median Disability of Arm, Shoulder and Hand (DASH) score was 10 (range 0–60). Average grip strength as percentage of the unaffected side was 80 %. Average Palmarflexion was 61 degrees, Dorsiflexion 66 degrees, Ulnar deviation 34 degrees, Radial deviation 19 degrees, Supination 74 degrees and Pronation 80 degrees. According to Lidstrom and Frykman’s radiological scoring system 39 patients had excellent and 8 had good anatomical results.

Conclusion: This relatively new technique has given good results in majority of patients. We recommend its use in displaced and comminuted fractures of distal radius in physiologically young patients with high need and demand.

Introduction and Aims: Severe Dupuytren’s contracture of the proximal interphalangeal (PIP) joint is a difficult condition to treat; a two-stage technique has been advocated by some surgeons for such cases. The present study set out to determine the early results of this technique.

Method: Thirteen patients (11 with primary and two with recurrent disease) with a severe Dupuytren’s contracture of the proximal interphalangeal (PIP) joint were treated by geometric correction (in line distraction followed by angular correction) using the OrthofixTM mini external fixator followed by its removal and partial fasciectomy (without collateral ligament or volar plate release). The mean duration of distraction was 14 days.

Results: In the PIP joint the mean true fixed flexion deformity pre-operatively was 75 degrees (range 45–90). At a mean follow-up of 21 months, the mean residual flexion deformity was 35 degrees (range 10–90). The mean arc of motion increased from 26 (range 10–55) to 51 degrees (range 0–90). At follow-up, the mean arc of motion was 33 degrees (range 0–70) and 73 degrees (range 45–110) at the distal interphalangeal and meta-carpophalangeal joints respectively. There were no cases of reflex sympathetic dystrophy or neurovascular damage. One patient had a fracture of the proximal phalanx and a second patient had an early recurrence, which led to a poor clinical outcome. The rest had an excellent clinical outcome according to the Michigan Hand Questionnaire.

Conclusion: Although the technique is challenging, the early results are promising and we recommend it for the management of this difficult problem.

Introduction: Displaced intra and extra-articular fractures of distal radius require anatomical reduction in physiologically young patients.

Material and methods: We used volarulnar tension band plating technique (without bone grafting) and early mobilisation to treat dorsally displaced and comminuted fractures of distal radius in 47 physiologically young patients with an average age of 48 years (range, 19–76 years).

Volar tilt, radial height, ulnar inclination and volar cortical angles were measured on the unaffected side. AO volar plate was pre-contoured to match the volar cortical angle of the unaffected side. Horizontal arm of the plate was þxed to distal fragment þrst. When the longitudinal arm of the plate was brought onto the radial shaft, the displaced distal fragment was levered out anteriorly to restore the normal volar tilt, ulnar inclination and radial height.

Results: The average follow-up was 26 months. According to Gartland and Worleyñs system 26 patients had excellent, 14 had good, 6 had fair and 1 had poor results. The median Disability of arm, shoulder and hand (DASH) score was 10 (range, 0–60). According to Lidstrom and Frykmanñs radiological scoring system 39 patients had excellent and 8 had good anatomical results.

Conclusion:We believe this technique is technically demanding and requires good understanding of anatomy and force transmission in an intact and fractured distal radius. This relatively new technique of volarulnar tension band plating of distal radius has given good results in majority of patients. We recommend its use in displaced and comminuted fractures in physiologically young patients with high need and demand.

Rotator cuff pathologies are related with higher incidence of morbidity in the modern society in young patients. Although it is well known that rotator cuff is sandwiched between the acromion and humeral head during various movements of the shoulder joint, only few studies have investigated this looking at the humeral head as a culprit for the rotator cuff pathology.

We carried out the cadaveric study of 15 shoulder joints to find out the influence of the humeral head anatomy on the rotator cuff pathology. We dissected 15 shoulder joints and looked at the rotator cuff tears. All the specimens were examined and photographed digitally from the superior aspect of shoulder joint. All these images were entered into a computer and using special software, we carried out 3D reconstruction of these images. With this software, the outermost point of intersection of humerus head with acromion decided. We calculated the area of the humeral head in an outside the acromion and correlated with the rotator cuff tear.

We found that the area of the humeral head outside the acromion is variable, ranging from 18% to 50% of diameter of humeral head (mean 34%, median 33%, mode 20%, 33%, 45%). When the area of humerus head outside the acromion is less than 32% of the diameter of head (i.e. humerus head was more under the acromion and less outside the outer most point of acromion), those specimens had either incomplete or complete rotator cuff tear.

We conclude that when the area of humeral head, covered under the acromion is more than 68% of the diameter of the head, they have more chances of developing rotator cuff pathology as compare to other individual.