The available scoring methods and outcome analysis methods in lower extremity skeletal trauma with vascular injuries are not always specific. Biochemical parameters like venous blood lactate, bicarbonate and serum CPK (at the time of admission and serial monitoring) were measured to assess whether they supplement clinical parameters in predicting limb salvageability in lower extremity skeletal trauma with vascular injuries. Materials and methods: 74 adult patients with long bone fracture of lower limb associated with vascular injury (open and closed) were included in the study group. Patients with significant head injury (who cannot provide informed consent) and those with mangled extremities (MESS score>8) were excluded. Pre-operative requirement for fasciotomy was recorded. A vascular surgery consultation was obtained. CT angiography and DSA were performed if needed only. Venous blood samples from the injured limb were withdrawn for lactate and bicarbonate analysis. Serum CPK was estimated at the time of admission and repeated at 6, 12, 24, 48 and 72 hours after admission. A record was maintained about the type and duration of surgery, blood loss, type of anaesthesia used and fasciotomy in the post-operative period.Introduction
Methodology
To critically evaluate exciting new technology to reconstruct menisci for the treatment of post menisectomy pain and relate results to indication and surgical technique in a non-inventor's general knee practice. We present our early experience of two non-comparative series with different meniscal implants. Series 1: Thirteen patients received a Menaflex implant (Regen Bio, USA). Mean age 30, male/female 11/2, mean length of implant 44mm, mean chondral grade 1.9 (Outerbridge). At 24 months clinical scores showed improvement in 12. Second look arthroscopy in 5 however showed disappointing amounts of regenerative tissue. One patient has been revised. Series 2: Twelve patients received an Actifit implant (Orteq, UK). Mean age 38, male/female 8/4, mean length implant 43 mm, mean chondral grade 1.3. At 12 months all have improved clinical scores. We have performed two second looks, one of these showed excellent integration. However one showed only 50% regeneration. Critical review of the initial implantation shows that there may not have been adequate preparation of the host meniscus tissue.Purpose
Methods
To identify the degree of morphological change achievable following the Bereiter trochleoplasty and to establish whether these results are comparable with functional outcomes. Seventeen consecutive patients (19 knees) with patellar instability secondary to trochlear dysplasia underwent trochleoplasty, of which 12 knees (12 patients) were radiologically evaluated pre- and post surgery using axial CT and MRI imaging. Their mean age at time of surgery was 28.1 years (15 to 44). The mean follow-up was 2.2 years (0.5 to 5). The following four radiological outcomes were used: trochlear depth (TD), transverse patellar shift (TPS), lateral patellar inclination angle (LPIA) and sulcus angle (SA). All knees were assessed post-operatively using MRI. The axial CT images were reformatted which allowed for direct comparison with MRI. Each knee was radiologically evaluated twice by a senior musculoskeletal radiology consultant to increase data accuracy and assess for intra-observer reliability using the intraclass correlation coefficient (ICC). Functional outcomes consisted of the KOOS, Lysholm, Kujala and Tegner scores.Purpose of Study
Methods
Recent advances in understanding of ACL insertional anatomy has led to new concepts of anatomical positioning of tunnels for ACL reconstruction. Femoral tunnel position has been defined in terms of the lateral intercondylar ridge and the bifurcate ridge but these can be difficult to identify at surgery. Measurements of the lateral wall either using C-arm x-ray control or specific arthroscopic rulers have also been advocated. 30 patients undergoing ACL reconstruction before and after introduction of a new anatomical technique of ACL reconstruction were evaluated using 3D CT scan imaging with cut away views of the lateral aspect of the femoral notch and the radiological quadrant grid. In the new technique, with the knee at 90 degrees flexion, the femoral tunnel was centred 50% from deep to shallow as seen from the medial portal (Group A). Group B consisted of patients where the femoral tunnel was drilled through the antero-medial portal and offset from the posterior wall using a 5mm jig.Hypothesis
Method
Management of open tibial fractures remains controversial. We hypothesised that unreamed intramedullary nail offers inherent advantages of nail as well as external fixation. We undertook a prospective randomised study to compare the results of management of open tibial fractures with either an external fixator or an undreamed intramedullary nail until fracture union or failure. Our study included 30 consecutive open tibial fractures (Gustilo I, II & IIIA) between 4 cm distal to knee and 4 cm proximal to ankle in skeletally mature adults, who presented to a level-1 trauma centre. Alternate patients were treated by either external fixation and unreamed nailing i.e. 15 in each group. Standard protocol for debridement and fixation was followed in all cases. All external fixators were removed at 6 weeks. All cases were followed up until fracture union, the main outcome measurement. 26 (87%) were males and 4 (13%) females; age range was 20-60 years (average 33.8). All fractures in both groups united. Time to union averaged 7.9 months for both groups. Incidence of wound problems, infection, hardware failure and delayed union were comparable. However, there was higher incidence of angular deformities and stiffness of knee and ankle in external fixation group, although not statistically significant. We found no statistically significant difference between unreamed intramedullary nailing and external fixation for the management of open tibial diaphyseal fractures, although ease of weight bearing as well as absence of angular deformities and joint stiffness were distinct advantages in the nail group. Therefore we recommend unreamed nail for Gustilo I, II and IIIA open tibial fractures.
There are numerous surgical techniques for medial patellofemoral ligament (MPFL) reconstruction. Problems with certain techniques include patellar fracture and re-rupture. To investigate the functional outcomes of MPFL reconstructions performed using a free gracillis tendon graft, oblique medial patella tunnel and interference screw femoral fixation. Patients were selected for MPFL reconstruction if they had recurrent patellar dislocations, and with the use of clinical and radiographic evaluation.Introduction
Aim
Current problem – Multiple surgical interventions for patellar instability and no defined criteria for use of medial patellofemoral ligament (MPFL) reconstruction. Investigate the functional outcomes of MPFL reconstructions that had been performed following selection for treatment based on a defined patellar instability algorithm.Introduction
Aims
We aim to assess the clinical and radiological outcome following cartilage repair in the knee using the TruFit plug (Smith &
Nephew). Eleven active sporting patients underwent cartilage repair using TruFit plugs between February 2006 and August 2007. Postoperatively patients were touch weight bearing for 2 weeks and partial until 4 weeks. Data was collected prospectively, patients underwent clinical review and completed Lysholm, IKDC subjective, Tegner, KOOS and SF-36 scores pre-operatively and at 6 monthly intervals. One patient has been excluded from the analysis as she emigrated and was lost to follow up. The remaining 10 patients (mean age 35 years (21–49)) had defects on the medial femoral condyle (n=6), lateral femoral condyle (n=3), and lateral trochlea (n=1). Patients received one (n=5), two (n=3) or three (n=2) plugs and four were primary procedures, and six revision procedures (1 failed OATS, 5 failed microfracture). Eight implantations were performed arthroscopically and, and two were mini-open. All patients were reviewed at 12 months, five were reviewed at 18 months and four have also been reviewed at 24 months. Statistically significant improvements from mean pre-operative scores are seen at 12 months; Lysholm (48.3 to 71), IKDC Subjective (37.7 to 65.1), Tegner (2.4 to 4.6), SF36 physical (39.5 to 50.3) and all components of KOOS. These improvements are maintained at the latest follow up. MRI evaluation including T2 mapping demonstrates reformation of the subchondral lamina, resorption of the graft and a similar signal from neo-cartilage as that of adjacent native cartilage. TruFit plugs offer an exciting novel solution for cartilage repair in the knee with advantages of low morbidity and rapid recovery without the need for prolonged non-weight bearing. The implant may be suitable for small lesions only and further prospective study is required to establish long-term outcome.
All patients were male, 4 patients had deficiencies in the right knee, 2 the left knee and the mean patient age was 28.8years (range 17–45). Four CMI were inserted for lateral meniscal deficiencies, two medial. The mean length of implant sutured in place was 41mm (range 35–55). Median pre op scores were KOOS P/S/ADL/QOL 53/100, 54/100, 66/100, 25/100, 44/100, IKDC 49.43%, Tegner 3, SF-36 35.38 PCS and 27.48 MCS and Lysholm 87/100. The mean elapsed time post meniscectomy was 20 months (range 2–51). All but one of the implants used were 9.5mm in width and sizes ranged 35–45mm. At early follow up there have been no complications and background pain has improved in all 6. MIR imaging has shown that none have separated. Post operative follow up suggest improved outcome.
Between May 1998 and May 2007 we carried out 50 Avon patellofemoral joint replacements in 32 patients with isolated patellofemoral osteoarthritis. There were no revisions in the first five years, giving a cumulative survival of 100% for those with a minimum follow-up of five years. The mean follow-up was 5.3 years (2.1 to 10.2). The median Oxford knee score was 30.5 (interquartile range 22.25 to 42.25). In patients with bilateral replacements the median Euroqol General health score was 50 which was significantly lower than that of 75 in those with a unilateral replacement (p = 0.047). The main complication was progression of disease, which was identified radiologically in 11 knees (22%). This highlights the need for accurate selection of patients. Our findings suggest that the Avon prosthesis survives well and gives a satisfactory functional outcome in the medium term.
As management of open tibial fractures remains controversial, we hypothesised that unreamed intramedullary nail offers inherent advantages of a nail as well as external fixation, while limiting the morbidity of external fixation. We undertook a prospective randomised study to compare management of open tibial fractures with external fixator or intramedullary nail until fracture union or failure. Our study included 30 consecutive open tibial fractures (Gustilo I, II &
IIIA) between 4 cm distal to knee and 4 cm proximal to ankle in skeletally mature adults, who presented to a level-1 trauma centre. Alternate patients were treated by external fixation or unreamed nail i.e. 15 in each group. Standard protocol for debridement and fixation was followed. External fixators were removed at 6 weeks. All cases were followed until fracture union, the main outcome measurement. 26 (87%) males and 4 (13%) females; age 20–60 years (Mean 33.8). All fractures in both groups united. Time to union averaged 7.9 months for both groups. Incidence of wound problems, infection, hardware failure and delayed union were comparable. However, there was higher incidence of angular deformities and stiffness of knee and ankle in external fixation group, although not statistically significant. We found no statistically significant difference between unreamed intramedullary nailing and external fixation for the management of open tibial diaphyseal fractures. Ease of weight bearing as well as absence of angular deformities and joint stiffness were distinct advantages in the nailing group. Therefore we recommend unreamed nail for Gustilo I, II &
IIIA open tibial fractures.
For meniscal allograft transplantation, cell viability and metabolic activity are desirable. The various modalities of preserving the menisci described in the literature include, deep freezing, gluteraldehyde, lyophillisation and cryopreservation. Since formalin in low concentrations is a proven and inexpensive method of tissue preservstion, we attempted to analyse the viability of fibrochondrocytes in the meniscal tissue preserved in three different concentrations of formalin. Twenty-four rabbit menisci were assessed, three groups of 6 menisci each were preserved in 0.25%, 1%, 5% formalin for a period of three weeks; fourth group of 6 fresh menisci were used as controls. The uptake of Na235SO4 and LDH (lactate de-hydrogenase) were analysed for indirect evidence of cell viability. Menisci preserved in 0.25% of formaldehyde showed statistically similar Na235SO4 uptake and LDH activity as the controls; reflecting a similarity in the level of cell viability and metabolic activity. The menisci preserved in 1% and 5% formaldehyde solution showed a decreased radioactive uptake as well as LDH activity.
To evaluate the mechanism of dislocation of the navicular in complex foot trauma; we hypothesize this is similar to lunate/perilunate dislocations. Our experience with 6 cases of total dislocation of navicular without fracture, and an analysis of 7 similar cases reported world-wide was used as the basis for this hypothesis. Radiographs of our patients and the published cases were analyzed in detail, and associated injuries/instablilities were assessed. The position of the dislocated navicular and the mechanism of trauma was considered and correlated, and this hypothesis was propounded. When the navicular dislocates without fracture, it most frequently comes to lie medially, with superior or inferior displacement, depending upon the foot position at injury. It is hypothesized that the forefoot first dislocates laterally (perhaps transiently) at the naviculocunieform joint by an abduction injury; in all cases we recorded significant lateral injury (either cuboid fracture, or lateral midfoot dislocation). The relocating forefoot subsequently pushes the unstable navicular from the talonavicular joint, and depending upon the residual attachments of soft tissues, this bone comes to lie at different places medially. This is a similar mechanism to the lunate dislocation in the wrist, where the relocating carpus push the lunate volarly. Our clinical experience with these complex injuries has shown that the whole foot is extremely unstable. For reduction, the talonavicular joint has to be reduced first, and then the rest of the forefoot easily reduces on to the navicular. An understanding of injury mechanics allows us to primarily stabilize both the columns of the foot, and subsequent subluxation and associated residual pain are avoided. Pure navicular dislocations are not isolated injuries, but are complex midfoot instabilities, and are similar to perilunate injuries of the wrist.
