Abstract

Aim

To assess the influence of posterior slope on Knee flexion and function in Asian and Caucasian populations.

Background: This meta-analysis aims to evaluate the quality of life in post traumatic amputees in comparison with a limb salvage group, using peer-reviewed studies in these areas.

Methods: Electronic databases were searched for studies on lower limb amputation and limb reconstruction following trauma. A manual review of the literature and abstracts was also conducted. Only studies having more than 24 months of follow up, and those using generic scales using physical and psychological parameters (SIP or SF36), were included. Two reviewers performed the search, inclusion, and data extraction independently.

Results: 214 studies were identified after extensive searching, Eleven studies fulfilled all the inclusion criteria, reviewing the outcomes of 1874 patients including 899 cases of amputation and 975 cases of reconstruction. Outcome assessments were based on two generic scales of measurement for quality of life, namely SIP or SF 36.

In the studies using SF36, the mean Physical Component Summary (PCS) for the amputation group was 39.76 +/−7.06 and mean Mental Component Summary (MCS) was 52.05+/−3.39. The mean PCS for the reconstruction group was 38.5+/−0.78 and the mean MCS was 50.76 +/− 3.09. The mean physical SIP score for amputation was 13.033 with SEM of 3.048, and the psychological SIP score was 15.953 with SEM of 1.153. The mean Physical SIP for reconstruction was 10.686 with SEM of 1.034 and the psychological SIP was 10.754 with SEM of 0.647. The Unpaired t test was used to compare the outcomes of amputation and reconstruction, studies using SF36 and SIP scores were compared independently. Our results show that physical morbidity in both groups is not significantly influenced by the modality of surgical intervention, but there is a statistically significant difference noted in psychological morbidity, the group with reconstruction being better. These results were consistent in studies using either of the two generic scales namely, SF36 or SIP scores.

Conclusion: This meta-analysis provides evidence that limb reconstruction in lower limb trauma yields better psychological outcomes without significant difference in physical morbidity compared to amputation.

Introduction: Early plaster immobilisation is important in fracture management to control pain and maintain alignment. In our institute, the initial plaster is routinely applied by junior trainees directly or is applied by Accident & Emergency (A& E) staff under the supervision of the junior trainees. In the U.K., plaster application technique has not been routinely and formally taught to the junior trainees in the hospital.

Method: We aimed to review the adequacy of plaster applied or supervised by junior trainees. The criteria for an adequate of plaster immobilisation for tibial diaphyseal fractures have not been reported in the literature. We had chosen 3 simple parameters, namely, change in alignment of fracture fragments, position of the ankle and a gap index of less than 0.15, which in our view are important in terms of initial management of tibial fracture in the A& E. The gap index reflects the amount of padding applied in the plaster. These parameters were merely chosen to assess the adequacy of initial plaster immobilisation by junior trainees and should not predict the long term success or failure of the management of fracture with plaster. Sixty-five patients with tibial diaphyseal fractures were retrospectively included in the present study. The initial and post-plaster application radiographs were assessed by two senior trauma & orthopaedic specialist registrars separately.

Result: Only forty-six percent (45%) of the cases had fulfilled all the three criteria. In subgroup analysis, position of the ankle is the most frequently neglected factor with 31% of the ankles held in equinus. Twenty eight percent (28%) of cases had worsening of the alignment of the fracture fragments. Fourteen percent (14%) of the cases had excessive padding applied as reflected by Gap Index of > 0.15.

Conclusion: This study highlighted that the basic plastering technique by the junior trainees is inadequate. We suggest that every trainee rotating to Trauma & Orthopaedic Surgery must be taught this fast-fading away basic plaster application technique during the induction period.

Background: Total knee replacement remains one of the most common knee surgery practices worldwide. The operative procedure universally requires the use of cutting jigs to resect predetermined amounts of bone irrespective of the preoperative anatomy and morphology of the femur and tibia.

Aims: The aims of this study were to elucidate anatomical morphological differences between ethnicities pre-operatively and to assess whether any change elucidated was preserved post-operatively.

Method: This was a retrospective study comparing the pre and postoperative lateral view X-Rays of TKRs performed. Distances measured from most prominent anterior point to midline and the most prominent posterior point to midline and their ratio was compared between two ethnic groups. Each x-ray measurement was triple checked.

Results: The study groups comprised of 60 Caucasian knees and 40 Asian knees. Preoperatively the mean ratio was 0.55 in Caucasians and 0.44 in Asians, with this difference being statistically significant (p value < 0.005). Post operatively the mean ratio was 0.59 in Caucasians and 0.55 in Asians and this difference was not statistically significant (p value =0.166). These findings were also cross-checked with range of movement measurements post-operatively in the same group of patients. There was no comparable improvement in range of movements (ROM) post-operatively in the Asian group.

Conclusion: We infer that the present TKR cutting jigs are not taking into account the anatomical differences within the knee of Asians individuals. This is converting the post operative distal femurs of this group to become morphologically comparable to the Caucasian knee and this is possibly affecting the kinematics of those knees leading to no significant improvement in the post operative ROM and affecting satisfaction with surgery.

Nerve blocks are a common form of peri-operative analgesia that is administered for patients undergoing joint Replacement surgeries. The long term sequel following these peripheral nerve blocks used in total knee replacement not reported in the literature. Nerve blocks given under the guidance of nerve stimulators are in practice in most of the hospitals and are considered safe.

We report a series of two cases with residual neurological deficit following these peripheral nerve blocks in total knee replacements. In both these cases the femoral, sciatic, obturator and lateral cutaneous nerve of thigh were blocked with 0.25% of Bupivacaine with the help of a nerve stimulator.

First patient post operatively had residual numbness in the right lower leg after 4 weeks of surgery. Nerve conduction studies confirmed absent response in right Saphenous and superficial peroneal nerves. Patient has no improvement in her neurological deficit even after 16 months post operatively. Further to this she developed complex regional pain syndrome on the affected side.

Second patient post operatively developed knee extensor weakness of grade II/V and loss of sensation in femoral nerve distribution. Nerve conduction studies confirmed severe femoral nerve damage around groin. She went through a turbulent phase, knee stiffness range of movements 0–20 degrees requiring Manipulation Under Anaesthesia, later Exploration and Release of adhesions which improved her range of movements to 0–95 degrees. At 12 months post operative the neurological status improved to grade 3/5 in knee extensors.

Conclusion: Long term Complications of Peripheral nerve blocks in total knee replacements are not reported in the literature. These complications though uncommon, unfortunately for patients affect the surgical outcomes. The purpose of this case series is not only to report complications but also to share our experience of managing these complications, their outcomes and relevant literature review.

Purpose Of Study: To evaluate the results and functional outcome of use of three lateral K wires in supracondylar fracture fixation in children.

Methods And Results: It is a prospective study of 25 cases of supracondylar fractures over a period of three years from 2001, in children between 2 to 9 years, comprising of closed manipulation and percutaneous fixation with 3 lateral K wires, all done by the same surgeon.

Patients were immobilised for 3 weeks and K wires removed at that time. They were followed up till they regained full range of movements in the elbow.

Of the 25 cases, 2 were previously fixed with crossed K wires and were revised because of displacement . One patient had a delayed fixation because of gross swelling and was initially managed with traction.

Pin tract infection was noted in one case and responded to antibiotic therapy.

All the patients regained full range of movements and no angulatory deformity or loss of fixation was noted at the end of follow up.

Conclusion: Fixation with three lateral K wires is an excellent technique in treating displaced supracondylar fractures in children.