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The Bone & Joint Journal
Vol. 96-B, Issue 6 | Pages 783 - 788
1 Jun 2014
Kanakaris N Gudipati S Tosounidis T Harwood P Britten S Giannoudis PV

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.

Cite this article: Bone Joint J 2014; 96-B:783–8.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_21 | Pages 33 - 33
1 Apr 2013
Eyre J Gudipati S Chami G Monkhouse R
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Background

Lisfranc/midfoot injuries are complex injuries with a reported incidence of 1 in 55000 in literature and frequently overlooked. But, recently they are becoming more commonly diagnosed with advent of CT scan and examination under anaesthesias (EUA) for suspicion fractures. Here we present a case series results of a single surgeons experience over the last 6 years.

Methods

Retrospective review of 68 patients treated by a single surgeon over the last 6 years. Injuries were diagnosed on plain Xrays, clinic examination. Any suspicious injury were further assessed by a CT scan, all injuries were confirmed by EUA and treated with open reduction and internal fixation within 4 weeks of injury. Post-operative immobilisation in full cast for 6 weeks then a removal boot with non-weight bearing for a total of 3months. They were followed up regularly initially at 3, 6 and 12months. At final review the following data was collected: clinical examination, plain x-ray looking for: late deformity, signs of OA in Lisfranc joint, Auto fusion rate, rate of metal work failure. The x-rays findings were correlated with: (1) type of fixation. (2) The following scores: FAOS, AOFAS-M, specially designed new foot and ankle score.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_19 | Pages 8 - 8
1 Apr 2013
Madhu T Gudipati S Scott B
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Introduction

To investigate if the gap index measured in the follow-up X-rays predicts the reduction of swelling in the plaster cast thereby increasing the risk of re-displacement of fracture treated by manipulation alone.

Materials/Methods

We selected for this study a cohort of children who presented with a traumatic displaced fracture of distal radius at the junction of metaphysis and diaphysis who were treated with manipulation alone. This cohort was chosen because of the high risk of re-displacement following closed manipulation of this unstable fracture and to maintain uniformity of the fracture type. Cast index and Gap index was measured in the intra-operative radiograph and at two-weeks to note the change in these indices. Gap index which is measured by summing radial and ulnar translation/inner diameter of cast in the AP X-ray and similar translation on the lateral x-ray/inner diameter of cast, with a measure of <0.15 considered to be a satisfactory cast.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 147 - 147
1 Jan 2013
Gudipati S Fogerty S Chami G Scott B
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Aim

To assess the results of Castles procedure performed at our hospital compared with those available in literature.

Introduction

Fifteen patients (19 hips) with severe disability and hip subluxation/dislocation underwent proximal femoral resection arthroplasty (Castles procedure) over a 10 year period under the care of 2 paediatric orthopaedic surgeons. We conducted a retrospective study of case series whether the surgery (Castles procedure) improved the pain levels, sitting tolerance, ability to use commode/nappy change, ease of dressing and the carers overall satisfaction with the procedure.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 132 - 132
1 Jan 2013
Gudipati S Kanakaris N Harwood P Britten S Giannoudis P
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Introduction

Reaming of the canal is an important step in the debridement phase of treating intramedullary infections. Numerous techniques of radical canal debridement have been successfully reported. The use of the Reamer-Irrigation-Aspiration system (RIA-Synthes) is currently expanding to include this clinical scenario.

Materials and methods

Prospective collection of data related to infected cases treated with the use of the RIA in a tertiary referral centre referring to a 3 year period. Peri-operative details, microbiology results, and follow-up outcome over a minimum period of 12 months post-surgery are reported.


Numerous procedures have been reported for the hallux valgus correction of the great toe. Scarf osteotomy is a versatile osteotomy to correct varying degrees of mild to moderate hallux valgus deformity. It can also be used for lengthening of the 1st ray as a revision procedure to treat metatarsalgia in patients who had previous shortening osteotomy.

We wish to report a patient who had lengthening SCARF osteotomy for the metatarsalgia following previous hallux valgus correction and developed arthritis of the 1st MTPJ in a short term which required fusion. A 49 year old female patient was seen with pain and tenderness over the heads of the 2nd and3rd metatarsal of the right foot. She had hallux valgus correction 10years ago with a shortening osteotomy of the 1st metatarsal. She developed metatarsalgia which failed to conservative management.

She had a lengthening SCARF osteotomy for the metatarsalgia in 2004. She had good symptomatic relief for two years and then started having pain over the 1st MTPJ. On examination she had limited movements of the 1st MTPJ and tenderness over the dorsolateral aspects of the 1st MTPJ suggestive of arthritis. Radiographs of the foot showed healed osteotomy with no evidence of AVN of the 1st MT head but features suggestive of osteoarthritis. She had fusion of the 1st MTPJ performed in 2008 for the arthritis following which symptoms resolved.

This case highlights that arthritis of the 1st MTPJ can occur in the absence of an AVN of the metatarsal head and patients need to be warned of this potential complaining when having the lengthening SCARF osteotomy for metatarsalgia following a previous shortening osteotomy of the 1st ray.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 40 - 40
1 Sep 2012
Sunderamoorthy D Gudipati S Harris N
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Numerous techniques are used for the fusion of failed TAR. We wish to report our results of the revision of failed TAR to fusion.

Between July 2005 and February 2011 the senior author had performed 20 arthrodeses in 19 patients (13 male and 6 female) who had failed total ankle arthroplasty (TAR). Their mean age was 63.5 years. All of them had the AES total ankle replacement. (Biomet UK). The mean period from the original TAR to fusion was 51 months (6 to72). The indication for revision of TAR to fusion was septic loosening in 4 patients and osteolysis and or aseptic loosening in 16 cases. Three types of fusion techniques were used.

The mean follow-up was 15 months. All 3 tibiotalar arthrodeses with screws alone fused successfully. Of the 13 patients where the fusion was augmented with an Ilizarov frame, 4 were done for septic loosening. There were 2 non unions of which one was stable without pain and the other required a further revision fusion with a frame and subsequently fused. Of the 9 patients who had a fusion with a frame for osteolysis and or aseptic loosening, there was one non union which was revised to a tibiotalocalacaneal fusion with a hind foot nail. The nail fractured at the level of the posterior oblique screw hole. The patient subsequently developed a relatively pain free non-union of the tibiotalar joint and not required further surgical intervention. The remaining 8 ankles fused at a mean of 5 months. The average time of frame removal was 17 weeks. There was four pin-site infection all of which settled with oral antibiotics. 5 patients had tibiotalocalacaneal fusion with a hind foot nail. The indication for the hind foot nail was significant osteolysis and loss of talar bone stock. The average shortening as a result of the fusion for the failed TAR was 1.5cms.

Our results were comparable to the previous reports of arthrodesis for failed total ankle replacement. We recommend the use of tibiotalocalcaneal fusion with a hind foot nail in the presence of severe osteolysis or accompanying subtalar arthritis. In the presence of good bone stock an ankle fusion supplemented with a circular frame gives a good predictable outcome.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 71 - 71
1 Sep 2012
Gudipati S Sunderamoorthy D Hannant G Monkhouse R
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Lisfranc injuries are not the common injuries of foot and ankle but there has been an increase in the incidence of these injuries due to road traffic accidents and fall from heights. We wish to present our retrospective case series of the operative management of the Lisfranc injuries by our senior author.

We retrospectively reviewed 68 patients with Lisfranc injuries who were managed operatively by the senior author over the last six years. The case note and the radiographs including the CT scans were reviewed. All of them were treated with open reduction and internal fixation within three weeks of injury. The male: female ratio was 43:25. 37 right: 31 left sided injuries. The average age was 40.6 years (range 16 – 81 years). The most common mechanism of injury was fall from steps at home followed by motor bike accident. They average follow-up was 19.5 months and they were assessed both clinically and radiographically at each follow-up.

The k wires were removed at an average of six weeks. 96% were pain free and fully weight bearing after six months. Two patients had lateral scar tenderness. Majority of them returned to normal activities at an average of 12 months. Two patients had initial wound complications which were treated successfully with oral antibiotics. None of them had degenerative changes.

Our results of early open reduction and internal fixation were comparable to the published literature.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_I | Pages 60 - 60
1 Jan 2011
Mann B Gudipati S Eleftheriou K Bull T
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Purpose of study: The aim of this study was to evaluate patient-orientated outcome of spinal dynesys fixation used for low back pain and also the re-operation rate in a retrospective review of 25 cases with an average follow-up period of four years.

Materials and Methods: A total of 25 patients who had undergone semi-rigid fixation of the lumbar spine with the Dynesys system in the Chase Farm Spinal Unit between November 2001 and March 2003 were reviewed.

Results: Two patients required removal of implant and revision to solid fusion. Both were one year post Dynesys instrumentation. All other patients had their original Dynesys implant in situ at latest follow-up. Two patients were referred to a pain specialist for further management. The mean Oswestry score pre-operatively and 4.4 year post operatively were 57.2 and 37.52 respectively. The mean VAS pre op was 9.32 and post op it was 5.04.

Conclusion: Dynamic stabilisation certainly continues to remain an attractive alternative to rigid stabilisation and the few retrospective and laboratory studies that exist in the current literature reveal results which are comparable with rigid fixation.

Discussion: Though te results were promising we think a large multicentre prospective studies are required to truly enable us to evaluate the efficacy of dynamic stabilisation. This study contributes towards furthering our understanding of this complex subject.

Ethics approval: None

Interest Statement: None


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 496 - 496
1 Oct 2010
Lawrence T Gudipati S
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Every surgeon needs to audit the quality of his work to ensure that complication rates are low, good function persists for the intermediate term, and patient satisfaction remains high. The use of the 12-point shortened WOMAC score and Orthowave patient satisfaction survey provides enough information for quantitative assessment of most practices. When applied to my hip arthroplasty practice, analysis of data related to 426 consecutive patients at 1–9 years of follow-up (mean 3.5) revealed pain relief was good to excellent in 96%; rate of recommendation of surgery was 97%. Overall satisfaction was good to excellent in 95%. Mean WOMAC scores improved from a preoperative mean value of 32.5 to mean 6.6 at latest follow-up. When the same scoring system was applied to my knee arthroplasty practice, results were surprisingly inferior. Potential areas for technical improvement were then identified and implemented. This study highlights the simplicity and usefulness of the shortened WOMAC score and Orthowave patient satisfaction survey in assessing and improving an arthroplasty practice.