Background

Stress fractures at tracker after computer navigated total knee replacement are rare. Periprosthetic fracture after Minimally Invasive Plate Osteosynthesis (MIPO) of stress fracture through femoral tracker is unique in orthopaedic literature. We are reporting this unique presentation of periprosthetic fractures after MIPO for stress fracture involving femoral pin site track in computer assisted total knee arthroplasty, treated by reconstruction nail (PFNA).

Introduction

Positive expectations can increase compliance with treatment and realistic expectations may reduce postoperative dissatisfaction. Recently there are articles regarding expectations of patients from their TKA in western literature and only few articles based on Korean populations which don't encompass the whole spectrum of expectations in Korean patients. In all those articles based on pre-operative expectation, results were applied to whole expectation category uniformly not differentially. We aimed to document the pre-operative expectations in Korean patients undergoing total knee replacement using an established survey form and to determine whether expectations were influenced by socio-demographic factors and socio-demographic factors influences expectation items in particular category uniformly or differentially.

Introduction

Unicompartmental knee arthroplasty (UKA) is becoming an increasingly popular option in single compartment osteoarthritis. As a result, diverse re-operations including revisions to total knee arthroplasty (TKA) has also increase. The objective of this study is to investigate the distribution of causes of re-operations after UKA and to analyze the types of re-operations.

Introduction

Significant donor site morbidity (3–61%) has been associated with tri-cortical iliac crest bone graft harvesting and reconstruction of the defect has been shown to reduce it. Chitra-HABG (Chitra-Hydroxyapatite-Bio-active glass ceramic composite) is an indigenously developed ceramic which has been evaluated as a bone graft substitute.

Fixed flexion deformity is common in neglected cases of advanced arthritis of the knee.

The need and means of complete correction of fixed flexion deformity remains controversial. We analysed 60 patients of advanced arthritis with severe flexion deformity > 300 who underwent total knee arthroplasty between January 2002 to January 2008. The age ranged from 54 to 78 years (mean age of 62 years). All surgeries were performed using posterior cruciate substituting implant. Patients were followed for an average period of 42 months.

All patients were operated in a single stage. Distal femoral over-resection was done in addition to posterior, postero-medial and postero-lateral release. Posterior release was done upto the linea aspera. In 2 cases posterior capsular was released directly. A criteria was developed for sequential release on the basis of degree of flexion deformity.

Flexion deformity was fully corrected in 48 cases where as 50 of residual flexion remained in 5 cases with preoperative deformity of 40–600 and 100 residual flexion remained in 6 cases with preoperative deformity > 600. One patient with pre op fixed flexion deformity of 90* had to be treated with arthrodesis.

Our experience suggest that predetermined routine femoral over-resection in moderate to severe flexion deformity prior to balancing knee is not fraught with complications if our criteria are followed. Additional bony cuts (over-resection) and posterior soft tissue release is complementary to each other in correction of flexion deformity and it should be a sequential release. This technique saves time, reduces intraoperative difficulties and helps to correct flexion deformity maximally.

Performing Bilateral Knee replacements simultaneously is a controversial issue with proponents on both sides of the argument. The advantages of simultaneous arthroplasties include the administration of a single anaesthetic, reduced hospital stay and consequent reduced costs. Reuben et al (J. Arthroplasty, 1998) reported a 36% reduction in hospital costs. Patients also have a quicker return to function and Leonard et al (J Arthroplasty 2003) reported a high patient satisfaction rate of 95%.

The primary disadvantages noted in previous studies include an increase in peri operative complications–both cardiac and pulmonary. An increase in mortality figures is perhaps the most serious complication recorded in some studies. Ritter etal (Clin. Orthop. 1997) reported a 30 day mortality rate of 0.99% in bilateral simultaneous TKA as compared to 0.3% in patients who underwent a staged procedure.

Our study comprised a total of 202 patients who underwent bilateral simultaneous total knee replacements at a District General Hospital in Harlow. Harlow is one of the centres involved in the multi centric trials for the PFC Sigma Knee System and is perhaps the only centre in the UK where bilateral simultaneous procedures are carried out in significant numbers. There were 103 males and 99 females. 12 of the patients had Rheumatoid arthritis. 45% of the patients were in the 71–80 years age group, 26% in the 61–70 years age group. The average age across the entire group was 71.3 years. 35% of patients had a BMI of 25–30, 23% a BMI of 30–35, while less than 5% had a BMI of greater than 40. Most patients (44%) were ASA grade 2. The 3 most common co morbidities included hypertension(85%), coronary artery disease(25%) and diabetes mellitus (12%). 90% of the patients had the procedure performed under a General Anaesthetic and Epidural. Tourniquet time ranged from 55–159 minutes. (average 96 minutes). The patella was resurfaced in all patients. Post operatively the average drain collection was 1200 mls(range 7002600mls). Average pre op Hb was 13.8 g/dl, the post op average being 9.7 g/dl. 71% of patients required blood transfusion after surgery (average 2.8 units). Average hospital stay was 12.4 days (range 5–38 days). 6 patients required HDU admission.

Complications: None in 60%; there were 3 deaths in the first 30 days(1.5%), 2 cases of pulmonary embolism(1%); 6 cases of Myocardial Infarction (3%). There were 14 superficial wound infections and 10 patients required wound washouts. An MUA was performed on 8 knees. 2 patients had Revision Knee replacements for infection.

These figures are comparable to those in published literature. We have found Bilateral simultaneous Total Knee replacements to be a safe procedure with quick return to function.

The contribution of incorrectly fitting footwear to the development of foot pain and deformity has been citied as an etiologic factor but is something that has not been fully evaluated. We examined the relationship between footwear characteristics and the prevalence of common forefoot problems in patients attending foot clinic.

Methods: Prospective study measuring shoe size (width & Length) and foot measurements in 50 patients attending foot clinic with foot problems. Comparison made with 50 random people with no foot complaints. Deformities, medical histories and pain scores were documented.

Results: Clinic patients: Mean age 49 range(19–68). 12 male 38 female. 21 out of 50 wearing shoes half a shoe size too small, 7 patients wearing shoes half a shoe size larger. 32 patients wearing shoes narrower than feet mean 6mm (range 2–9mm.) Deformities: 27 hallux valgus, 3 bunionette, 6 hammertoes, 5 callosities. Mean pain VAS 5 range (3–10). 11 patients were diabetic, 6 had peripheral vascular disease.

Random patients: Mean age 41 range(19–65). 19 male 31 female. 7 out of 50 wearing shoes half a size smaller, 13 wearing shoes half a size larger, 15 wearing shoes narrower than feet mean 4 mm (range 2–7mm). Deformities: 6 hallux valgus, 3 hammer toes, 8 callosities. Mean pain VAS 1 (1–3). 8 people were diabetic.

Conclusion: A large proportion of patients attending foot clinic wore ill-fitting shoes. Women wore shoes that were shorter and narrower compared to their feet than men. Wearing shoes smaller and narrower than the feet was associated with hammer toes, hallux valgus deformity and foot pain. Incorrectly fitting footwear may be a significant contributing factor associated with forefoot pathology and foot pain. These findings highlight the need for footwear assessment in the management of foot problems.

Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience.

Aims: This study reports the mid-term results of a prospective series of 200 ankle replacements using the Scandinavian Total Ankle Replacement (STAR). 105 patients were more than five years since surgery.

Method: 200 patients; 85 male, 115 female; mean age 60 years (18–83) underwent primary replacement. The mean follow-up was 54 months (4–110). The diagnosis was inflammatory joint disease (IJD) for 119 patients and osteoarthritis (OA) for 81.

Results: 144 patients had a good outcome and uncomplicated recovery. A further 18 patients had a complication, which resolved with non-operative treatment (three prolonged wound healing, 15 malleolar fractures, either at surgery or at a later date). A further eight patients were clinically satisfactory but the x-rays showed adverse features (five aseptic loosening and three recurrent deformity). Five patients have a poor outcome due to persistent pain and stiffness but have not required further surgery. A further nine patients had a complication necessitating surgery (three calcaneal osteotomy and lateral ligament reconstruction, one tibial osteotomy to improve alignment, one autogenous bone graft for osteolysis, one for late medial malleolar fracture, one split skin graft for delayed healing, two for removal of heterotopic bone). At two years the AOFAS score for pain improved from 0 to 35 (maximum 40) and the functional score from 28 to 35 (maximum 60). There were 16 total failures that required fusion (11) or revision (five). The causes were nine aseptic loosening, three recurrent deformity, two fracture malleolus, one deep infection, one persistent pain. The cumulative five-year survival rate was 89% (95% CI 81% to 96%), with time to decision to revision or fusion as the endpoint.

Conclusions: There was no difference in survival between ankle replacement for OA or IJD. Ten out of the 16 failures occurred early (< two years), which we attribute to technical error or attempting replacement of ankles with severe deformity. The failure rate after two years is approximately 1% per annum.

Abstract: The impact of FOI and the rising tide of litigation have focused clinicians on their vulnerability. As the British Orthopaedic News states, the Bristol Enquiry made 198 recommendations of which only a few were specific to paediatric cardiac surgery. With this climate in mind, a Research Project on a system of Risk Management has been established in Trauma & Orthopaedics and A& E in Sligo General Hospital.

A “Clinical Incident Data Collection Form” has been developed to collect and analyse different classifications such as potential risks, near misses, clinical incident, equipment failure and drug error. Trauma, Orthopaedic and Emergency speciality trigger lists will be set up. A Research Officer is in post and a Multidisciplinary Steering Group has been developed, and speciality links have been established. An education programme has commenced for multidisciplinary staff.

The aim is to design and test the Clinical Risk Management in action in order to control and reduce risk in clinical care in the Trauma & Orthopaedic and A& E Department in Sligo General Hospital.

Abstract: Monteggia fracture dislocation in an uncommon injury in children. In the less severe injuries, with minimum angulation of the ulnar fracture, the radial head dislocation is frequently missed. The treatment of these late recognised injuries (more than one month) remains controversial, with frequent complications and high failure rates reported in literature.

We have devised a new operative technique which has proved so far to be very successful and reliable. The procedure can be recommended only for children who have no major intra-articular injury, no epiphyseal damage and only mild adaptive changes of the radial head. It is also contraindicated if there is significant overgrowth of the radius as well as secondary changes in the proximal and distal radioulnar joints. The parents are warned of possible complications and residual loss of some movements.

Under general anaesthesia, a curved longitudinal incision is made centred over the ulnar deformity extending proximally to the lateral epicondyle. The essence of the operation is the oblique ulnar metaphyseal osteotomy. The cut is made starting proximal medial to distal lateral. The osteotomy recreates the instability allowing open reduction of the radial head. It also allows for ulnar lengthening by the sliding of the osteotomised surfaces with graft interposition if necessary. The radial head is approached between the anconeus and wrist extensors, through the same exposure. The annular ligament is dividend and radial head reduced into its anatomical position. The ulna is securely fixed in the angulated position using a one third tubular plate. Finally, after checking the stability of the radial head in all forearm movements, the annular ligament is repaired. An above elbow cast is applied with forearm in supination and elbow in 90 degrees of flexion.

The cast is worn for six weeks, with weekly check radiographs. Active use of the arms is encouraged after this with follow up at increasing intervals. The follow up of our cases has shown that the ulnar angulation completely remodels, with normal development of the radial head. A functional range of forearm rotation and full flexion/extension at the elbow are regained with time. We have not noted any residual subluxation/dislocations in our cases.

Objective: Spontaneous spinal subdural haematoma is a rare cause of spinal cord compression usually confined to a few vertebral levels. When the haematoma extends over several spinal segments, surgical decompression is a major undertaking. A minimally invasive technique of decompression, using topical recombinant tissue plasminogen activator (rt-PA), is presented in two patients with extensive spinal intradural haematoma.

Clinical Presentation: Two patients, receiving long-term anticoagulation therapy, presented with acute-onset back pain progressing to paraparesis. MRI of the spine demonstrated spinal subdural haematomas extending over fifteen vertebral levels in one and twelve in the other patient.

Intervention: An angiography catheter was introduced into the subdural space through a limited laminectomy. Thrombolysis and evacuation of haematoma was then achieved by intermittent irrigation of the subdural space with recombinant tissue plasminogen activator (rt-PA), followed by saline lavage. Post-operative imaging demonstrated satisfactory decompression in both patients. There was significant improvement of neurological function in one patient.

Conclusion: Topical application of rt-PA for spinal sub-dural haematoma allows evacuation of the haematoma through a limited surgical exposure. Decompression of the subdural space by this minimally invasive technique may be advantageous over extensive surgery by minimizing surgical exposure, reducing postoperative pain and risk of neuronal injury. This technique may be useful in patients presenting with compression extending over several vertebral levels or poor surgical candidates.