Introduction

Adhesive capsulitis is a common condition causing painful limitation of shoulder movements. Hydrodistension is one of the techniques, is well recognised and has shown good outcomes. However, the results of hydro distension release in secondary adhesive capsulitis are not clear.

Aim

To see if minor upper limb surgery procedures like CTR, Trigger release, Joint injections are safe for a remote telephonic review by specialist nurse. This arrangement was to help maintain our current agreed departmental New to Follow up ratio of 1:1.56 and also to improve access to specialist clinics.

Introduction

The MHRA guidelines for metal on metal (MOM) suggest cobalt and chromium levels of more than 7ppb as potential for soft tissue reaction. However, in some patients soft tissue reaction is seen even in the presence of normal serum metal ions levels.

Introduction

The Bankart lesion is the most common form of labro-ligamentous injury in patients with traumatic dislocations of the shoulder. Various methods have been described each with its own advantages and disadvantages. We describe 5-year results of arthroscopic Bankart repair using knotless anchors.

Background

Revision surgery for a failed metal on metal (MoM) hip arthroplasty is often unpredictable and challenging due to associated massive soft tissue and bony lesions. We present the analysis and early outcomes of revision surgery in failed MoM hip arthroplasties at our institution.

A prospective study was done to assess the outcome of MPFL reconstruction for patellar instability using quadriceps graft. MPFL reconstruction was done using superficial strip of quadriceps by an anteromedial incision and attached close to medial epicondyle of femur. There were 15 knees in thirteen patients with a mean age of 23.4 years. All patients had MPFL reconstruction and 5 had tibial tuberosity transfers. With a mean follow-up of 39.4 (12–57) months, the mean pre-op Kujala scores improved from 47.8 to 87.2. The mean Lysholm scores improved from 54.2 to 86.8. None of the patients had patella re-dislocations. MPFL reconstruction with quadriceps graft appears to be effective producing good results in patients with patellar instability.

Total knee replacement (TKR) can be associated with significant post-operative blood loss requiring blood transfusion and haematinics. With increase in the use of navigation for total knee replacement, it is anticipated the blood loss may be lower as the medullary cavity is not breached. Hence, a prospective study was performed to compare the blood loss and the transfusion rates between patients with navigated and conventional total knee replacement.

Between September 2006 and December 2009, nearly 100 patients underwent total knee replacement by a single surgeon. Patients who underwent revision total knee replacement and complex primary total knee replacement were excluded. There were 73 patients with an average age of 70.3 (47-91) years. There were 37 males and 36 females with an average BMI of 30. Thirty eight patients underwent navigated TKR and 35 patients conventional TKR. Left knee was replaced in 29 patients, right knee in 40 patients and 4 patients underwent non-simultaneous bilateral total knee replacements. Cruciate retaining prosthesis was used in 17 patients and cruciate substituting prosthesis in 56 patients. Patella was not replaced in any patient.

The average pre-operative haemoglobin was 13.26 (8.7-18.4) g/dl in the navigated group and 13.47 (9.6-15.8) g/dl in the conventional group. The average tourniquet time was 110(90-150) minutes in the navigated group and 96.7(60-145) minutes in the conventional group. Seven patients in the navigated group and 3 patients in the conventional group did not have documentation of the tourniquet time. The average post-operative haemoglobin in the navigated group was 10.34 (7.5-14.8) g/dl and 10.03 (7.5-12.2) g/dl in the conventional group. Six patients each in the navigated group and conventional group required blood transfusion. Six patients in the navigated group and 8 patients in the conventional group were started on haematinics.

This study does not show any significant difference in the blood loss as estimated by the average drop in the post-operative haemoglobin between navigated and conventional total knee replacement. There was also no difference in the rates of blood transfusion between both the groups. However the average operative time was marginally higher in the navigated group than the conventional group.

To analyse the intra-operative variation in mechanical axes of the lower limb at various stages during navigated total knee replacement.

A prospective study was performed to analyse the intra-operative variation in the mechanical axes of the lower limb during navigated total knee replacement. All consecutive patients who underwent navigated total knee replacement were included and patients with inadequate data were excluded from the study. The intra-operative initial, trial and the final mechanical hip-knee-ankle axes were recorded from the navigation system. The differences between these axes were calculated and analysed. There were forty patients, of which 24 were females and 16 males with the age ranging from 37-89 (average 68.4) years. The right knee was replaced in 27 and the left knee in 13 patients. The average initial mechanical axes alignment was 0.03° valgus (3° varus to 3° valgus), trial alignment 0.64° varus (3° varus to 1.5° valgus) and final alignment 0.25° varus (4° varus to 4° valgus). Average deviation from initial to trial axes was 0.97°, trial to final axes was 0.74° and initial to final axes was 1.08°. The correlation co-efficient between the initial and the trial axes was 0.25, trial and final axes was 0.43 & initial and final axes was 0.09.

This study highlights a significant variation in mechanical axes between the different stages of navigated total knee replacement. The potential sources of intra-operative errors causing these changes could be soft tissue imbalance, variations in implant placement and possible tracker micro motion. Execution of bony cuts in near normal neutral alignment does not guarantee achievement of near normal final alignment. We advocate surgeons to be vigilant to avoid potential malalignment during navigated total knee replacement.

Introduction:: Various reference axes are used in total knee arthroplasty to determine the femoral rotation including transepicondylar axis, posterior condylar axis and Whiteside’s line. However, there are currently no golden standards as to the ideal axes to determine the true femoral rotation.

Materials and Methods: A prospective observational study was performed to analyse the various axes used to determine femoral rotation during total knee replacement. All consecutive patients who underwent MRI of the knee between December 2006 and May 2007 were considered to be included in the study. Patients below the age of 20 years, above the age of 40 years and mass lesions obscuring the bony landmarks were excluded. The transepicondylar, posterior condylar, posterior femoral cortical, anterior femoral cortical and tibial anteroposterior axes were measured on the PACS system.

Results: Of the 100 patients, there were 75 males and 25 females with a mean age of 31(20–39) years. The mean relation between the posterior condylar axes and transepicondylar axes was 3.9 (SD−1.71, 95% CI 3.58–4.26), posterior condylar axes and posterior femoral cortical axes was 5.85 (SD−2.76, CI 5.3–6.4), posterior condylar axis and anterior cortical axis was 6.21 (SD−3.09, CI 5.6–6.8) and posterior condylar axes and tibial anteroposterior axes was 89.6 (SD−5.18, CI 88.5–90.6).

Conclusion: The transepicondylar axis appears to be the most consistent amongst the landmarks used to determine femoral rotation. However even the transepicondylar axis shows a significant variation. If transepicondylar axis is not available we suggest the use of femoral anterior cortical axes as a reference landmark

Introduction: Primary bone lymphoma is a rare neoplastic disease of bone. Treatment consists predominantly of chemotherapy and radiotherapy. Surgery can be considered for large lytic lesions with impending pathological fractures. This study was performed to find the functional and oncological outcome of patients who underwent limb salvage surgery and custom mega prosthesis for lymphoma of bone.

Materials and Methods: Eight patients with lymphoma of bone underwent limb salvage surgery and reconstruction with custom made prosthesis. Males predominated in the study with the average age of 30 years. Lower limb was commonly involved: 6 patients had tumour involving the femur. Five patients had pathological fracture. Resection and reconstruction was done using custom mega prosthesis. Proximal humeral prosthesis was used for proximal humeral tumour and proximal femoral or total hip prosthesis for proximal femoral lesion. One patient each had total femoral prosthesis and total knee prosthesis.

Results: With an average follow-up of 78.6 months, two patients died of disease and one patient was alive with disease. The patient with femoral shaft lesion had intra-operative vascular injury requiring vascular repair. The patient with total knee prosthesis had superficial skin necrosis which required skin cover. The functional outcome was satisfactory in 5 patients.

Discussion: Primary bone lymphoma accounts for 7% of all bone tumours. There is a male predominance and femur is the most common site of involvement. Five patients in our series had pathological fractures warranting surgical stabilisation. Limb salvage surgery with custom mega prosthesis appears to be a feasible option as more than 65% of our patients had satisfactory functional outcome. They were able to mobilise early with good pain relief and a useful functional limb.

To analyse the intra-operative variation in mechanical axes of the lower limb at various stages during navigated total knee replacement. A prospective study was performed to analyse the intra-operative variation in the mechanical axes of the lower limb during navigated total knee replacement. All consecutive patients who underwent navigated total knee replacement were included and patients with inadequate data were excluded from the study. The intra-operative initial, trial and the final mechanical hip-knee-ankle axes were recorded from the navigation system. The differences between these axes were calculated and analysed. There were forty patients, of which 24 were females and 16 males with the age ranging from 37–89 (average 68.4) years. The right knee was replaced in 27 and the left knee in 13 patients. The average initial mechanical axes alignment was 0.03° valgus (3° varus to 3° valgus), trial alignment 0.64° varus (3° varus to 1.5° valgus) and final alignment 0.25° varus (4° varus to 4° valgus). Average deviation from initial to trial axes was 0.97°, trial to final axes was 0.74° and initial to final axes was 1.08°. The cor-relation co-efficient between the initial and the trial axes was 0.25, trial and final axes was 0.43 & initial and final axes was 0.09.

This study highlights a significant variation in mechanical axes between the different stages of navigated total knee replacement. The potential sources of intra-operative errors causing these changes could be soft tissue imbalance, variations in implant placement and possible tracker micro motion. Execution of bony cuts in near normal neutral alignment does not guarantee achievement of near normal final alignment. We advocate surgeons to be vigilant to avoid potential malalignment during navigated total knee replacement.

Significant concerns remain in computer navigated surgery regarding potential errors due to inadequate tracker or array fixation, cutting guide block movements, saw blade deviation, variable component seating and standardisation and validity of radiographic measurements of alignment for outcome assessment. There are no studies in the literature comparing computer generated axes at different steps of operation as well as radiographic axes using scanograms to our knowledge. Long leg films involve significant radiation, which can be minimised by the use of scanograms.

A prospective study was performed to compare the per-operative and post-operative alignment of the lower limbs after navigated total knee replacements. All consecutive patients who underwent navigated total knee replacement between May 2006 and November 2006 were included in the study. Patients with inadequate data, patients who refused to participate in the study or lost contact, obvious measurement errors and patients having had recent operations were excluded. The intra-operative initial, trial and the final axes were recorded from the navigation system. Post-operatively a CT (Computer Tomogram) scanogram of the lower limbs was performed as per the scanogram protocol. Measurement of the mechanical hip-knee-ankle axis of the lower limb was performed on the computer. Results were analysed using appropriate statistical methods and comparison made between initial, trial, final and scanogram axes with assessment of their correlation coefficients.

Twenty-five patients were initially recruited in the study, of which, 15 were available with completed data. There were four males and 11 females with the age ranging from 57–80 (average 70) years. The right knee was replaced in 12 and the left knee in three patients. The average initial alignment was 0.09° valgus (0.5° varus to 1° valgus), trial alignment 0.59° varus (2° varus to 1° valgus), final alignment 0.56° varus (4° varus to 1.5° valgus) and average radiographic alignment was 0.52° varus (3.1° varus to 1.8° valgus) in maximum possible extension. Average deviation from initial to trial alignment was 0.69° varus, trial to final was 0.03° varus and final to radiographic alignment was 0.12° valgus.

Correlation co-efficient of 0.62 between the initial and final axes with average difference of 0.72° varus (p= 0.11, unequal variance 2 tailed) demonstrates reasonable reproducibility of the alignment with computer-guided surgery, also confirming the fact that there is some variation between the initial cut angles and final mechanical axes. Correlation co-efficient of 0.92 between final axes and radiographic axes suggests that scanogram is an imaging modality with reasonable accuracy for measuring mechanical limb alignment despite significantly low radiation and relatively low resolution. Potential errors in radiographic measurements due to rotational malposition combined with flexion deformity is highlighted.

To evaluate the long term functional and the oncological outcomes of patients who underwent scapulectomy as a limb saving procedure for various tumours of the scapula.

A retrospective study was done in twenty-five patients who underwent scapulectomy for various tumours between 1989 and 2005. We describe twenty-three patients of scapular tumours who were followed up for a minimum of two years after surgery. Nineteen patients had malignant neoplasms of which chondrosarcoma was commonest, followed by Ewing’s sarcoma. Surgical staging was done using Enneking’s system; with stage II B being the commonest. Eight patients underwent subtotal scapulectomy of Malawer Type IIA and fifteen patients underwent total scapulectomy (Type III A). All patients with Ewing’s and Osteosarcoma received neoadjuvant chemotherapy.

With a follow-up ranging from 25–202 months, functional prognosis and oncological outcomes were evaluated for all patients. Two patients had superficial wound infections requiring antibiotics and one had skin necrosis requiring skin cover. Three patients died of pulmonary metastasis and the fourth patient died of local recurrence complicated by multiple metastasis. Functional results were analysed using Musculoskeletal Tumour Society scoring system. The Kaplan Meier 5-year survival computed in 19 patients with malignant tumours was 75.9%.

Scapulectomy is a more realistic option for bone and soft tissue tumours around shoulder girdle. It permits a curative, non-ablative, alternative to forequarter amputation in carefully selected patients.

Purpose Of The Study: To find the functional and oncological outcome of patients who underwent limb salvage surgery and custom mega prosthesis for Malignant Fibrous Histiocytoma of bone.

Methods And Results: Twenty patients with histologically diagnosed Malignant Fibrous Histiocytoma of bone were treated by resection and reconstruction with custom mega prosthesis between May 1991 and December 2002. The average age was 42 and two-thirds of the patients were males. Majority of the tumours were located around the knee and were in Stage II disease of the Enneking system. Wide margins of resection were achieved in 18 patients and reconstruction was done with total knee prosthesis in patients with distal femoral and proximal tibial tumours. The proximal humeral and proximal femoral sites were reconstructed with their respective prosthesis. Fourteen patients treated after 1996 received chemotherapy. With an average follow-up of 57.7 months, 4 patients had amputation for local recurrence and five patients died of disease. Two patients had fracture of prosthesis necessitating revision of prosthesis in one. Functional result was excellent in 5 patients and good in 9 patients. The Kaplan-Meier 5-year survival rates of the patients treated without chemotherapy and with chemotherapy were 50% and 75.8% respectively.

Conclusion: MFH is an aggressive malignant tumour with a poor prognosis. A combined approach using neoadjuvant chemotherapy together with adequate surgical margins improves survival.