Background

Despite arthroscopy being the gold standard for long head of biceps pathology, the literature is seemingly lacking in any critical appraisal or validation to support its use. The aim of this study was to evaluate its appropriateness as a benchmark for diagnosis. The objectives were to evaluate whether the length of the tendon examined at arthroscopy allows visualisation of areas of predilection of pathology and also to determine the rates of missed diagnoses when compared to an open approach.

Background

Distal radius fractures are common injuries but no clear consensus regarding optimal management of unstable fractures exists. Open reduction and internal fixation with volar plates is an increasingly popular but the associated complication rate can be 10%. Intramedullary nails are an alternative offering the potential advantages of reduced risk of tendon injury and intra-articular screw penetration. This article systematically reviews the published literature evaluating the biomechanics, outcomes and complications of intramedullary nails in the management of distal radius fractures.

Recent literature has demonstrated that conventional arthroscopic techniques do not adequately visualise areas of predilection of pathology of the long head of biceps (LHB) tendon and are associated with a 30–50% rate of missed diagnoses. The aim of this study was to evaluate the safety, effectiveness and ease of performing biceps tenoscopy as a novel strategy for reducing the rate of missed diagnoses.

Five forequarter amputation cadaver specimens were studied. The pressure in the anterior compartment was measured before and after surgical evaluation. Diagnostic glenohumeral arthroscopy was performed and the biceps tendon was tagged to mark the maximum length visualised by pulling the tendon into the joint. Biceps tenoscopy was performed using 3 different techniques (1. Flexible video-endoscopy, 2. Standard arthroscopy via Neviaser portal. 3. Standard arthroscope via antero-superior portal with retrograde instrumentation). Each was assessed for safety, ease of the procedure and whether the full length of the extra-articular part of the LHB tendon could be visualised. The t-test was used to compare the length of the LHB tendon visualised at standard glenohumeral arthroscopy vs that visualised at biceps tenoscopy. An open dissection was performed after the arthroscopic procedures to evaluate for an iatrogenic injury to local structures.

Biceps tenoscopy allowed visualisation to the musculotendinous junction in all cases. The mean length of the tendon visualised was therefore significantly greater at biceps tenoscopy (104 mm) than at standard glenohumeral arthroscopy (33 mm) (mean difference 71 mm, p<0.0001). Biceps tenoscopy was safe with regards to compartment syndrome and there was no difference between pre- and post-operative pressure measurements (mean difference 0 mmHg, p=1). No iatrogenic injuries were identified at open dissection.

Biceps tenoscopy allows excellent visualisation of the entire length of the LHB tendon and therefore has the potential to reduce the rate of missed diagnoses. This study did not demonstrate any risk of iatrogenic injury to important local structures or any risk of compartment syndrome. Clinical evaluation is required to further validate this technique.

The majority of studies reporting sensitivity and specificity data for imaging modalities and physical examination tests for long head of biceps (LHB) tendon pathology use arthroscopy as the gold standard. However, there is little published data to validate this as an appropriate benchmark. The aim of this study was to determine the maximum length of the LHB tendon that can be seen at glenohumeral arthroscopy and whether it allows adequate visualisation of common sites of pathology.

Seven female cadaveric specimens were studied. Mean age was 74 years (range 44–96 years). Each specimen underwent arthroscopy in lateral decubitus (LD) and beach chair (BC) positions. The LBH-tendon was tagged with a suture placed with a spinal needle marking the intra-articular length and the maximum excursions achieved using a hook and a grasper in both LD and BC positions. T-tests were used to compare data.

The mean intra-articular and extra-articular lengths of the tendon were 23.9 mm and 82.3 mm respectively. The mean length of tendon that could be visualised by pulling it into the joint with a hook was significantly less than with a grasper (LD: hook 29.9 mm, grasper 33.9 mm, mean difference 4 mm, p=0.0032. BC: hook 32.7 mm, grasper 37.6 mm, mean difference 4.9 mm, p=0.0001). Using the BC position allowed visualisation of a significantly greater length than the LD position when using either a hook (mean difference 2.86 mm, p=0.0327) or a grasper (mean difference 3.7 mm, p=0.0077). The mean length of the extra-articular part of the tendon visualised using a hook was 6 mm in LD and 8.9 mm in BC. The maximum length of the extra-articular portion visualised using this technique was 14 mm (17%).

Pulling the tendon into the joint with a hook does not allow adequate visualisation of common distal sites of pathology in either LD or BC. Although the BC position allows a significantly greater proportion of the tendon to be visualised this represents a numerically small value and is not likely to be clinically significant. The use of a grasper also allowed greater excursion but results in iatrogenic tendon injury which precludes its use. The reported incidence of pathology in Denard zone C (distal to subscapularis) is 80% and in our study it was not possible to evaluate this zone even by using a grasper or maximum manual force to increase excursion. This is consistent with the extremely high rate of missed diagnoses reported in the literature. Surgeons should be aware that the technique of pulling the LHB-tendon into the joint is inadequate for visualising distal pathology and results in a high rate of missed diagnoses. Furthermore, efforts to achieve greater excursion by “optimum” limb positioning intra-operatively do not confer an important clinical advantage and are probably unnecessary.

This article is a systematic review of the published literature about the biomechanics, functional outcome and complications of intramedullary nailing of fractures of the distal radius.

We searched the Medline and EMBASE databases and included all studies which reported the outcome of intramedullary (IM) nailing of fractures of the distal radius. Data about functional outcome, range of movement (ROM), strength and complications, were extracted. The studies included were appraised independently by both authors using a validated quality assessment scale for non-controlled studies and the CONSORT statement for randomised controlled trials (RCTs).

The search strategy revealed 785 studies, of which 16 were included for full paper review. These included three biomechanical studies, eight case series and five randomised controlled trials (RCTs).

The biomechanical studies concluded that IM nails were at least as strong as locking plates. The clinical studies reported that IM nailing gave a comparable ROM, functional outcome and grip strength to other fixation techniques.

However, the mean complication rate of intramedullary nailing was 17.6% (0% to 50%). This is higher than the rates reported in contemporary studies for volar plating. It raises concerns about the role of intramedullary nailing, particularly when comparative studies have failed to show that it has any major advantage over other techniques. Further adequately powered RCTs comparing the technique to both volar plating and percutaneous wire fixation are needed.

Cite this article: Bone Joint J 2015;97-B:1370–6.

Trans-articular coronal shear fractures of the distal humerus pose a significant challenge to the surgeon in obtaining an anatomical reduction and rigid fixation and thereby return of good function. A variety of approaches have been described which include the extended lateral and anterolateral approaches and arthroscopically-assisted fixation for non-comminuted fractures. Fixation methods include open or percutaneous cannulated screws and headless compression screws directed either anterior to posterior or posterior to anterior. We describe an illustrated, novel approach to this fracture which is minimally invasive but enables an anatomical reduction to be achieved.

A 15 year old male presented with a Bryan and Morrey type 4 fracture as described by McKee involving the left distal humerus. He was placed in a lateral position with the elbow over a support. A posterior longitudinal incision and a 6cm triceps split from the tip of the olecranon was made. The olecranon fossa was exposed and a fenestration made with a 2.5mm drill and nibblers as in the OK (Outerbridge-Kashiwagi) procedure. A bone lever was then passed though the fenestration and used to reduce the capitellar and trochlear fracture fragments into an anatomical position with use of an image intensifier to confirm reduction. The fracture was then fixed with two headless compression screws from posterior to anterior into the capitellar and trochlear fragments (see images). Early mobilisation and rehabilitation were commenced. Follow-up clinical examination and radiographs at six weeks revealed excellent range-of-motion and function with anatomical bony union.

We believe that this novel approach to this fracture reduces the amount of soft tissue dissection associated with conventional approaches and their associated risks and also enables earlier return to function with restoration of anatomy.

Individuals learn to master new motor skills (such as learning a new surgical technique) by evaluating available feedback to alter future performance. Continuous concurrent augmented feedback is supplementary information presented to the learner throughout the performance of a task. An example of this type of feedback is the visual information provided by computer navigation during arthroplasty surgery. This type of feedback is a potentially powerful tool for learning because it theoretically guides the learner to the correct response, reduces errors, and reinforces correct actions. However, motor learning theory suggests that this type of feedback may impair learning because of development of dependence on the additional feedback or distraction from intrinsic feedback. In the current era of reduced number of training hours it is essential to assess the role of computer navigation on trainees.

Our objective was to determine whether computer navigation influences the learning curve of novices performing hip resurfacing arthroplasty. We conducted a systematic review and critical appraisal of the literature. There is some evidence from randomised controlled trials that navigation use by trainees facilitates accurate placement of arthroplasty components compared to conventional instrumentation. There is no evidence that training with computer navigation impairs performance in retention tests (re-testing on same task after an interval of time) or transfer tests (re-testing in different conditions i.e. without concurrent feedback).

We conclude that although there are significant limitations of the published literature on this topic there is no available evidence that supports concerns regarding the theoretical detrimental effects of computer navigation on the learning curve of arthroplasty trainees.

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.

Aim: To relate clinical progress following cartilage repair using TruFit plugs with appearance on MRI imaging with a view to determining safe healing in order for patients to return to activity, without needing invasive assessment.

Methods: 26 active sporting patients underwent cartilage repair using TruFit CB plugs (Smith & Nephew) for symptomatic chondral defects in the knee between February 2006 and September 2008. The plugs are a biphasic synthetic implant designed to reform both bone and articular cartilage. As part of this prospective series patients underwent MRI at post op time-points of 6, 12, 18 and 24 months. MRI was performed using a 1.5 Tesla scanner and later using a 3T scanner. We report the results of both including T2 cartilage mapping.

Results: All 26 patients were improved at latest follow-up when compared to pre-operative scores (mean follow up 15 months (range 6–30 months)). MRI evaluation demonstrates oedema like signal surrounding the plugs at an early stage but by 6 months the oedema resolves and the subchondral lamina is seen to reform. By 12 months the bone part of the plug has similar appearance to host bone and the neo-cartilage shows similar signal to native cartilage on all MRI modalities (1.5T, 3T and T2 mapping). This suggests that the repair tissue contains a high percentage of hyaline like cartilage. In one patient slow clinical improvement was reflected in the MRI appearance.

Conclusion: MRI imaging appears to relate to clinical improvement according to KOOS, IKDC, Lysholm, Tegner and SF36 scores. This indicates that MRI is a useful imaging tool for assessing healing, and knowledge of the recovery pattern is important for quantifying healing and for better advising patients on when it may be safe to load repaired areas.

Purpose: To investigate the validity of previous observations that meniscal repair has a better success rate when associated with ACL reconstruction.

Methods and Results: The case notes of 170 patients who underwent meniscal repair between May 1999 and May 2007 were analysed for causes of re-operation and relation to status of the ACL. Mean age at the time of surgery was 28 years.

41 patients underwent re-operation at a mean time interval of 21 months (range 2 weeks - 87 months). 79 patients (Group A) had isolated meniscal tears. 44 patients (Group B) had meniscal repair at the same time as elective ACL reconstruction and underwent brace-free, accelerated rehabilitation. 47 patients (Group C) had meniscal repair in association with ACL disruption and underwent staged ligament reconstruction.

In Group A, 23 patients underwent re-operation (Indications; meniscal symptoms 21, stiffness 1, infection 1). Nineteen repairs (23.8%) were found to have failed. In Group B, 15 patients underwent re-operation (Indications; meniscal symptoms 12, stiffness 1, revision ACL 2). Twelve (27.2%) repairs were found to have failed. In Group C, Nine (19.6%) repairs were found to have failed. 6 at the time of staged ACL reconstruction and 3 subsequently, at further arthroscopy. There was no statistical difference between the groups with respect to the incidence of failed meniscal repairs.

Analysis of possible predictive factors including age, gender, location of lesion and the type of repair did not show statistical significance.

Conclusions: Reoperation rate following meniscal repair is high. Meniscal repair for tears associated with ACL disruption in this group did not appear to have a higher success rate compared to isolated tears. This raises questions regarding the current practice of ignoring meniscal repair and instituting brace-free, early, aggressive rehabilitation following concomitant ACL reconstruction.

Aim: To assess the safety and clinical and radiological outcome of the TruFit CB porous, resorbable scaffold for symptomatic osteochondral and chondral articular defects in the knee.

Methods: 11 active sporting patients underwent cartilage repair using TruFit CB plugs (Smith & Nephew) for symptomatic defects on the medial or lateral femoral condyle. All had failed previous treatment (debridement/microfracture) and had persistent symptoms. Postoperatively patients were touch weight bearing for 2 weeks and partial until 4 weeks. Data was collected prospectively. The mean age was 34 (range 19 – 50) and 5 were male. Four lateral femoral condyle defects were treated, all associated with lateral meniscal tears. Four medial defects were associated with ACL injury (1), PCL injury (1) or isolated chondral injury (2). Single plugs were required in 5 (9mm in 3 and 7mm plugs in 2), 2 patients required 2 plugs (9mm and 7mm), and 2 required 3 (2×9mm + 1×7mm).

Results: All 11 patients were improved at a mean follow up of 14.5 months (3–21 months) with 4 currently back to full pre-injury level of sport. Subjective IKDC scores improved from 45 pre-op to 79 post-op (p< 0.05), Lysholm from 47 to 71 (p< 0.05), and latest Tegner activity score at 5. MRI evaluation including T2 mapping demonstrates reformation of the subchondral lamina and resorption of the graft. 2nd look arthroscopy was undertaken in 2 showing a well healed and well integrated surface.

Conclusion: These preliminary results indicate that TruFit CB plugs offer a potential solution for small focal chondral defects, offering an alternative to microfracture or osteochondral grafting with advantages of low morbidity and rapid recovery without the need for prolonged non-weight bearing.

The purpose of this study was to investigate the safety and outcome of bilateral simultaneous ACL reconstruction. In patients presenting with an ACL-deficient knee, 2 – 4% have bilateral ACL deficiency. A staged or simultaneous approach can be adopted when the patient requires reconstructive surgery for both knees. We report a case series of 8 patients (6 male, 2 female, average age 30.4 years) who underwent bilateral simultaneous ACL reconstruction.

Simultaneous or bilateral ACL reconstruction using ipsilateral patella tendon graft has been reported as a safe procedure with outcome and complication rate no different to unilateral procedures. Considerable cost savings of simultaneous over staged procedures have also been described. There are no case series in the published literature that describe the use of hamstring tendon autograft for bilateral simultaneous ACL reconstruction.

We used two camera stack systems and instrument sets to allow for simultaneous bilateral surgery by two surgical teams. Quadrupled hamstring tendon graft was used in 4 patients although in one patient patella tendon graft was used on the second side due to poor quality of hamstring tendons. Patella tendon graft was also used in a further 4 patients. At two weeks all patients were able to discard crutches and were independent in mobility. There was no difference in outcome at one year between those patients undergoing bilateral simultaneous ACL reconstruction in comparison to the outcomes of unilateral ACL reconstruction with respect to Lysholm, Tegner and IKDC scores. The mean follow up period was 2.3 years.

Our results demonstrate that bilateral simultaneous ACL reconstruction is safe and cost effective. A simultaneous approach also has the benefit of reducing the overall period of rehabilitation required by the patient. We report good short-term functional outcome but no long-term data is yet available.

Aim: To assess the results and complications of the opening wedge form of distal femoral varus osteotomy (DFVO) in treating valgus arthritis and ligament instability of the knee.

Methods: Patients undergoing DFVO were assessed prospectively using validated scoring systems and pre/post operative alignment radiographs. All had failed non operative and arthroscopic procedures and were keen to avoid arthroplasty. The lateral based opening wedge osteotomy aimed to correct the weight bearing line to position 50% medial to lateral and was held with either the Puddu femoral plate (Arthrex UK) or the Tomofix plate (Synthes UK).

Results: 26 distal femoral osteotomies were performed in 23 patients with a mean age of 34 (16 –58). The mean duration of follow up is 32.5 months (1–72). 8 were undertaken for primary valgus malalignment, and 15 for secondary valgus with OA due to previous lateral menisectomy. Simultaneous additional procedures included microfracture (3), MACI (1), meniscal transplantation (1), and MCL advancement (1). Mean hospital stay was 4 days (2–6). Post op alignment was out by greater than 10% of intended in 2/3. 3 early major complications required re-operation: 2 for plate and screw cut out and 1 for infection. 2 developed delayed union requiring bone grafting. Failure with conversion to arthroplasty has occurred in 2 (1 lateral UKA, 1 TKA), and 2 patients are awaiting either multi-ligament reconstruction or collagen meniscal implantation. The overall mean Tegner score is 4 (2–6), and 20 of the 23 patients feel satisfied with the outcome having avoided arthroplasty.

Conclusion: Opening wedge DFVO is a technically difficult procedure with significant complications, but in the right indication offers long lasting pain relief and joint preservation prior to arthroplasty. New techniques including accurate closing wedge fixation systems and computer guided operative planning and surgery may offer improvements to this vital surgical option.

Background: The timing of surgery for closed ankle fracture is controversial. Conventional teaching recommends either immediate surgery or a delay of 5–7 days in order to minimise soft tissue complications. However, there have been no large studies to produce clear guidelines and the literature is conflicting. Some authors suggest that delayed surgery results in increased risk of wound complications, less satisfactory rate of anatomical reduction, increased hospital stay and health service cost.

Objective: We aimed to determine whether surgery can be safely performed in an intermediate time frame with respect to soft tissues complications.

Method: We performed retrospective analysis of case notes and plain radiographs of 85 patients undergoing open reduction and internal fixation for closed ankle fractures at our unit in 2004. Data was analysed using the StatView statistical analysis program. Continuous variables were assessed for association with wound complication by means of an unpaired t-test. Nominal variables were assessed using Fisher’s exact test.

Results: The overall rate of infection in our population of 85 patients was 9.4%. This comprised 7 superficial wound infections and one deep infection. Patients were classified into early (within 1 day), intermediate (between 2–6 days) and delayed (after 6 days) groups according to the time delay prior to surgery. Only 1 patient in the intermediate surgery group developed infection compared to 6 in the delayed group and this was statistically significant (p = 0.046).

Conclusion: We suggest that with experience, meticulous soft tissue handling and good operative technique, delaying surgery until swelling has subsided is unnecessary in the majority of patients and is associated with a higher risk of wound complication.

Objective: Diagnostic delay is well recognised in soft tissue sarcoma (STS). The aim of this paper is to assess whether symptom duration/time to diagnosis, has any impact on patient survival and also if patient and tumour-related factors are related to the duration of symptoms prior to presentation.

Method: We performed a retrospective analysis of prospectively collected data for all patients diagnosed or treated with STS at our centre over a 20-year period. Information regard¬ing when the patients first experienced symptoms was entered into a local oncology database at their first consultant-outpatient appointment. Symptom duration was defined as time in weeks from first symptoms experienced by the patient to the time of diagnosis. Data analysis was performed using StatView and R. Risk factors were assessed by Kaplan-Meier analysis and the Cox proportional hazards model. Stat¬istical significance was determined using 95% confidence intervals where appropriate. Students t-test was used to compare categorical data.

Results: The study population comprised 1508 patients. 159 had metastatic disease at diagnosis and overall 5-year survival in this group was 14%. In view of this poor prognosis these patients were excluded from further analyses. In the remaining 1349 patients overall 5-year survival was 60%. Mean symptom duration within our study was 70.2 weeks. A Cox Proportional hazards model showed that duration of symptoms had a significant impact on survival (p=0.0037) with each additional week of symptoms reducing the monthly hazard rate by 0.2%. Patient and tumour-related factors that were significantly associated with longer symptom durations were low grade, subcutaneous tumours, and those patients with either epitheliod or synovial sarcomas. Symptom duration was not associated with tumour size or patient age/gender.

Conclusion: Patients presenting with long symptom durations/diagnostic delay, tend to have low grade disease and a more favourable outcome than patients who experience short symp¬tom durations.

Current survival rates for cancer in the UK are perceived to be worse than those in mainland Europe. In order to asses this we investigated the prognostic value of patient and treatment parameters in the management of osteosarcoma, and whether these parameters are equally important across international boundaries.

Retrospective, cross-sectional study of patients (n=428) diagnosed with non metastatic distal femur or proximal tibia osteosarcoma, between 1990–1997 at two specialist orthopaedic oncology centres; Birmingham, UK and Bologna, Italy. Disease free survival (DFS) and overall survival (OS) were assessed by Kaplan-Meier, Fisher’s PLSD and Cox proportional hazard regression. Results : DFS and OS were 43% and 60% at 5 years in Centre 1 and 56% and 73% at Centre 2 respectively. Median survival was 108 weeks at Centre 1 and 136 weeks at Centre 2. A significant difference in DFS and OS was demonstrated between the centres (p=0. 0019 and p=0. 0280 respectively). The most important prognosticators were raised alkaline phosphatase (p=0. 002 and p=0. 0019), degree of chemotherapy induced necrosis (p=0. 0001 and p=0. 0002) and tumour volume > 150cm³ (p=0. 0037 and p=0. 0057).

The most significant combination of prognosticators was alkaline phosphatase and tumour necrosis. 75% of patients in centre 2 had a good chemotherapy response (> 90% necrosis) compared to only 29% in Centre 1. The other prognostic indicators were evenly matched. Chemotherapy regime was found to have significantly different outcome in DFS and OS.

This is a retrospective study designed to explore possible reasons for differences in survival between two international centres. It would appear that all known patient factors were matched between the centres but that the main difference was in the effectiveness of chemotherapy. Further international prospective studies are needed to confirm these findings.