Aim

Melioidosis is a significant public health problem in endemic regions such as India. Lack of awareness, predominant empiric antibiotic use reducing culture yields, morphotypic variability of cultures and frequent misidentification by automated blood culture systems, pose myriad challenges in diagnosis and treatment. Through this series, we present our experience of Hematogenous Osteomyelitis with Burkholderia pseudomallei.

Abstract

Aim

Management of infection after osteosynthesis (IAO) poses a significant challenge in the setting of multidrug resistant organisms (MDRo). We have analysed whether IAO with MDRo has an adverse outcome.

Introduction

We describe five results of a novel single stage arthroscopic technique for the treatment of articular cartilage defects of the knee. This involves micro drilling and application of Atelo-collagen (Coltrix) and fibrin gel scaffold.

Bowel management following joint replacement is often neglected leading lot of patient distress, with the advent of the enhanced orthopedic rehabilitation program, there is a need of a guideline to ensure prompt and quick recovery of bowel habits before discharge. Our aim was to identify the incidence of constipation in joint replacement patients, to evaluate the current practice of bowel management and formulate a protocol for management of constipation to improve the practice. We conducted a prospective study of 50 patients who underwent joint replacement procedures at our institute between September and October 2015. Following initial audit, we formulated a protocol for bowel management, and performed a re-audit by collecting a prospective data of 50 patients. The statistical analysis was done and calculating the mean and standard deviation for continuous variable and Fischer's exact test was used and significance level was set at 0.05. Incidence of constipation was 88% and laxatives were prescribed in 42%. More importantly, there was no correlation between constipation and pre operative fasting (p Value 0.33), post operative fasting (p Value 0.1822), type of surgery (p value 1.00) and type of anaesthesia (p Value 0.27). Following introduction of bowel protocol the laxative prescription increased to 98% (Prophylactic in 81%), consequently the incidence of constipation reduced to 18%. Implementing bowel protocol significantly will improve the patient care and reduce the rate of complications.

Chondral defects of the knee are common and often seen in young and active individuals. A novel single stage arthroscopic technique for the treatment of articular cartilage defects in the knee is described. This involves microfracture and application of concentrated bone marrow aspirate cells (BMAC) with fibrin and Hyaluronic Acid as a gel. After a representative preclinical study, the 5 year results of a prospective clinical study are presented.

The pre-clinical study involved two groups of rabbits with standardised lesions treated with microfracture alone and microfracture combined with fibrin/HA/BMAC application. New cartilage from both groups was subjected to staining with H&E for tissue morphology, toluidine blue (collagen) and safranin O (GAG), immunohistochemistry with antibodies for collagen type I and II, and scanning and transmission electron microscopy to analyse the microstructural morphologies. The fibrin/HA/BMAC group scored better than the microfracture group on all tests.

A subsequent prospective clinical study patients (n=60) with symptomatic ICRS grade III/IV chondral defects (lesion size 2–8cm2). The surgical procedure involved debridement of the lesion, micro-fracture and application of fibrin/HA/BMAC gel under CO2 insufflation. Patients underwent morphological evaluation with MRI (T2*-mapping and d-GEMRIC scans). Clinical assessment employed the Lysholm, IKDC and KOOS scores while radiological assessment was performed with MOCART score.

At 5 years, Lysholm score was 78, compared to 51 pre-operatively (p<0.05). KOOS (symptomatic) improved to 90 from 66 (p<0.05). IKDC (subjective) went to 80 from 39 (p<0.05). The mean T2* relaxation-times for the repair tissue and native cartilage were 26 and 29.9 respectively. Average MOCART score for all lesions was 70.

This technique shows encouraging clinical results at 5 year follow-up. The morphological MRI shows good cartilage defect filling and the biochemical MRI suggests hyaline like repair tissue.

Introduction

We describe a single stage arthroscopic procedure for the treatment of articular cartilage defects in the knee. The novel procedure involves microdrilling and application of atellocollagen and fibrin gel. The aim of the study was to evaluate the clinical outcomes at 4 years.

We describe a novel single stage arthroscopic repair procedure for articular cartilage defect in the knee. The aim of the study was to evaluate the clinical and radiological outcomes at two years.

The pre-clinical study involved two groups of New Zealand rabbits, treated with microfracture alone and microfracture combined with fibrin gel and concentrated bone marrow aspirate cells (BMAC) application. New cartilage from both groups was studied with histological staining, immunohistochemistry and electron microscopy. The fibrin gel-BMAC group scored better than the microfracture group on all counts.

This is a prospective study of 30 patients with symptomatic ICRS grade III/IV chondral defects, ranging from 2–8 cm², which were assessed clinically and radiologically. The surgical procedure involved debridement of the lesion, microfracture and arthroscopic application of concentrated BMAC with fibrin gel under CO₂ insufflation. Patients underwent morphological MRI, quantitative T2*-mapping and d-GEMRIC scan. Clinical assessment was carried out using the Lysholm, IKDC and KOOS scores while radiological assessment used the MOCART score.

At 2 year follow-up, Lysholm score was 80.1, as compared to 50.8 pre-operatively (p < 0.05). KOOS (symptomatic) was 92.1, as compared to 65.7 pre-operatively. IKDC (subjective) was 83, up from 39 preoperatively. The mean T2* relaxation-times for the repair tissue and native cartilage were 29.1 and 29.9 respectively. Average MOCART score for all lesions was 72.

Our technique shows encouraging clinical and radiological results. The morphological MRI shows good cartilage defect filling and the biochemical MRI (T2*-mapping) suggests hyaline like repair tissue.

Introduction

Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty. We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban.

Introduction

Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty but do not recommend one particular pharmacotherapy over another.

Study design

Prospective clinical and radiological analysis of children with complex cervical deformities for the safety of cervical pedicle screw insertion.

Study Design

Prospective analysis of computerised tomogram images of 376 normal pediatric cervical pedicles

PURPOSE OF STUDY

20-70% of patients need blood transfusion postoperatively. There remain safety concerns regarding allogenic blood transfusion. Tranexamic acid (TA) is a synthetic antifibrinolytic agent that has been successfully used to stop bleeding in other specialties. We applied TA topically prior to the wound closure to find out the effect on blood loss as well as need for subsequent blood transfusion. This method of administration is quick, easy, has less systemic side effect and provides a higher concentration at the bleeding site.

Introduction: Failures of treatment of osteoid osteoma (OO) are related to errors in exact localization and incomplete excision of the nidus. Intraoperative Iso-C 3D navigation allows exact localization, excision and confirmation of excision by percutaneous Methods:

Methods: We report the successful percutaneous excision of OO in 11 patients (extremities-5; spine-6). All patients had a minimally invasive reflective array (MIRA) fixed to the same bone in the extremities and to the adjacent spinous process or body(caudal) in spine, followed by registration of anatomy. A tool navigator was utilized to plan the key hole incision so that the trajectory did not involve important anatomical structure. A sleeve was then introduced which allowed the usage of instruments like a burr and curette to deroof the nidus, curette the nidus and obtain material for histopathology and further burr the cavity to ensure complete eradication of the nidus. Following excision, registration using Iso-C 3D C-arm was done to confirm the complete eradication of the nidus.

Results: The age of the patients varied from 10 to 27. In the extremities, location of the MIRA was in the same bone and firm anchorage was obtained using either a single Steinman pin locator (4 patients) or a double pin locator (1 patient). In spine the MIRA was attached to the adjacent spinous process (caudal) in the cervical, thoracic or lumbar region (5 patients) and in sacrum (1 patient) it is attached using a Steinman pin to the adjacent vertebral body. Excellent three-dimensional view of the nidus and localization was possible in all patients. A safe trajectory that avoided anatomical structures was possible in all patients using a tool navigator. The incision ranged from 1 to 4 cms. Adequate material for histology was obtained in ten patients that confirmed the diagnosis of osteoid osteoma and in one patient histopathological confirmation was not possible because the nidus was completely destroyed during the process of deroofing and burring. In ten patients, post excision ISO-C 3D scans confirmed adequate removal and in one patient, it was successful in identifying incomplete removal requiring further excision of the nidus. The average operating time was 62 mins (37–90 mins) and the blood loss was less than 30 cc in all patients. All patients achieved excellent pain relief and were asymptomatic at an average follow up of 3.4 (2.2 – 3.9) years.

Conclusions: Iso-C 3 D navigation offers the advantage of excellent localization of the nidus and percutaneous excision of these tumors, thereby conserving bone in critical locations like the spine and upper end of femur. It also offers the advantage of intraoperative confirmation of adequate excision and allows harvesting the nidus for histological confirmation.

Introduction: Today’s aging population has resulted in an increase in the number of major orthopaedic surgical interventions in the elderly. Total knee replacement (TKR) is one of the commonest operations in orthopaedic practice. The fourth annual report of the National Joint Registry showed that there were 60 986 TKR performed in England and Wales in 2006. The true figure is probably much higher. Literature showed that 20–70% of patients who had TKR needed 1–3 units of blood.

Although safer than ever, allogeneic transfusion is still associated with risks for the recipient (haemolysis, infection, immunosuppression, transfusion-related acute lung injury and even death).

Tranexamic acid (TA) is a synthetic antifibrinolytic agent that has been successfully used to stop bleeding after dental operation, removal of tonsils, prostate surgery, heavy menstrual bleeding, eye injuries and in patients with Haemophilia.

In this study Tranexamic acid was applied topically to the exposed tissue around the knee joint prior to the wound closure and tourniquet release. It is anticipated that this method of administration is quick, easy, associated with less systemic side effect. Also, it provides a higher concentration of the Tranexamic acid at the bleeding site.

Objectives: To find out whether Tranexamic acid can reduce blood loss and subsequent blood transfusion significantly after total knee replacement when applied topically without extra side effects.

Design: A double blind randomised controlled trial of 150 patients who underwent unilateral primary cemented total knee replacement. This number gives a 90% power to detect a 50% reduction in blood loss and 80% power to detect a reduction in blood transfusion from current local standard 30% to 10%.

Outcome Measures: Blood loss, transfusion, Length of stay, complications, Euroqol and Oxford Knee Score.

Results: The two groups were comparable in age, weight, height, BMI, Tourniquet time, and type of anaesthesia. There has been significant differences in the amount of blood loss and blood transfusion in favour of tranexamic acid (p-values are 0.001 and 0.007 respectively). Fourteen patients needed blood transfusion ranged from 2–6 units. Thirteen were in the Placebo group and only one in the Tranexamic acid. There has been no significant difference among other outcomes in particular complications rates such as DVT and pulmonary embolism.

Aim: Accurate soft tissue balance in total knee arthroplasty (TKA) is not only technically challenging but also difficult to teach to trainees; we believe that computer navigation provides a very useful tool for objective and reproducible soft tissue balance.

Methods: We studied 52 patients (31 females and 21 males) with knee osteoarthritis and recorded the change of the Medial (MCL) and Lateral Collateral Ligament (LCL) length at full extension and at 90o flexion. Pre- and post-operative results were compared. The assessment was performed by consultant orthopaedic surgeons using trackers and navigation knee replacement software. Data was analysed using the student t-test

Results: The navigation software programme was used to measure the change of the collateral ligament length. Ligament laxity is represented by a negative number and a positive number is used to represent stretching and apparent elongation of the ligament.

The medial collateral (MCL) length at full extension ranged from −9mm to 11mm and post-operatively was reduced to −16mm and 8mm, (p=0.042). At 90o flexion the length ranged from −3mm to 9mm and postoperatively was reduced to −8mm and 10mm (p=0.025).

The lateral collateral (LCL) length at full extension changed from −10mm to 9mm pre-operatively to −13mm and 6mm post-operatively (p=0.011). At 90o flexion the range from −8mm and 9mm pre-operatively changed to − 5mm and 11mm post-operatively (p=0.005).

All the above changes correspond to improvement in the post-operative axial alignment.

Conclusion: Our results demonstrate that computer navigation provides a useful adjunct to the accurate and reproducible soft tissue balance in knee arthroplasty which can be used to evaluate results and for training purposes.

Aim: The difficulty in accurately assessing coronal alignment of a total knee prosthesis (TKR) is widely accepted in the literature yet standard practice in the UK is to obtain AP and lateral knee views only; we compared standard AP knee films with long leg views of TKR in order to determine the most optimal way of assessment of the prosthetic knee alignment.

Methods: We included all patients who underwent TKR between January and September 2005 at Kings College Hospital under the care of one orthopaedic consultant. We excluded 11 patients with revision surgery, augmented prosthesis, high tibial osteotomies or severe tibiotalar joint arthritis.

We included 50 sets of radiographs from 48 patients (17 men and 31 women). The prostheses used were PFC (40) and Scorpio (10) and six of them were navigated and 44 were standard TKR.

We compared the difference between the angle of the tibial component with the mechanical axis of the tibia in the long leg image and the angle of the prosthesis with the midline of the visualised tibia in a standard antero-posterior knee view. Statistical analysis was carried out using the student t-test.

Results: The mean difference between the two views was 5.34o (range 1.9o – 12o) (p< 0.001). We did not find any difference between the Scorpio and PFC knees or between navigated and non navigated prostheses.

Conclusion:We concluded that the long leg views compared with the standard antero-posterior knee views provide more accurate information on the position and alignment of the tibial component of a TKR.

Aims: Kinematics of the arthritic knee joint is to date not very well understood, yet this is a significant parameter affecting the results of knee arthroplasties; we studied the axial rotation of the tibia during knee flexion in osteoarthritic knees in order to understand better the kinematics of the arthritic joint.

Methods: Tibial rotation and the screw home mechanism were studied in 55 consecutive patients (31 females and 24 males) with diagnosed knee OA. The assessment was performed by consultant orthopaedic surgeons using the trackers and the software of a navigation system, prior to any soft tissue release. The Student t-test was used for the statistical analysis.

Results: We identified 3 different patterns of tibial rotation during knee flexion.

26 knees had normal tibial rotation pattern with the tibia rotating internally during knee flexion (mean rotation: 15.5°).

We also recorded that most of the tibial rotation occurs in the first 0–30° of flexion (70%) p< 0.001.

Conclusion: The screw home mechanism and the normal tibial rotation upon knee flexion were absent or distorted in the majority of osteoarthritic knees. We found three distinctive patterns of the tibial rotation (normal, erratic and reversed) during knee flexion.

Introduction: Achilles tendinopathy is a source of significant pain and disability. While many patients respond to non-operative treatment, a proportion will require operative treatment. Both open decompression and percutaneous longitudinal tenotomy have been described. We describe a new technique and present the results of percutaneous circumferential decompression of the tendon, dividing adhesions between the paratenon and the tendon.

Methods: We followed up 10 patients for a mean of 10 months (5–19) post operatively. They were scored pre and post operatively using the tegner activity score, the puddu score and an analogue pain score. The functional result was also assessed with the SF12 questionnaire.

Results: All patients reported significant improvements in pain (p=0.007), tegner (p=0.007) and puddu (p=0.005) scores. They would all undergo the procedure again. The SF12 scores were not significantly different from a normal population.

Discussion: We believe that this technique addresses the underlying pathology, giving excellent results without the potential complications of an open decompression.

Hallux valgus is a common condition and surgical correction has remained a challenge. Scarf osteotomy with Akin procedure is well accepted method. Akin procedure gives spurious correction of the distal alignment of big toe. This study was performed to see alternative way to get best correction without additional phalangeal procedure. Senior author used innovative Y-V medial capsulorraphy with standard Scarf osteotomy. This technique allows reduction of MP joint along with correction of pronation deformity and reduction of sesamoids.

We report the use of a modified Y-V medial capsular repair in association with Scarf osteotomy for Hallux valgux in 45 patients (55 feet) aged 18 to 76 years (mean 43 years) between October 2004 and December 2005. Clinical follow up was both subjective and objective. Patients were asked about rating of their satisfaction and objective assessment was done in form of AOFAS score. Using this technique none of the patients required an additional proximal phalangeal osteotomy with metatarsal osteotomy. At six months follow up American Orthopaedic Foot and Ankle Society score improved from 46 to 87. Intermetatarsal (IM) angle and the hallux valgus (HV) angle improved from 16° to 9° and from 31° to 16° respectively (p< 0.05). At final follow up 8 patients were very satisfied, 12 were satisfied while 5 were not satisfied.

Of the 55 procedures 51 did not develop any complications. Two had superficial infections, treated successfully with oral antibiotics only. Two patients had recurrence, one was treated with Akin and second patient declined surgery as she was not bothered with it.

We recommend the use of this modified ‘Y-V’ medial capsular repair to reduce the need for an additional procedure to augment the correction achieved during Scarf osteotomy for hallux valgus. This reduces hallux valgus angle and maintains it.