Abstract

Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients.

Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months.

The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527).

Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities.

Abstract

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

A recent meta-analysis published in the British Medical Journal suggested an increased risk of infection, but none of the studies were large enough to reach statistical significance. A prospective, randomised trial was designed at our institution to investigate the wound healing and complications related to surgery following fracture neck of femur in the elderly.

We wished to assess the usefulness of Inspace balloon arthroplasty (IBA), in our Upper limb unit by regular patient reviews prospectively. This prospective study was started adhering to local approval process. Patients were identified in routine clinical practice by three upper limb consultants presenting with pain and disability and diagnosis of cuff tear was established clinically and on MRI. The patients were explained of ‘available’ treatment options and an information leaflet about balloon arthroplasty provided. Patients were seen in 4 weeks, in a dedicated clinic to find out their willingness to participate. Consultant shoulder surgeons carried out all Balloon arthroplasties and where the cuff was reparable or contraindications identified were excluded from study.

All the patients were reviewed by an independent clinician pre-operatively and post operatively using the assessment tools of Oxford Shoulder Scores (OSS), SF12 and VAS at 6 weeks, followed by 3, 6, 12 months and annually after.

We performed a total of 32 IBA procedures. At the latest follow-up we identified that 24 patients have completed 2 years post procedure. Of these patients 1 deceased after 6 months, 3 were lost to follow up one each at 6, 12 and 24 months. Three were revised to reverse TSA. The OSS reflects that the positive difference of 10 in the average scores (24 pre-operative versus 34 at 2 years) noted at one year follow up were maintained at 2 years. Similar observations made analysing at 12 months and 2 years scores for the VAS pain scores of 3 at 2 years compared to pre-operative score of 6 and so were improvements in both physical & mental components of SF12.

Our study observes that the IBA provides a sustainable pain relief and functional improvements over 2 years and may be a suitable alternative in physiologically compromised patients with irreparable RCT.

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

One of the disadvantages of lateral decubitus position during arthroscopic rotator cuff repair is the difficulty to control arm rotation intraoperatively making it necessary to create additional portals for anchor placement or an additional scrubbed assistant to control arm rotation.

Accurate implant size estimation for internal fixation of long bone fractures can reduce intra-operative errors, operative time and radiation exposure. With the advent of pre-packed sterile implants, the exponential increase in the number of internal fixation devices and the lack of standard templates for them on PACS systems, templating has become increasingly difficult. This often results in the opening up of wrong implants leading to increased costs both in terms of increased operative time and additional implants. We describe a technique to determine implant size preoperatively using sterile implant boxes. Post anaesthesia and positioning, the pre packed implant box of approximate size is placed over the limb across the fracture site. An X-ray is then taken using the C-arm. In case of a plate, the number of holes desired on either side of the fracture, the shape of the implant and planned placement of screws are seen. Different implant boxes with the contained implant are placed and once the most appropriate implant for the particular fracture is reached, the box is opened and implant is kept ready for insertion. This technique has been found to be accurate, easy, reproducible and effective for estimating the implant size thereby decreasing the chances of opening wrong implants and saving the intra operative time substantially.

Aim

To determine the benefit of dissolvable Balloon Arthroplasy in managing patients with massive irreparable rotator cuff tears (RCT).

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.

Introduction

The wrist arthroscopy has been performed since 1979. With the advances in technology and surgical expertise, wrist arthroscopy has become third commonest procedure after knee and shoulder joint. Wrist arthroscopy has become a gold standard for diagnosing TFCC pathologies and other intercarpal disorders. Our aim was to compare the clinical, MRI and arthroscopic findings while treating various wrist pathologies.

The carpometacarpal joint of the thumb is one of the most common locations of degenerative arthritis. Surgical options include trapezio-metacarpal fusion, replacement or resection arthroplasty with or without interposition.

We report the medium term results of a Modified Thompson's suspensionplasty. The radial half of the APL tendon was looped around the FCR tendon to create the suspension. The remainder of the tendon is then used for interposition.

We carried out a retrospective review of 50 patients (67 hands) who underwent this procedure from January 1999 to December 2005. There were 41 female (52 hands) and 9 male (15 hands). The average age at the time of surgery was 62 years (range 41 years – 79 years). The average follow up was 5.33 years (1-9 yrs). 22 patients also had a concurrent second procedure to the same thumb and a further three had a third procedure.

The average PRWHE score was 25 (0 – 80) and the average DASH score was 40 (24 – 100)

There were eight complications which included four persistent radial sided wrist pain. Two of these underwent tenotomy of FCR, whilst two responded to conservative measures. Two patients had symptoms related to scapho-trapezoid arthritis, which responded to an injection. One patient had superficial infection which settled with oral antibiotics, whilst another patient had early chronic regional pain syndrome. Overall the satisfaction rate was 90% with 48 patients (96%) willing to undergo the same procedure again.

We conclude that the modified Thompson's suspensionplasty gives excellent medium term results.

Fractures of distal tibia are common and often present with dilemma of appropriate and safe management. The use of locking plates has changed the way these fractures have been managed as it avoids extensive soft tissue dissection and periosteal stripping

The aims of this study were to look at the results of stabilization and analyse the complications of fractures of distal tibia treated with Locked plates

We carried out a retrospective study of patients who underwent surgical treatment for distal tibial fractures using MIPO (Minimally invasive Percutaneous Osteosynthesis) technique. The data was gathered from theatre data base. We studied a period between Nov 2006 to May 2009. We collected patient demographics as well as the type of fractures, mechanism of injury, radiological union and associated complications. There were no open fractures in the study. The limb was splinted for two weeks after surgery in a back slab. The patients were followed up at 6 weeks, 3, 6, 9 and 12 months after surgery.

There were 45 patients in the study with 29 males & 16 females between ages of 20 – 87 (avg. 49 yrs). 24 patients sustained injury due to a fall, 12 were involved in RTA and the remaining 9 were sports related injuries. The mean time to surgery was 3.15 days (1 – 7) and surgery was carried either by the consultant or their direct supervision. The mean hospital stay was 7 days (2 – 35) and mean time to radiological evidence of callus was 9 weeks. All patients eventually returned to their preinjury employment. 76% showed radiological union at 6 months and 90% at 9 months.

There were 3 superficial wound infections, 2 deep infections whilst 2 needed bone grafting and 1 implant failure. 2 patients developed mild form of CRPS which resolved at 12 months. 11 patients had metal discomfort of which 9 had removal of hardware. All these patients had the tip snapped off.

MIPO with LCP is a reliable and reproducible technique in treatment of closed unstable fracture of distal tibia. Patients must be counselled about implant removal after fracture union. Avoid snapping the tip of the LCP.

Aim

To assess the influence of posterior slope on Knee flexion and function in Asian and Caucasian populations.

Knee warmth is a common clinical observation following total knee arthroplasty (TKA). This can cause concern that infection is present. The purpose of our study was to establish the pattern of knee skin temperature following uncomplicated TKA. It was a prospective study carried out between 2001 and 2004. A pocket digital surface thermometer was used.

A preliminary study established that the best site to measure knee skin temperature was superomedial to the patella and the best time was 12 noon. Patients with an increased risk of infection and those with a contralateral knee pathology or a previous surgery were excluded. Forty-eight patients fulfilled the inclusion criteria and consented to participate; the skin temperature of operated and contralateral knees was measured pre-operatively and daily during the first six weeks post-operatively. Measurements were also taken at 3, 6, 12 and 24 months following surgery. During the course of the study, patients developing complications of the operated knee or any pathology of the contralateral knee were excluded.

Thirty-two patients completed the main study. Following surgery, systemic and both knees temperatures increased. Whereas systemic and contralateral knee temperatures settled within one week, the operated knee temperature took a longer time. The difference in temperature between the two knees had a mean value of +2.9°C at 7 days. This mean value decreased to +1.6°C at 6 weeks, +1.3°C at 3 months, +0.9°C at 6 months +0.3°C at 12 months and +0.04°C at 24 months. Following uncomplicated TKA, the operated knee skin temperature increases compared to the contralateral knee. This increase peaks at day 3 and diminishes slowly over several months; however, it remains statistically significant up to 6 months.

These results correlate with the findings of previous studies that showed a prolonged elevation of inflammatory markers.

Introduction: Early plaster immobilisation is important in fracture management to control pain and maintain alignment. In our institute, the initial plaster is routinely applied by junior trainees directly or is applied by Accident & Emergency (A& E) staff under the supervision of the junior trainees. In the U.K., plaster application technique has not been routinely and formally taught to the junior trainees in the hospital.

Method: We aimed to review the adequacy of plaster applied or supervised by junior trainees. The criteria for an adequate of plaster immobilisation for tibial diaphyseal fractures have not been reported in the literature. We had chosen 3 simple parameters, namely, change in alignment of fracture fragments, position of the ankle and a gap index of less than 0.15, which in our view are important in terms of initial management of tibial fracture in the A& E. The gap index reflects the amount of padding applied in the plaster. These parameters were merely chosen to assess the adequacy of initial plaster immobilisation by junior trainees and should not predict the long term success or failure of the management of fracture with plaster. Sixty-five patients with tibial diaphyseal fractures were retrospectively included in the present study. The initial and post-plaster application radiographs were assessed by two senior trauma & orthopaedic specialist registrars separately.

Result: Only forty-six percent (45%) of the cases had fulfilled all the three criteria. In subgroup analysis, position of the ankle is the most frequently neglected factor with 31% of the ankles held in equinus. Twenty eight percent (28%) of cases had worsening of the alignment of the fracture fragments. Fourteen percent (14%) of the cases had excessive padding applied as reflected by Gap Index of > 0.15.

Conclusion: This study highlighted that the basic plastering technique by the junior trainees is inadequate. We suggest that every trainee rotating to Trauma & Orthopaedic Surgery must be taught this fast-fading away basic plaster application technique during the induction period.

Background: Total knee replacement remains one of the most common knee surgery practices worldwide. The operative procedure universally requires the use of cutting jigs to resect predetermined amounts of bone irrespective of the preoperative anatomy and morphology of the femur and tibia.

Aims: The aims of this study were to elucidate anatomical morphological differences between ethnicities pre-operatively and to assess whether any change elucidated was preserved post-operatively.

Method: This was a retrospective study comparing the pre and postoperative lateral view X-Rays of TKRs performed. Distances measured from most prominent anterior point to midline and the most prominent posterior point to midline and their ratio was compared between two ethnic groups. Each x-ray measurement was triple checked.

Results: The study groups comprised of 60 Caucasian knees and 40 Asian knees. Preoperatively the mean ratio was 0.55 in Caucasians and 0.44 in Asians, with this difference being statistically significant (p value < 0.005). Post operatively the mean ratio was 0.59 in Caucasians and 0.55 in Asians and this difference was not statistically significant (p value =0.166). These findings were also cross-checked with range of movement measurements post-operatively in the same group of patients. There was no comparable improvement in range of movements (ROM) post-operatively in the Asian group.

Conclusion: We infer that the present TKR cutting jigs are not taking into account the anatomical differences within the knee of Asians individuals. This is converting the post operative distal femurs of this group to become morphologically comparable to the Caucasian knee and this is possibly affecting the kinematics of those knees leading to no significant improvement in the post operative ROM and affecting satisfaction with surgery.

Aims: To compare the preoperative knee function in patients of Asian origin and Caucasians living in the same community.

Background: The prevalence of osteoarthritis is high in all ethnic and demographic groups. The timing of surgery is important as poor preoperative functional status is related to poor postoperative function.

Methods: Prospective study of 63 Asian patients age and sex matched with Caucasian patients undergoing total knee arthroplasty. Pre operative Knee Society Clinical Rating System scores were recorded as a separate Knee Score and Knee Function.

Results: The mean preoperative Knee Score in Asian patients was 37.6 in comparison to 41.5 in Caucasians (p< 0.10) this difference was not statistically significant. The mean preoperative Knee Function in Asian patients was 32.5 in comparison to 45.0 in Caucasians (p< 0.0001) this difference was highly statistically significant.

Conclusions:Patients of Asian origin undergoing total knee arthroplasty have lower preoperative knee function to Caucasians. Cultural beliefs and social support explain part of this discrepancy but health care providers must also attempt to educate patients and close family members about the importance of timing the surgery to obtain the optimum benefits of pain relief and function.

Background: Aseptic loosening of the tibial component is the one of the commonest cause of failure following a TKR. Good cement penetration into bone can reduce this and this has led to the development of new devices and techniques to improve the pressurisation during the cementing process.

We have conducted a case controlled study on a novel cementing technique and compared the results with published optimum levels.

Methods: 104 patients that underwent TKR at our institution were studied. Half of these were cemented using a double mix of cement inserted under pressure via an inexpensive alternative to the cement gun. The data was collected prospectively and included patient information, knee outcome scores and radiological assessment and there was a minimum 4 years follow-up.

Results: We found a significant difference in the number of early lucent lines as well as the size of the cement mantle particularly in the most important Zones. Despite pressurisation 1 of the 14 zones did not improve and we have examined the reasons for this.

In order to achieve optimum cement penetration we recommend that attention is paid to good pressurization and cement penetration and describe our technique for doing this.