Aims

In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia.

Aims

This is a prospective randomised study which compares the radiological and functional outcomes of ring and rail fixators in patients with an infected gap (> 3 cm) nonunion of the tibia.

Aim

To determine effectiveness of Collagenase Clostridium Histolyticum (CCH) in deformity correction and hand function for patients with Dupuytren's disease.

The management of upper limb nonunions can be challenging and often with unpredictable outcomes. In the study we present the results of treatment of upper limb nonunions treated in our institution with BMP-7 biological enhancement.

Between 2004 and 2011 all consecutive patients who met the inclusion criteria were followed up prospectively. Union was assessed with regular radiological assessment. At the final follow up clinical assessment included the disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement and patient satisfaction. The mean follow up was 12 months (12–36).

In total 42 patients met the inclusion criteria with a mean age of 47. Anatomical distribution of the nonunion sites included 19 cases of mid/proximal radius/ulna, 14 humerus, 6 distal radius and 3 clavicles. 5 patients had septic nonunion, 35 had atrophic nonunion, 11 had previous open fractures, and 10 had bone loss (range 1–3 cm). The mean number of operations performed and the mean time from injury to BMP application was 1.5 and 26 months, respectively. 40 patients had both clinical and radiological union whereas 2 had partial radiological union but a pain free range of motion. BMP was applied in isolation in 1 case and 41 cases the application was combined with autologous bone grafting. The range of movement of the affected limb, DASH score and patient satisfaction were optimum at the final follow up.

This study supports the use of BMP-7 as a bone stimulating adjunct for the treatment of complex and challenging upper limb nonunions.

Introduction

Clavicle fractures can cause pain and functional impairment if not managed appropriately. This paper evaluates the prevalence of clavicular fractures, estimates number of cases requiring operative treatment, whether removal of implant is a frequent necessity and compares the final functional outcome of the operative and non-operative group.

Introduction

The muscles of the leg collectively comprise the calf pump, however the action of each muscle group on calf pump function is not known. Patients with foot or ankle injury or surgery are often advised to perform foot and ankle movements to help prevent deep venous thrombosis. Our aim was to determine which foot and ankle movements were most effective in stimulating the calf pump. Method: Nine healthy participants were enrolled in this research and ethics approved prospective study. Participants with a previous history of peripheral vascular disease, varicose veins, deep venous thrombosis or previous foot and ankle surgery were excluded. Each participant followed a standardized protocol of foot and ankle movements, starting with foot in neutral position and the baseline and movement peak systolic velocity within the popliteal vein was measured during each movement. The movements tested were toe dorsiflexion, toe plantar flexion, ankle dorsiflexion, ankle plantar flexion.

Introduction

The incidence of deep venous thrombosis (DVT) in patients with lower limb cast immobilization occurs in up to 20% of patients. This may result from altered calf pump function causing venous stasis. Our aim was to determine the effects of below knee cast on calf pump function.

Purpose

The purpose of this study was to determine whether intra-operative identification of osseous ridge anatomy (lateral intercondylar “residents” ridge and lateral bifurcate ridge) could be used to reliably define and reconstruct individuals' native femoral ACL attachments in both single-bundle (SB) and double-bundle (DB) cases.

To estimate the prevalence of clavicular fractures, number of cases required operative treatment, and whether removal of the implant is a frequent necessity.

Between November 2005 and Nov 2007 all patients presenting in our institution with clavicular fractures were eligible for participation. Patients below 18 years of age, and pathological fractures were excluded. Retrospective review of clinical notes and radiographs. Demographic details, mode of injury, treatment protocol, operative procedures performed, time to union, complications post-surgery stabilization, and the number of cases that required implant removal were documented and analysed in a computerized database. The mean time of follow up was 24 weeks (12–48).

Out of 16,280 adult fractures that presented to our institution, 200 (1.23%), (137 males) patients met the inclusion criteria with a mean age of 43 years (19–95) and a mean ISS of 9 (4–38). There were 4 of the medial, 153 of the middle and 43 of the lateral clavicle fractures (3 were open). 178 (89%) patients were treated non-operatively and 22 (11%) operatively. Indications for surgery included open fracture, bony spike/skin threatened, grossly displaced/comminuted fracture, polytrauma and non-union. Mean time to radiological union was 14 weeks (5–38 weeks). Out of the 200 patients 12 (6%) developed non-union. Out of the 22 operated patients, 7 (32%) required plate removal and 1 had screw removal. Indications for removal of implant included, periprosthetic fracture (1), prominent metal work through skin (3), pain in shoulder (2), pressure symptoms (1). Post removal of implant, 6 (75%) patients claimed improvement in symptoms. Functional outcome was excellent/good in 90% of cases.

The incidence of clavicular fractures was 1.23%. A small number of patients (11%) required operative treatment out of which one third had metal work removal. The majority of clavicular fractures can be treated non-operative with good functional results.

Introduction: The JRI Furlong HAC LOL hemiarthroplasty stem has shown increased periprosthetic fracture rates compared to previous literature (15.2% vs 7.4%) [1,2,3]. This study seeks to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted to influence the type of prosthesis used (cemented or uncemented).

Methodology: A 5 year prospective cohort of 560 consecutive patients underwent hemiarthroplasty (cemented or uncemented). A nested case-control study to determine risk factors affecting intra-operative fracture was carried out.

Clinical outcomes and radiographic analysis was performed. The Vancouver Classification was used to classify periprosthetic fracture.

The MDI score was calculated using radiographs, as a control (gold standard), Yeung’s CBR score was calculated [4]. See Figure 1. A receiver operating characteristic (ROC) curve was formulated for both and area under the curve (AUC) compared. Intra and inter-observer correlations were determined.

Cost analysis was also worked out.

Results: 407 uncemented and 153 cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture.

62 periprosthetic fractures occurred in the uncemented group (15.2%), 9 in the cemented group (5.9%), p< 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, p< 0.001 and 90 day mortality 19.7%, p< 0.03.

MDI’s AUC was 0.985 compared to CBR’s 0.948, p< 0.001. See Figure 2. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, PPV 90.5%, NPV 98%. ANCOVA ruled out any other confounding factors as being significant.

The intra and inter-observer Pearson correlation scores were r=0.99, p< 0.001.

The total extra cost due to the intra-operative fractures was £93,780.

Discussion: The MDI score is a useful, cost effective way of preventing this serious complication from occurring. We recommend that any femur scoring 21 or less on the MDI score be considered for cemented hemiarthroplasty.

Level of evidence: Level 2 Diagnostic Study: Development of diagnostic criteria on basis of consecutive patients (with universally applied reference “gold” standard).

The aim of this study was to establish a classification system for the acromioclavicular joint using cadaveric dissection and radiological analyses of both reformatted computed tomographic scans and conventional radiographs centred on the joint. This classification should be useful for planning arthroscopic procedures or introducing a needle and in prospective studies of biomechanical stresses across the joint which may be associated with the development of joint pathology.

We have demonstrated three main three-dimensional morphological groups namely flat, oblique and curved, on both cadaveric examination and radiological assessment. These groups were recognised in both the coronal and axial planes and were independent of age.

Introduction: The JRI Furlong HAC LOL hemiarthroplasty stem has shown increased periprosthetic fracture rates compared to previous literature(15.2% vs 7.4%). This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted to influence the type of prosthesis used (cemented or uncemented).

Methodology: Over 5 years prospectively, a cohort of 560 consecutive patients undergoing hemiarthroplasty (cemented and uncemented) were evaluated. Clinical outcomes and radiographic analysis was performed. The Vancouver Classification was used to classify peri-prosthetic fracture. The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al’s CBR score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined. Cost analysis was also worked out for adverse outcomes.

Results: 407 uncemented and 153 cemented stems were implanted. 62 periprosthetic fractures occurred in the uncemented group (15.2%), 9 occurred in the cemented group (5.9%), p< 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, p< 0.001. MDI’s AUC was 0.985 compared to CBR’s 0.948, p< 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. ANCOVA analysis ruled out any other confounding factors as being significant. The intra and inter-observer Pearson correlation scores were r=0.99, p< 0.001. The total extra cost due to the intra-operative fractures was ú40,140.

Discussion: The MDI score has been shown to be a potentially useful, cost effective way of preventing this serious complication from occurring. We recommend that any femur scoring 21 or less on the MDI score be considered for cemented hemiarthroplasty. Level of evidence: Level 2 Diagnostic Study: Investigating a diagnostic test against gold standard.

Disorders of the pisotriquetral joint are well recognised as the cause of pain on the ulnar side of the wrist. The joint is not usually examined during routine arthroscopy because it is assumed to have a separate joint cavity to the radiocarpal joint, although there is often a connection between the two.

We explored this connection during arthroscopy and in fresh-frozen cadaver wrists and found that in about half of the cases the pisotriquetral joint could be visualised through standard wrist portals. Four different types of connection were observed between the radiocarpal joint and the pisotriquetral joint. They ranged from a complete membrane separating the two, to no membrane at all, with various other types of connection in between.

We recommend that inspection of the pisotriquetral joint should be a part of the protocol for routine arthroscopy of the wrist.

Suture anchors have changed the practice of repair of tendons in modern Orthopaedics. The purpose of the study was to identify the ideal suture anchor length for anchoring flexor digitorum profundus tendon to the distal phalanx.

We dissected 395 distal phalanges from 80 embalmed hands. Phalanges from two little fingers and three thumbs were damaged, hence were excluded from the study. We measured the Anteroposterior and Lateral dimensions at three fixed points on the distal phalanges of all 395 fingers using a Vernier’s Callipers with 0.1mm accuracy.

The mean value of the Anteroposterior width of the distal phalanx at the insertion of the FDP was found to be 3.4mm for the little finger; 3.9mm for the ring finger; 4.3mm for the middle finger; 4.0mm for the index finger and 5.0mm for the thumb respectively. The commonly available anchors and drill bits were found to be too long when used for anchoring the flexor digitorum profundus tendon in certain distal phalanges. Our findings may be a reason for poor outcome of FDP repair to distal phalanx using suture anchors. New designs for tissue anchors for distal phalanges may be necessary.

Objective: To study the role of anterior spinal surgery in scoliosis in Indian settings and to discuss the complications.

Study Design: Prospective study

Subjects: The present study comprises of forty patients of scoliosis in growing age group (10–25 years) with Cobbs angles ranging from 52”–98”. They were treated with Leeds procedure which is by anterior loosening followed by Posterior Harrington fixation + Luque derotation + Fusion and Costoplasty.

Results: Average correction of the deformity after surgery was 45%. Satisfaction level of patients and parents was good in 60% of the cases. Majority of the curves were thoracic (60%), and right sided (72%). The modality of treatment was decided on the basis of personality of each case, its demand and requirement, time of presentation and the potential for increasing severity. Anterior spinal surgery for scoliosis is an effective procedure in hands of experienced surgeons and it reduces stiffness of the curve, shortens the anterior column, and decreases thoracic lordosis that leads to some improvement of pulmonary function. But there is greater risk of damage to vital structures with higher risks of cardio-respiratory failure. The potential risks have to be balanced with the expected rewards. The optimum method of correction has to be decided by careful preoperative evaluation.

Conclusions: This study reaffirms the role of anterior spinal surgery in India as the patients due to lower levels of health awareness present late and with severe deformities. Combined procedure of anterior and posterior surgery causes lesser decrease in pulmonary functions than costoplasty alone, and achieves better cosmetic correction.

Disorders of the pisotriquetral joint can cause ulnar sided wrist pain. This joint is not usually seen during routine wrist arthrosopy because it often has a separate joint cavity. The senior author believes that it is more commonly seen from the 6R portal if looked for, than one would expect from the assumed anatomy.

This study assessed the frequency with which the pisotriquetral joint could be observed in 36 consecutive wrist arthroscopies. The connection between the radiocarpal and the pisotriquetral joint were found to vary from a complete membrane separating the two, to no membrane at all, with variations in between. The types of connections are described. The anatomy of the connections was also studied by dissecting the wrist joints of eight fresh frozen cadavers. The findings matched the arthroscopic observations.

In more than 50% of patients, the pisotriquetral joint could be clearly visualised by arthroscopy. The technique and findings have been recorded on video and form part of the presentation.

The purpose of the study was to define the anatomy of the distal biceps tendon and it’s attachment to the proximal radius (bicipital tuberosity). Distal ruptures of the biceps tendon are not uncommon. Surgical treatment needs an understanding of the precise anatomy of the distal biceps tendon and it’s insertion; of which there are no reports in the literature.

Eighty cadaver elbows were dissected. Six were damaged, hence they were excluded from the study. The skin over the cadaver elbows was removed. The distal biceps tendon was dissected and followed to it’s insertion on to the bicipital tuberosity. Measurements of tendon dimensions were taken at the elbow joint and at it’s insertion.

The whole distal biceps tendon twists in a predictable manner. The tendon fibres too change orientation. The tendon inserts on the posterior margin of the bicipital tuberosity in a thin C-shaped manner. All the biceps insertions had a significantly large bursa associated with it.

Both the biceps tendon and it’s intra-tendinous fibres twist. This has biomechanical implications. The dimensions of the biceps tendon at the elbow and at it’s insertion affect the biomechanics. The insertion into bone in a thin C shaped fashion has connotations on methods of repair.

Ankle fractures are common injuries and commonly require operative stabilisation. The aim of treatment should be anatomical reduction as this will lead to good long-term results. Non-anatomically reduced fractures will lead to a poor functional outcome and development of osteoarthritis. Our aim was to determine whether revision of non-anatomical fixations within 12 months of initial surgery improved outcome.

We present eight cases of non-anatomical ankle fixations that were revised by the senior author over a 4-year period. There were 4 females and 4 males. The mean age was 45.6 years at review (range 28–63) and the mean time from initial fixation to revision was 5.25 months (range 2–11). Mean time at review was 26.6 months (range 7–45). Clinical scoring for functional outcome was performed using the American Orthopaedic Foot and Ankle Society (AOFAS) rating system for the ankle and hindfoot. Mean AOFAS score prior to revision was 40 (range 19–69) and the mean score at review was 80 (range 54–100).

All patients reported benefit in terms of function from the revision procedure. The aim of initial surgery is for anatomical reduction of the ankle joint. Should suboptimal fixation be encountered within 12 months of the initial surgery, we feel revision surgery is justified.

In this study, we reviewed the records of 881 patients with fracture neck of femur over 5 years. Of these, 372 patients underwent hemiarthroplasty (231 cemented and 141 uncemented). The aim was to analyse the factors, which may contribute towards the mortality in cemented versus uncemented group.

The mean age in the cemented and uncemented group was 82 and 81 years respectively. 136 (58.8%) patients were operated within 24 hours of admission in the cemented group as compared to 63 (44.6%). The mean operative time was 81minutes for cemented hemiarthroplasty and 61 minutes for uncemented hemiarthroplasty. 77% of the cemented hemiarthroplasty was performed by Registrar grade as compared to 69% in the uncemented group. Of the 231 patients in the cemented group, 52% received general and 48% received spinal anaesthesia. Of the 141 patients in the uncemented group, 30% received general and 70% received spinal anaesthesia.

There was an 8% 30-day mortality compared to 11% 30-day mortality in uncemented group (p< 0.05). The mean age of patients in the mortality group was age 86 yrs in cement and 84 yrs in uncemented group. Most operations were done within 24–48 hours. There was significant co morbidity in patients who died. The average operative time of patients who died in both groups was same.

There was an increased mortality rate in the uncemented group as compared to the cemented group (p< 0.05). Based on our study, we conclude that cement is not a risk factor. Duration and timing of surgery is not associated with increased mortality. There was no difference in 30-day mortality rates between patients receiving general or spinal anaesthesia. Significant co morbid factor is associated with increased mortality.

To assess the incision used for routine primary Carpal Tunnel Decompression (CTD), preferred modes of division of the flexor retinaculum and the accuracy with which the motor branch of the median nerve could be identified.

A simple questionnaire was distributed at an orthopaedic regional meeting, which contained a list of simple questions, and a scale photocopy of the palm of a left hand. The surgeons were asked to indicate upon the hand the incision they would make and their prediction of the location of the motor branch of the Median nerve. The data was feed into a desk top spreadsheet program where it was analysed.

43 complete questionnaires were returned, comprising all grades from SHO to consultants. A great majority used a McDonald’s spatula during their division of the retinaculum, with an equal proportion cutting down onto the McDonald’s spatula as were cutting up from it. The shape of the incision was straight in a majority of cases, though some consultants and SpRs tended towards curved or S-shaped incisions. Length of incision varied, among all grades, from 2cm to 6cm, with Juniors tending towards shorter incisions. With respect to Ulna (Medial) or Radial (Lateral) position of the incision, the tendency was to place the incision Radially. 72% of surgeons located the position of the motor branch within 2cm of the actual position, as predicted by Kaplan’s lines.

The surgeons audited tended towards lateral incisions, and hence potentially placing the palmar cutaneous and the motor branches of the median nerve at greater risk.