Aims

Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation.

Aims

Our aim was to investigate the prevalence of Propionibacterium (P.) acnes in the subcutaneous fat and capsule of patients undergoing shoulder surgery for frozen shoulder or instability.

Manipulation under anaesthetic (MUA) is an established treatment for frozen shoulder. Frozen shoulder may coexist with other shoulder conditions, whose treatment may differ from MUA. One such condition is calcific tendonitis. Only one study to date documents treatment of patients with frozen shoulder and concurrent calcific tendinitis.

The objective was to demonstrate that MUA and injection is a satisfactory treatment for concurrent diagnosis of frozen shoulder and calcific tendinitis.

Patients with a clinical diagnosis of frozen shoulder and radiological evidence of calcific tendinitis were prospectively recruited from Jan 1999 – Jan 2009. Treatment by MUA and injection was performed. Clinical examination, Oxford Shoulder Scores and need for further treatment were used as outcome measures.

Fourteen patients (median age 53.5 years) were identified with frozen shoulder and concurrent calcific tendinitis. Significant improvement in both Oxford Shoulder Score and range of movement was achieved following MUA (P values < 0.001). Two patients required further treatment (not for calcific tendinitis). This improvement was maintained in the long term (median 107 wks).

It is our belief that MUA and injection is a safe and effective treatment, addressing the frozen shoulder with MUA takes priority, and as such frozen shoulder “trumps” other pathologies occurring simultaneously.

Aims

To establish if the principles of Enhanced Recovery, an evidence-based, integrated, multi-modal approach to improving recovery following colonic resection are transferable to elective orthopaedic primary arthroplasty surgery. The principles are to reduce the stress response provoked by surgery and eliminate the peri-operative catabolic state by optimally managing patients' metabolism, expectations, postoperative pain and mobility. This combination of interventions has not been tested in Orthopaedics before.

Manipulation under anaesthetic (MUA) for the treatment of frozen shoulder is well established and effective however timing of surgery remains controversial. Intervention before 9 months has previously been shown to be associated with improved outcome. We test this theory by measuring Oxford Shoulder Score (OSS), re-MUA and subsequent surgery rate.

A retrospective review of a prospectively collected, single surgeon, consecutive patient series revealed 244 primary frozen shoulders treated by MUA within 4 weeks of presentation. The mean duration of antecedent symptoms was 28 weeks (95% CI 4-44 weeks) and time to follow up was 26 days (95% CI 11-41 days). The mean OSS improved by 16 points (2-tailed t test p< 0.001) with a mean follow up OSS of 43 (95% CI 38-48). 195 shoulders were manipulated before 38 weeks (9 months) and had the same mean change in OSS (16) as the 49 shoulders manipulated after 38 weeks. 48 shoulders, including 15 diabetic shoulders required further MUA. 8 shoulders had subsequent surgery. These events were also independent of antecedent symptom duration.

Early MUA does not appear to produce improved outcomes when compared to later intervention but we note does result in an earlier return to function.

Twenty-two patients with piriformis syndrome underwent surgery between October 1995 and February 2002. The mean age was 56 years (range 28-90). Only 2 patients (9%) gave a history of trauma to the ipsilateral buttock. All the patients complained of deep buttock pain, which radiated to the ankle in 14 (63%), the calf in 4 (18%) and the thigh in 3 patients (13.6%). The symptoms were chronic, with a mean of 70 months (range 12-192) and patients had been previously seen by a mean of 2.6 specialists (range 1-6). There was associated neurosensory loss in 11 patients (50%). The symptoms were exacerbated by passive stretching and active contraction of the piriformis muscle. MRI of the lumbar spine (every case) and gluteal region (8 cases) were negative, while NCV tests (20 cases) were positive in 11 patients (55%). Previous conservative measures such as physiotherapy (59%) and epidural (40%) had failed. Every patient had surgical division of the piriformis tendon at the greater trochanter by the senior author. Abnormal anatomy was identified in 6 cases (29%).

At 6 weeks (n=22), the symptoms had resolved in 6 patients (27%), were better in 8 (36%), no different in 7 (32%) and worse in 1 (4.5%). After a mean follow-up of 52 months (range 11-86), seven (35%) of patients were cured, 3 (15%) were better, 8 (40%) were no different, 2 (10%) were worse than pre-operatively and 2 had died of unrelated causes. Seventy-five percent of patients said that with hindsight they would undergo surgery again. One patient suffered a post-operative below knee DVT requiring no treatment.

Surgery for piriformis syndrome in this selected group of patients led to an improvement or resolution of chronic symptoms in 64% of patients at 6 weeks, and 50% of patients after a mean follow-up of 52 months with minimal associated morbidity.

Enhanced Orthopaedic Recovery (EOR) is an evidence-based, integrated, multi-modal approach to improving recovery following elective orthopaedic surgery. The principles of EOR are to reduce time to functional recovery of postoperative patients safely with subsequent benefits to their length of stay in hospitals, their quality of life and health economics and outcomes. The combination of interventions used has been shown to be effective following major gastro-intestinal surgery but have not been tested in Orthopaedics until now. They aim to reduce the stress response provoked by surgery and the peri-operative catabolic state by optimally managing patient metabolism, post-operative pain, mobility and expectations.

Simple interventions along the patients’ journey include pre-operative educational classes, pre-operative carbohydrate loading, a (short) two hour fast ensuring surgery performed on anabolic patients, post operative pain and metabolic optimisation, empowering patients with ownership of their post-operative recovery and proactive post-discharge management. We found that these simple interventions translate well into elective orthopaedic arthroplasty surgery, can be achieved without additional cost and have little impact on intra-operative practice.

We conducted a single surgeon, consecutive patient, interventional, cohort study of lower limb primary joint arthroplasty surgery (primary total knee and primary total hip arthroplasty) in a busy district general hospital, 30 bed orthopaedic department. We reviewed the preceding 141 primary joint replacements (75 total hip and 66 total knee arthroplasties) before prospectively assessing the next 50 total hip and 32 total knee arthroplasties. A Mann-Whitney test between the two periods showed a highly statistically significant fall in time to discharge (median hospital stay 6.5 - 4 nights, p< 0.001). We noted no adverse effects as a result implementing EOR.

We have shown that by implementing EOR, reduced time to functional recovery and subsequent hospital discharge can be safely achieved with consequent quality of life and health economic benefits.

We present 11 cases of total femur implanted in patients affected by severe bone defects in septic or aseptic prosthesis failures or tumours. Good results were obtained with a precise preoperative technical and surgical planning, without septic complications. We reported results and complications of our series.

From June 2003 we have elaborated a new procedure consisting in an osteoinductive-antibiotic gel, positioned on the spongiosametal surfaces of the implant. The gel contains five elements: Cancellous bone chips, Platelet-Rich Plasma, Bone marrow, Fibrin glue, Vancomycin and Tobramycin. Blood loss, operative time Hemoglobin drop values and clinical results were collected. Our procedure shows a quickly osteointegration of the implants without septic complications due to the local delivery of antibiotics. The procedure is safe and easy because includes only autologous factors without risks of disease transmission or immune response.

In primary total hip arthroplasty in patients affected by congenital dysplasia of the hip, stabilisation of the cup because of the altered shape of the acetabulum presents a problem. We have obviated this by creating a standard protocol with a press-fit classification that helps us to resolve such problems. In 269 cases (from 1994 to 2004) of patients affected by congenital dysplasia of the hip, we have always reconstructed the acetabulum using autologous bone grafts. After the right preparation of the acetabulum, when the cover of the metal back is complete and the stability is optimal (type I), bone grafts are not required (106 cases). After positioning of the cup, if we find defects that leave less than 30% of the external surface of the metal back uncovered but the stability is good (type II) (138 cases), we reconstruct such defects with small bone grafts (bone chips) captured by the femoral head of the patient. Greater bony defects that, after positioning of the metal back, do not allow an adequate stability and leave more than 30% of the cup (type III) uncovered (25 cases), we reconstruct the acetabulum with part of the femoral head fixed with screws. The follow-up at more than 5 years is between good and excellent (89–100) in all pateitns according to the Harris Hip Score.

In cementless joint arthroplasty, the first goal is stabilisation of the prosthetic components, due to bone ingrowth. In the past, to achieve the best fixation, orthopaedic surgeons used osteoconductive materials (HA, TriCa-Ph). To accelerate the fixation process, we have developed an osteoinductive procedure with growth factors. A product created from cancellous bone (BMP’s), bone marrow (stem cells) and platelet-rich plasma (growth factors) is applied to the tri-dimensional fixation surface (spongiosametal) of the prosthesis. Since June 2003, we have treated 15 arthroplasties with this procedure (11 THA, four TKA). The average duration of clinical follow-up was 6 months (range from 2 to 9 months). In case of THA, the average Harris Hip Score was 96 (Range from 91 to 100). In case of TKA, the average of HSS scoring was 90 (range from 85 to 100). The radiographic examinations were good. DEXA and RSA evaluations are underway.

We have studied the ability of a range of antibiotics to penetrate intervertebral disc tissue in vitro, using a mouse disc model. Equilibrium concentrations of antibiotics incorporated into the entire disc were determined by bioassay using a microbial growth-inhibition method. Uptake was significantly higher with positively-charged aminoglycosides compared with negatively-charged penicillins and cephalosporins. Uncharged ciprofloxacin showed an intermediate degree of uptake. Our results support the hypothesis that electrostatic interaction between charged antibiotics and negatively-charged glycosaminoglycans in the disc is an important factor in antibiotic penetration, and may explain their differential uptake.

Of 135 consecutive patients admitted with subtrochanteric fractures of the femur, 104 were studied; half had internal fixation with a Zickel nail and half had a nail-plate device. Fractures treated with a Zickel nail had significantly less blood loss during operation and took less time to walk with full weight-bearing, but the incidence of technical error at operation was higher. Errors included malalignment of the cross-pin, penetration of the femoral cortex and comminution of the greater trochanter. There was mechanical failure within one year of surgery in 17% of the nail-plate series but no implant failures in the Zickel nail group within the same period. The total time spent in hospital was similar in both groups. The Zickel nail provides better fixation for subtrochanteric fractures than a simple nail-plate but, because of technical difficulty, its use should be reserved for surgeons of reasonable experience.