Drug Free Sport New Zealand (DFSNZ) aims to maintain New Zealand Sport as a drug free environment and thereby enhance our proud and successful sporting culture. New Zealand is bound into the World Anti-Doping Code and must therefore adhere to World Anti-Doping rules.

Detection of doping violations is one of the functions of DFSNZ. An aim of DFSNZ is to eliminate the risk of athletes failing a sports anti-doping test as a result of using legitimately prescribed medication as treatment without a Therapeutic Use Exemption (TUE). This can create major problems for the athlete who may then have to appear before the Sports Tribunal.

Some substances on the prohibited list are used by Orthopaedic Surgeons as part of regular management. “National level” athletes require a TUE to be completed prior to use of these medications or immediately following use in emergency situations. Examples are:

Narcotics and Intravenous Corticosteroids perioperatively.

Other athletes who are not in this category but may be tested do not require a TUE immediately but still have to be able to provide evidence that the medication was used for therapeutic use if they were subsequently to fail a test. It is the athlete’s responsibility to notify the surgeon and obtain the appropriate documentation. Athletes in the Testing Pools will carry a card with reference to MIMS Resources, the DFSNZ website and Hot-line. From time to time athletes stressed by the situation of their injury may forget to notify the surgeon, prior to surgery, of anti-doping requirements. Surgeon (and anaesthetist) awareness and support for the programme will enhance the overall care of the patient and limit subsequent demands on both the patient and medical staff. The aim of this presentation is to enlighten NZOA members regarding the correct procedures to follow should a prohibited substance be required when treating an athlete who is subject to drug testing in sport.

Wrist ganglia are the commonest benign tumours of the hand consisting of a collagenous walled cavity containing gelatinous mucin material. These lesions can be managed by either reassurance alone, aspiration or surgical excision. However studies evaluating patient outcomes following these treatment modalities are limited and between them have often presented inconsistent results. Some recently published data has suggested that there is no long-term benefit of excision or aspiration over reassurance alone and as a result surgical excision of wrist ganglia has fallen out of favour with some health care trusts.

This aim of this retrospective, questionnaire based study was to assess patient outcomes following wrist ganglion excision surgery and to compare these results with current published evidence. Sixty two patients were identified from the hospital records database between July 2003 and March 2008. Fifty patients (80.6%) responded to a questionnaire by post or telephone call with a mean time to follow up of thirty nine months (range 16 to 71 months). Pain and cosmetic concern were the primary symptoms preoperatively, experienced by 78% and 70% of patients respectively. 26% to 48% of patients experienced other symptoms such as pins and needles, numbness, weakness and stiffness. Following surgery, there was a statistically significant reduction in all symptoms experienced. Ganglions recurred at the same location in five patients (12%) of which four would consider further surgery. 96% of patients were satisfied with the treatment they received.

Our results regarding symptomatic relief are comparable with current published data. In addition our data provides further evidence that ganglion excision surgery prevents recurrence to a greater extent than either aspiration or reassurance alone. Furthermore our recurrence rate is lower than other published reports evaluating ganglion excision surgery which we believe underestimate the benefits offered by this treatment modality. As a result, wrist ganglion excision surgery remains an important treatment modality offering excellent results in terms of symptom resolution, patient satisfaction and ganglion recurrence.

Between 1995 and 2000, nine patients between the ages of 12 and 15 years were treated for very large osteochondral fractures of the lateral femoral condyle with internal fixation of the displaced osteochondral fragment with bioabsorbable pins. Initial healing in these patients has been assessed with either follow up arthroscopy or MRI scanning. Early results suggested very good healing of the detached fragments.

The aim of this study was to review these patients at greater than five years follow up to assess how the healed articular cartilage has survived and performed. Eight of the nine patients were able to be followed up for clinical assessment, IKDC rating, Noyes Cincinnati Knee rating, radiologic and MRI assessment. Under the IKDC Knee Scoring system, five patients scored a final grade of A, two patients scored a grade of B and one patient scored C. Under the Noyes Cincinnati Knee Scoring system, three of the eight patients scored excellent, two scored good and three had a final rating of fair. There were no poor results.

X-rays, including weight bearing views, were assessed for evidence of lateral compartment degeneration. Six patients had normal knee x-rays. Two patients had subchondral bony irregularity in the lateral compartment with subtle lateral compartment narrowing.

We found that MRI scanning with specific cartilage sequences was an accurate way to assess healing and integrity of the articular cartilage at greater than 5 years. All patients had intact articular cartilage in the lateral compartment with no area of full thickness articular cartilage loss. Six of the eight patients had a small abnormal cleft-like signal corresponding to the likely posterior margin of the initial fracture fragment. Two patients had no cleft-like signal. The meniscii appeared normal in all patients. No evidence of pin tracts remained.

Our five-year follow up results suggest that the majority of the reattached articular cartilage does survive and these young, active patients’ knees have functioned well. The outcome in the longer term remains guarded. We recommend that internal fixation of these fragments with bioabsorbable pins, or other appropriate means of fixation, is a worthwhile procedure.

Many two-part fractures of the proximal humerus are treated conservatively due to the frequent failure of internal fixation. The current investigation examines the biomechanical properties of a unique plate versus a standard plate for internal fixation of proximal humerus fractures. The unique plate employs screws that thread into the plate, creating a multi-planer, fixed angle device. A cadaveric model was developed that relied on the rotator cuff musculature as the primary deforming force. The locking plate displayed significantly greater holding power on the humeral head (p=0.007). This may lead to more consistent results in two-part fractures treated with internal fixation.

The current investigation evaluates a unique plate designed to treat fractures of the proximal humerus. The plate employs screws that thread into the plate creating a fixed angle device. This plate was tested versus a standard cloverleaf plate.

The locking plate displayed greater holding power on the humeral head in the model tested. This may lead to decreased failure rates in two-part fractures treated with internal fixation.

Many two-part fractures of the proximal humerus are treated conservatively due to the frequent failure of common internal fixation modalities. This is done with the acceptance of possible non-union and loss of function. A more reliable method for stable internal fixation is therefore desirable.

A significant difference was found (p=0.007) with the locking plate displaying greater holding capability on the humeral head.

Eight pairs of preserved, cadaveric humeri were dissected and plated with either the locking plate or standard cloverleaf plate followed by an osteotomy at the surgical neck. A servo-hydraulic testing machine was then used to pull on the rotator cuff musculature until failure was achieved. Failure of the plate-head interface was reached in five of the eight pairs. Previous biomechanical studies have not taken into account the clinical mode of failure when testing internal fixation modalities for proximal humerus fractures. The current study has reproduced failure into varus by relying on the rotator cuff musculature as the primary deforming force.

Funding: All implants donated by Synthes, Canada

A variety of surgical procedures are reported for the management of large volumetric bone loss about the ankle. Although the success rates of these various methods are generally adequate for fusion, they commonly utilize autogenous bone graft and usually result in limb shortening. In seven patients a titanium spinal cage was utilized as a structural support augmented with bone graft for complex ankle arthrodesis. This technique offers immediate structural support, maintenance of limb length, and limits autogenous graft morbidity. Early results of ankle arthrodesis with this cage are encouraging with regard to fusion rates, aesthetic attribute and functional outcome.

To present a novel method of tibio-talar and tibio-calcaneal arthrodesis utilizing a titanium spinal cage for the management of bone loss.

Complex ankle arthrodesis management with a spinal cage offers reliable fusion rates (comparable with existing techniques) without limb shortening.

A variety of procedures are reported for the challenging management of bone loss in ankle arthrodesis. Although the success rates of these various methods are generally good, they commonly utilize large autogenous bone grafts and are subject to donor site morbidities. Most methods also require significant shortening with commensurate functional and aesthetic deficits.

Early results of ankle arthrodesis with a titanium spinal cage are encouraging with regard to fusion rates and functional outcome. A cohort of seven patients treated by this technique has resulted in a 100% fusion rate without loss of limb length. Hindfoot and SMFA scores have revealed good functional results for a usually devastating problem.

A titanium cage was utilized as a structural support for complex ankle arthrodesis with large volumetric bone loss. The cage was contoured at the time of each operation to fit in situ. This technique offers immediate structural support and reliable fusion while limiting autogenous graft morbidity and limb shortening.

We studied the results of multi-level surgical intervention for children with cerebral palsy.

Thirty patients, aged 7–16 years, with spastic diplegia (n=20), or spastic hemiplegia (n=10) were studied prospectively by gait analysis. Multilevel surgery included a combination of psoas lengthening, medial hamstring lengthening, rectus femoris transfer and gastrocnemius lengthening +/− foot surgery or femoral derotation osteotomies. Gait analyses were carried out pre-op and at 6 and 24 months post-op.

Children with spastic diplegia increased their walking velocity by an average of 20% at two years (p< 0.05). Mean stride length increased from 89cm pre-op to 102cm at two years (p< 0.05) with similar improvements in both groups of children. Maximum knee extension in stance improved from an average 17.5 degrees flexion pre-operatively to an average 5 degrees flexion postoperatively (p< 0.05). Peak knee flexion in swing was maintained and the timing improved. Peak ankle dorsiflexion in stance was unchanged following surgery but the timing of peak ankle dorsiflexion was normalised to late stance (from 24% of cycle pre-operatively to 48% of cycle post-operatively (norm = 48%). Average maximum hip extension in stance did not change. The mean anterior pelvic tilt did not change post-operatively. However, a number of children with spastic diplegia had increased anterior pelvic tilt post-operatively.

These results are similar to those reported internationally, with most improvement seen distally at the knee and ankle and less improvement at the hip. Increased anterior pelvic tilt was seen as a consequence of hamstring lengthening in some more involved patients.

Special Report: The clinical limitations of surgery in high-level athletes have not been established. Rehabilitation protocols based on animal experiments may be misleading. Current rehabilitation protocols are based on clinical experience rather than experimental science. Fitness for return to sport requires functional goals to be achieved by each athlete. Three common injuries in rugby will be considered to illustrate criteria for safe return to sport: Anterior cruciate ligament reconstruction, open shoulder reconstruction for anterior instability and isolated posterior cruciate ligament injury treated non-operatively

Deep vein thrombosis is uncommon in children but can occur given certain circumstances. Protein C deficiency has recently been described in a child with deep vein thrombosis complicating septic arthritis. We present four case reports of children who developed deep vein thrombosis in association with musculoskeletal sepsis. All had evidence of musculoskeletal sepsis and thrombosis. One child died. Prothrombotic screens were performed demonstrating normal haematological parameters in the three surviving children. The high mortality of deep vein thrombosis complicating musculoskeletal sepsis is emphasised, particularly the potential for septic embolic complications. Deep vein thrombosis should be considered in any child with musculoskeletal sepsis and generalised limb swelling. Early recognition and treatment can lead to favourable outcomes.