The purpose of this study was to report the experience of dynamic
intraligamentary stabilisation (DIS) using the Ligamys device for
the treatment of acute ruptures of the anterior cruciate ligament
(ACL). Between March 2011 and April 2012, 50 patients (34 men and 16
women) with an acute rupture of the ACL underwent primary repair
using this device. The mean age of the patients was 30 years (18
to 50). Patients were evaluated for laxity, stability, range of
movement (ROM), Tegner, Lysholm, International Knee Documentation Committee
(IKDC) and visual analogue scale (VAS) scores over a follow-up period
of two years.Aims
Patients and Methods
The optimal timing of total knee replacement
(TKR) in patients with osteoarthritis, in relation to the severity
of disease, remains controversial. This prospective study was performed
to investigate the effect of the severity of osteoarthritis and
other commonly available pre- and post-operative clinical parameters
on the clinical outcome in a consecutive series of cemented TKRs.
A total of 176 patients who underwent unilateral TKR were included
in the study. Their mean age was 68 years (39 to 91), 63 (36%) were
male and 131 knees (74%) were classified as grade 4 on the Kellgren–Lawrence
osteoarthritis scale. A total of 154 patients (87.5%) returned for
clinical review 12 months post-operatively, at which time the outcome
was assessed using the Knee Society score. A low radiological severity of osteoarthritis was not associated
with pain 12 months post-operatively. However, it was significantly
associated with an inferior level of function (p = 0.007), implying
the need for increased focus on all possible reasons for pain in
the knee and the forms of conservative treatment which are available
for patients with lower radiological severity of osteoarthritis. Cite this article:
We review our experience of Coonrad-Morrey total elbow arthroplasty
(TEA) for fractures of the distal humerus in non-rheumatoid patients
with a minimum of ten years follow-up. TEA through a triceps splitting approach was peformed in 37 non-rheumatoid
patients for a fracture of the distal humerus between 1996 and 2004.
One patient could not be traced and 17 had died before the tenth
anniversary of their surgery. This left 19 patients with a minimum
follow-up of ten years to form the study group. Of these, 13 patients
were alive at the time of final review. The other six had died,
but after the tenth anniversary of their elbow arthroplasty. Their
clinical and radiological data were included in the study. Aims
Patients and Methods
In this study we randomised 140 patients who
were due to undergo primary total knee arthroplasty (TKA) to have the
procedure performed using either patient-specific cutting guides
(PSCG) or conventional instrumentation (CI). The primary outcome measure was the mechanical axis, as measured
at three months on a standing long-leg radiograph by the hip–knee–ankle
(HKA) angle. This was undertaken by an independent observer who
was blinded to the instrumentation. Secondary outcome measures were
component positioning, operating time, Knee Society and Oxford knee
scores, blood loss and length of hospital stay. A total of 126 patients (67 in the CI group and 59 in the PSCG
group) had complete clinical and radiological data. There were 88
females and 52 males with a mean age of 69.3 years (47 to 84) and
a mean BMI of 28.6 kg/m2 (20.2 to 40.8). The mean HKA
angle was 178.9° (172.5 to 183.4) in the CI group and 178.2° (172.4
to 183.4) in the PSCG group (p = 0.34). Outliers were identified
in 22 of 67 knees (32.8%) in the CI group and 19 of 59 knees (32.2%)
in the PSCG group (p = 0.99). There was no significant difference
in the clinical results (p = 0.95 and 0.59, respectively). Operating time,
blood loss and length of hospital stay were not significantly reduced
(p = 0.09, 0.58 and 0.50, respectively) when using PSCG. The use of PSCG in primary TKA did not reduce the proportion
of outliers as measured by post-operative coronal alignment. Cite this article:
Total wrist arthrodesis (TWA) produces a spectrum of outcomes.
We investigated this by reviewing 77 consecutive TWA performed for
inflammatory and post-traumatic arthropathies, wrist instability
and as a salvage procedure. All operations were performed by a single surgeon using a specifically
designed pre-contoured dorsally applied non-locking wrist arthrodesis
plate at a single centre. Aims
Patients and Methods
An extensive review of the spinal and arthroplasty
literature was undertaken to evaluate the effectiveness of local
antibiotic irrigation during surgery. The efficacy of antibiotic
irrigation for the prevention of acute post-operative infection
after total joint arthroplasty was evaluated retrospectively in
2293 arthroplasties (1990 patients) between January 2004 and December
2013. The mean follow-up was 73 months (20 to 139). One surgeon
performed all the procedures with minimal post-operative infection. The intra-operative protocol included an irrigation solution
of normal saline with vancomycin 1000 mg/l and polymyxin 250 000
units/l at the rate of 2 l per hour. No patient required re-admission
for primary infection or further antibiotic treatment. Two morbidly obese
patients (two total hip arthroplasties) developed subcutaneous fat
necrosis requiring debridement and one was revised because the deep
capsular sutures were contaminated by the draining subcutaneous
haematoma. One patient who had undergone total knee arthroplasty
had unrecognised damage to the lateral superior geniculate artery
and developed a haematoma that became infected secondarily four
months after the surgery and underwent revision. The use of antibiotic irrigation during arthroplasty surgery
has been highly effective for the prevention of infection in the
author’s practice. However, it should be understood that any routine
prophylactic use of antibiotics may result in resistant organisms,
and the wise stewardship of the use of antibiotics is an important
part of surgical practice. Cite this article:
In our department we use an enhanced recovery
protocol for joint replacement of the lower limb. This incorporates the
use of intravenous tranexamic acid (IVTA; 15 mg/kg) at the induction
of anaesthesia. Recently there was a national shortage of IVTA for
18 weeks; during this period all patients received an oral preparation
of tranexamic acid (OTA; 25 mg/kg). This retrospective study compares
the safety (surgical and medical complications) and efficacy (reduction
of transfusion requirements) of OTA and IVTA. During the study period
a total of 2698 patients received IVTA and 302 received OTA. After
adjusting for a range of patient and surgical factors, the odds
ratio (OR) of receiving a blood transfusion was significantly higher
with IVTA than with OTA (OR 0.48 (95% confidence interval 0.26 to
0.89), p = 0.019), whereas the safety profile was similar, based
on length of stay, rate of readmission, return to theatre, deep
infection, stroke, gastrointestinal bleeding, myocardial infarction,
pneumonia, deep-vein thrombosis and pulmonary embolism. The financial
benefit of OTA is £2.04 for a 70 kg patient; this is amplified when
the cost saving associated with significantly fewer blood transfusions
is considered. Although the number of patients in the study is modest, this
work supports the use of OTA, and we recommend that a randomised
trial be undertaken to compare the different methods of administering
tranexamic acid. Cite this article:
We examined the outcomes and levels of patient
satisfaction in 202 consecutive cases of ultrasound-guided supraclavicular
brachial plexus block (SBPB) in upper limb surgery performed between
September 2007 and March 2010. All blocks were performed by orthopaedic surgeons using ultrasound
visualisation with a high-frequency linear probe. The probe was
placed in the coronal–oblique plane in the supraclavicular fossa,
and the puncture was ‘in-plane’ from lateral to medial. Most of
the blocks were performed with 0.75% ropivacaine/1% lidocaine (1:1),
with or without adrenaline in 1:200 000 dilution. In 201 patients
(99.5%) the brachial plexus block permitted surgery without conversion
to general anaesthesia. The mean procedure time for block was 3.9
min (2 to 12), the mean waiting time for surgery was 34.1 min (10
to 64), the mean surgical time was 75.2 min (6 to 232), and the
mean duration of post-anaesthetic analgesia was 437 min (171 to
992). A total of 20 patients (10%) developed a transient Horner’s syndrome.
No nerve injury, pneumothorax, arterial puncture or systemic anaesthetic
toxicity were recorded. Most patients (96.7%) were satisfied with
ultrasound-guided SBPB. This study demonstrates the efficacy and
safety of ultrasound-guided SBPB for orthopaedic surgery on the
upper limb. Cite this article:
The pre-operative level of haemoglobin is the strongest predictor
of the peri-operative requirement for blood transfusion after total
knee arthroplasty (TKA). There are, however, no studies reporting
a value that could be considered to be appropriate pre-operatively. This study aimed to identify threshold pre-operative levels of
haemoglobin that would predict the requirement for blood transfusion
in patients who undergo TKA. Analysis of receiver operator characteristic (ROC) curves of
2284 consecutive patients undergoing unilateral TKA was used to
determine gender specific thresholds predicting peri-operative transfusion
with the highest combined sensitivity and specificity (area under
ROC curve 0.79 for males; 0.78 for females).Aims
Patients and Methods
The osteoinductive properties of demineralised
bone matrix have been demonstrated in animal studies. However, its therapeutic
efficacy has yet to be proven in humans. The clinical properties
of AlloMatrix, an injectable calcium-based demineralised bone matrix
allograft, were studied in a prospective randomised study of 50
patients with an isolated unstable distal radial fracture treated
by reduction and Kirschner (K-) wire fixation. A total of 24 patients
were randomised to the graft group (13 men and 11 women, mean age
42.3 years (20 to 62)) and 26 to the no graft group (8 men and 18
women, mean age 45.0 years (17 to 69)). At one, three, six and nine weeks, and six and 12 months post-operatively,
patients underwent radiological evaluation, assessments for range
of movement, grip and pinch strength, and also completed the Disabilities
of Arm, Shoulder and Hand questionnaire. At one and six weeks and
one year post-operatively, bone mineral density evaluations of both
wrists were performed. No significant difference in wrist function and speed of recovery,
rate of union, complications or bone mineral density was found between
the two groups. The operating time was significantly higher in the
graft group (p = 0.004). Radiologically, the reduction parameters
remained similar in the two groups and all AlloMatrix extraosseous leakages
disappeared after nine weeks. This prospective randomised controlled trial did not demonstrate
a beneficial effect of AlloMatrix demineralised bone matrix in the
treatment of this category of distal radial fractures treated by
K-wire fixation. Cite this article:
The types of explosive devices used in warfare
and the pattern of war wounds have changed in recent years. There has,
for instance, been a considerable increase in high amputation of
the lower limb and unsalvageable leg injuries combined with pelvic
trauma. The conflicts in Iraq and Afghanistan prompted the Department
of Military Surgery and Trauma in the United Kingdom to establish
working groups to promote the development of best practice and act
as a focus for research. In this review, we present lessons learnt in the initial care
of military personnel sustaining major orthopaedic trauma in the
Middle East.
The aim of this study was to report a single surgeon series of
consecutive patients with moderate hallux valgus managed with a
percutaneous extra-articular reverse-L chevron (PERC) osteotomy. A total of 38 patients underwent 45 procedures. There were 35
women and three men. The mean age of the patients was 48 years (17
to 69). An additional percutaneous Akin osteotomy was performed
in 37 feet and percutaneous lateral capsular release was performed
in 22 feet. Clinical and radiological assessments included the type
of forefoot, range of movement, the American Orthopedic Foot and
Ankle (AOFAS) score, a subjective rating and radiological parameters. The mean follow-up was 59.1 months (45.9 to 75.2). No patients
were lost to follow-up.Aims
Patients and Methods
Peri-prosthetic infection is amongst the most
common causes of failure following total knee replacement (TKR).
In the presence of established infection, thorough joint debridement
and removal of all components is necessary following which new components
may be implanted. This can be performed in one or two stages; two-stage revision
with placement of an interim antibiotic-loaded spacer is regarded
by many to be the standard procedure for eradication of peri-prosthetic
joint infection. We present our experience of a consecutive series of 50 single-stage
revision TKRs for established deep infection performed between 1979
and 2010. There were 33 women and 17 men with a mean age at revision
of 66.8 years (42 to 84) and a mean follow-up of 10.5 years (2 to
24). The mean time between the primary TKR and the revision procedure
was 2.05 years (1 to 8). Only one patient required a further revision for recurrent infection,
representing a success rate of 98%. Nine patients required further
revision for aseptic loosening, according to microbiological testing
of biopsies taken at the subsequent surgery. Three other patients
developed a further septic episode but none required another revision. These results suggest that a single-stage revision can produce
comparable results to a two-stage revision. Single-stage revision
offers a reduction in costs as well as less morbidity and inconvenience
for patients. Cite this article:
Minimally invasive total knee replacement (MIS-TKR)
has been reported to have better early recovery than conventional
TKR. Quadriceps-sparing (QS) TKR is the least invasive MIS procedure,
but it is technically demanding with higher reported rates of complications
and outliers. This study was designed to compare the early clinical
and radiological outcomes of TKR performed by an experienced surgeon
using the QS approach with or without navigational assistance (NA),
or using a mini-medial parapatellar (MP) approach. In all, 100 patients
completed a minimum two-year follow-up: 30 in the NA-QS group, 35
in the QS group, and 35 in the MP group. There were no significant
differences in clinical outcome in terms of ability to perform a
straight-leg raise at 24 hours (p = 0.700), knee score (p = 0.952),
functional score (p = 0.229) and range of movement (p = 0.732) among
the groups. The number of outliers for all three radiological parameters
of mechanical axis, frontal femoral component alignment and frontal
tibial component alignment was significantly lower in the NA-QS
group than in the QS group (p = 0.008), but no outlier was found
in the MP group. In conclusion, even after the surgeon completed a substantial
number of cases before the commencement of this study, the supplementary
intra-operative use of computer-assisted navigation with QS-TKR
still gave inferior radiological results and longer operating time,
with a similar outcome at two years when compared with a MP approach. Cite this article:
We prospectively randomised 78 patients into two groups, ‘drains’ or ‘no drains’ to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient. Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.
Oxidised zirconium was introduced as a material for femoral components
in total knee arthroplasty (TKA) as an attempt to reduce polyethylene
wear. However, the long-term survival of this component is not known. We performed a retrospective review of a prospectively collected
database to assess the ten year survival and clinical and radiological
outcomes of an oxidised zirconium total knee arthroplasty with the
Genesis II prosthesis. The Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS)
and a patient satisfaction scale were used to assess outcome.Aims
Methods
We report a new surgical technique for the treatment
of traumatic dislocation of the carpometacarpal (CMC) joint of the
thumb. This is a tenodesis which uses part of the flexor carpi radialis. Between January 2010 and August 2013, 13 patients with traumatic
instability of the CMC joint of the thumb were treated using this
technique. The mean time interval between injury and ligament reconstruction
was 13 days (0 to 42). The mean age of the patients at surgery was
38 years: all were male. At a mean final follow-up of 26 months (24 to 29), no patient
experienced any residual instability. The mean total palmar abduction
of the CMC joint of the thumb was 61° and the mean radial abduction
65° The mean measurements for the uninjured hand were 66° (60° to
73°) and 68° (60° to 75°), respectively. The mean Kapandji thumb
opposition score was 8.5° (8° to 9°). The mean pinch and grip strengths
of the hand were 6.7 kg (3.4 to 8.2) and 40 kg (25 to 49), respectively.
The mean Disabilities of the Arm, Shoulder, and Hand questionnaire
score was 3 (1 to 6). Based on the Smith and Cooney score, we obtained
a mean score of 85 (75 to 95), which included four excellent, seven
good, and two fair results. Our technique offers an alternative method of treating traumatic
dislocation of the CMC joint of the thumb: it produces a stable
joint and acceptable hand function. Cite this article:
While many forefoot procedures may be performed
as a day case, there are no specific guidelines as to which procedures
are suitable. This study assessed the early post-operative pain
after forefoot surgery performed a day case, compared with conventional
inpatient management. A total of 317 consecutive operations performed by a single surgeon
were included in the study. Those eligible according to the criteria
of the French Society of Anaesthesia (SFAR) were managed as day
cases (127; 40%), while the remainder were managed as inpatients. The groups were comparable in terms of gender, body mass index
and smoking status, although the mean age of the inpatients was
higher (p <
0.001) and they had higher mean American Society
of Anaesthesiologists scores (p = 0.002). The most severe daily
pain was on the first post-operative day, but the levels of pain
were similar in the two groups; (4.2/10, Apart from the most complicated cases, forefoot surgery can safely
be performed as a day case without an increased risk of pain, or
complications compared with management as an inpatient. Cite this article:
Total knee arthroplasty (TKA) is a major orthopaedic
intervention. The length of a patient's stay has been progressively
reduced with the introduction of enhanced recovery protocols: day-case
surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case
TKA. These constraints may be social, linked to patient’s comorbidities,
or due to surgery-related adverse events (e.g. pain, post-operative
nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and
multimodal opioid-sparing analgesia, day-case TKA might be achievable
in a limited group of patients. The younger, male patient without
comorbidities and with an excellent social network around him might
be a candidate. Demographic changes, effective recovery programmes and less invasive
surgical techniques such as unicondylar knee arthroplasty, may increase
the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced
against any increase in morbidity and mortality and the cost of
advanced follow-up at a distance with new technology. These factors
need to be evaluated before adopting this ultimate ‘fast-track’
approach. Cite this article:
