Diagnostic and operative codes are routinely collected for every patient admitted to hospital in the English NHS. Data on post-operative complications following foot and ankle surgery have not previously been available in large numbers. Data on symptomatic venous thromboembolism events and mortality within 90 days were extracted for patients undergoing fixation of an ankle fracture, first metatarsal osteotomy, hindfoot fusions and total ankle replacement over a period of 42 months. For ankle fracture surgery (45 949 patients), the rates of deep-vein thrombosis (DVT), pulmonary embolism and mortality were 0.12%, 0.17% and 0.37%, respectively. For first metatarsal osteotomy (33 626 patients), DVT, pulmonary embolism and mortality rates were 0.01%, 0.02% and 0.04%, and for hindfoot fusions (7033 patients) the rates were 0.03%, 0.11% and 0.11%, respectively. The rate of pulmonary embolism in 1633 total ankle replacement patients was 0.06%, and there were no recorded DVTs and no deaths. Statistical analysis could only identify risk factors for venous thromboembolic events of increasing age and multiple comorbidities following fracture surgery. Venous thromboembolism following foot and ankle surgery is extremely rare, but this subset of fracture patients is at a higher risk. However, there is no evidence that thromboprophylaxis reduces this risk, and these national data suggest that prophylaxis is not required in most of these patients.
This study was performed to determine whether
pure cancellous bone graft and Kirschner (K-) wire fixation were sufficient
to achieve bony union and restore alignment in scaphoid nonunion.
A total of 65 patients who underwent cancellous bone graft and K-wire
fixation were included in this study. The series included 61 men
and four women with a mean age of 34 years (15 to 72) and mean delay
to surgery of 28.7 months (3 to 240). The patients were divided
into an unstable group (A) and stable group (B) depending on the
pre-operative radiographs. Unstable nonunion was defined as a lateral
intrascaphoid angle >
45°, or a radiolunate angle >
10°. There were
34 cases in group A and 31 cases in group B. Bony union was achieved
in 30 patients (88.2%) in group A, and in 26 (83.9%) in group B
(p = 0.439). Comparison of the post-operative radiographs between
the two groups showed no significant differences in lateral intrascaphoid
angle (p = 0.657) and scaphoid length
(p = 0.670) and height (p = 0.193). The radiolunate angle was significantly
different
(p = 0.020) but the mean value in both groups was <
10°. Comparison
of the dorsiflexion and palmar flexion of movement of the wrist
and the mean Mayo wrist score at the final clinical visit in each
group showed no significant difference (p = 0.190, p = 0.587 and
p = 0.265, respectively). Cancellous bone graft and K-wire fixation
were effective in the treatment of stable and unstable scaphoid
nonunion. Cite this article:
Many orthopaedic surgeons believe that obese patients have a higher rate of peri-operative complications and a worse functional outcome than non-obese patients. There is, however, inconsistency in the literature supporting this notion. This study was performed to evaluate the effect of body mass index (BMI) on injury characteristics, the incidence of complications, and the functional outcome after the operative management of unstable ankle fractures. We retrospectively reviewed 279 patients (99 obese (BMI ≥ 30) and 180 non-obese (BMI <
30) patients who underwent surgical fixation of an unstable fracture of the ankle. We found that obese patients had a higher number of medical co-morbidities, and more Orthopaedic Trauma Association type B and C fracture types than non-obese patients. At two years from the time of injury, however, the presence of obesity did not affect the incidence of complications, the time to fracture union or the level of function. These findings suggest that obese patients should be treated in line with standard procedures, keeping in mind any known associated medical co-morbidities.
We report the incidence and intensity of persistent
pain in patients with an otherwise uncomplicated total ankle replacement
(TAR). Arthroscopic debridement was performed in selected cases
and the clinical outcome was analysed. Among 120 uncomplicated TARs, there was persistent pain with
a mean visual analogue scale (VAS) of 2.7 (0 to 8). The intensity
of pain decreased in 115 ankles (95.8%). Exercise or walking for
more than 30 minutes was the most common aggravating factor (62
ankles, 68.1%). The character of the pain was most commonly described
as dull (50 ankles, 54.9%) and located on the medial aspect of the
joint (43 ankles, 47.3%). A total of seven ankles (5.8%) underwent subsequent arthroscopy.
These patients had local symptoms and a VAS for pain ≥ 7 on exertion.
Impingement with fibrosis and synovitis was confirmed. After debridement,
the median VAS decreased from 7 to 3 and six patients were satisfied.
The median VAS for pain and the American Orthopaedic Foot and Ankle
Society score of the ankles after debridement was similar to that
of the uncomplicated TARs (p = 0.496 and p = 0.066, respectively). Although TAR reduces the intensity of pain, residual pain is
not infrequent even in otherwise uncomplicated TARs and soft-tissue
impingement is the possible cause. Cite this article:
Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.
We compared the intracompartmental pressures
(ICPs) of open and closed tibial fractures with the same injury pattern
in a rabbit model. In all, 20 six-month-old New Zealand White male
rabbits were used. They were randomised into two equal groups of
ten rabbits; an open fracture group (group 1) and a closed fracture
group (group 2). Each anaesthetised rabbit was subjected to a standardised
fracture of the proximal half of the right tibia using a custom-made
device. In order to create a grade II open fracture in group 1,
a 10 mm segment of fascia and periosteum was excised. The ICP in
the anterior compartment was monitored at six-hourly intervals for
48 hours. Although there was a statistically significant difference
in ICP values within each group (both p <
0.001), there was no
significant difference between the groups for all measurements (all
p ≥ 0.089). In addition, in both groups there was a statistically
significant increase in ICP within the first 24 hours, whereas there
was a statistically significant decrease within the second 24 hours
(p <
0.001 for both groups). We conclude that open tibial fractures
should be monitored for the development of acute compartment syndrome
to the same extent as closed fractures. Cite this paper:
In a randomised prospective study, 20 patients with intra-articular fractures of the distal radius underwent arthroscopically- and fluoroscopically-assisted reduction and external fixation plus percutaneous pinning. Another group of 20 patients with the same fracture characteristics underwent fluoroscopically-assisted reduction alone and external fixation plus percutaneous pinning. The patients were evaluated clinically and radiologically at follow-up of 24 months. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and modified Mayo wrist score were used at 3, 9, 12 and 24 months postoperatively. In the arthroscopically- and fluoroscopically-assisted group, triangular fibrocartilage complex tears were found in 12 patients (60%), complete or incomplete scapholunate ligament tears in nine (45%), and lunotriquetral ligament tears in four (20%). They were treated either arthroscopically or by open operation. Patients who underwent arthroscopically- and fluoroscopically-assisted treatment had significantly better supination, extension and flexion at all time points than those who had fluoroscopically-assisted surgery. The mean DASH scores were similar for both groups at 24 months, whereas the difference in the mean modified Mayo wrist scores remained statistically significant. Although the groups are small, it is clear that the addition of arthroscopy to the fluoroscopically-assisted treatment of intra-articular distal radius fractures improves the outcome. Better treatment of associated intra-articular injuries might also have been a reason for the improved outcome.
Intra-operative, peri-articular injection of
local anaesthesia is an increasingly popular way of controlling
pain following total knee replacement. The evidence from this study suggests that it is safe to use
peri-articular injection in combination with auto-transfusion of
blood from peri-articular drains during knee replacement surgery.
An intra-operative splash is a common occurrence in elective knee and hip replacement surgery and can potentially transmit bloodborne diseases, with devastating consequences. This study aimed to quantify the risk of a splash and to assess its correlation with body mass index, duration of surgery and the volume of lavage fluid used. Between December 2007 and April 2008, 62 consecutive patients (38 women, 24 men) undergoing an elective total knee or total hip replacement (TKR, THR) were recruited into the study (32 TKRs and 30 THRs) after appropriate consent. A splash occurred in all 62 cases. A THR had a slightly higher risk of a splash than a TKR, but this was not statistically significant (p = 0.27). The correlation between body mass index, duration of surgery and the amount of pulse lavage used with a splash was r = 0.013, (non-significant), r = 0.52, (significant) and r = 0.92 (highly significant), respectively. A high number of splashes are generated during a TKR and a THR. The simple visor mask fails to protect the surgeon, the assistant or the patient from the risk of a splash and reverse splash, respectively.
Patient specific cutting guides generated by
preoperative Magnetic Resonance Imaging (MRI) of the patient’s extremity
have been proposed as a method of improving the consistency of Total
Knee Arthroplasty (TKA) alignment and adding efficiency to the operative
procedure. The cost of this option was evaluated by quantifying the
savings from decreased operative time and instrument processing
costs compared to the additional cost of the MRI and the guide.
Coronal plane alignment was measured in an unselected consecutive
series of 200 TKAs, 100 with standard instrumentation and 100 with
custom cutting guides. While the cutting guides had significantly lower
total operative time and instrument processing time, the estimated
$322 savings was overwhelmed by the $1,500 additional cost of the
MRI and the cutting guide. All measures of coronal plane alignment
were equivalent between the two groups. The data does not currently
support the proposition that patient specific guides add value to
TKA.
The purpose of this study was to compare the
results of proximal and distal chevron osteotomy in patients with moderate
hallux valgus. We retrospectively reviewed 34 proximal chevron osteotomies without
lateral release (PCO group) and 33 distal chevron osteotomies (DCO
group) performed sequentially by a single surgeon. There were no
differences between the groups with regard to age, length of follow-up,
demographic or radiological parameters. The clinical results were
assessed using the American Orthopaedic Foot and Ankle Society (AOFAS)
scoring system and the radiological results were compared between
the groups. At a mean follow-up of 14.6 months (14 to 32) there were no significant
differences in the mean AOFAS scores between the DCO and PCO groups
(93.9 (82 to 100) and 91.8 (77 to 100), respectively; p = 0.176).
The mean hallux valgus angle, intermetatarsal angle and sesamoid
position were the same in both groups. The metatarsal declination
angle decreased significantly in the PCO group (p = 0.005) and the
mean shortening of the first metatarsal was significantly greater
in the DCO group (p <
0.001). We conclude that the clinical and radiological outcome after
a DCO is comparable with that after a PCO; longer follow-up would
be needed to assess the risk of avascular necrosis. Cite this article:
To review the current best surgical practice and detail a multi-disciplinary
approach that could further reduce joint replacement infection. Review of relevant literature indexed in PubMed.Objectives
Methods
Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69). The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union. Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation.
In a series of 1304 patients (1867 knees), the results of simultaneous and staged bilateral total knee arthroplasty were compared with each other and with unilateral total knee arthroplasty. The bilateral procedures had a significantly higher rate of complications than unilateral procedures, almost entirely because of thromboembolic problems. However, this did not correspond to an increase in mortality. If a bilateral procedure was indicated, then a simultaneous procedure had no increased risk over a staged procedure. There was no increase in cardiovascular complications, the rate of deep-vein thrombosis or pulmonary embolism or mortality. The rate of infection was lower with a bilateral procedure and the overall revision rate was less than 1% in all groups. The prosthesis functioned as well in all groups in the medium and longer term periods. We feel that simultaneous bilateral total knee arthroplasty is a safe and successful procedure when compared with a staged bilateral procedure. It also has the added benefit of single anaesthetic, reduced costs and decreased total recovery time when compared to a staged bilateral procedure. For these reasons it should be considered as an option in the presence of bilateral knee joint disease.
In this study we present our experience with
four generations of uncemented total knee arthroplasty (TKA) from Smith
&
Nephew: Tricon M, Tricon LS, Tricon II and Profix, focusing
on the failure rates correlating with each design change. Beginning
in 1984, 380 Tricon M, 435 Tricon LS, 305 Tricon 2 and 588 Profix
were implanted by the senior author. The rate of revision for loosening
was 1.1% for the Tricon M, 1.1% for the Tricon LS, 0.5% for the
Tricon 2 with a HA coated tibial component, and 1.3% for the Profix
TKA. No loosening of the femoral component was seen with the Tricon
M, Tricon LS or Tricon 2, with no loosening seen of the tibial component
with the Profix TKA. Regarding revision for wear, the incidence
was 13.1% for the Tricon M, 6.6% for the Tricon LS, 2.3% for the
Tricon 2, and 0% for the Profix. These results demonstrate that
improvements in the design of uncemented components, including increased
polyethylene thickness, improved polyethylene quality, and the introduction
of hydroxyapatite coating, has improved the outcomes of uncemented
TKA over time.
We systematically reviewed the published literature
on the complications of closing wedge high tibial osteotomy for
the treatment of unicompartmental osteoarthritis of the knee. Publications
were identified using the Cochrane Library, MEDLINE, EMBASE and
CINAHL databases up to February 2012. We assessed randomised (RCTs), controlled
group clinical (CCTs) trials, case series in publications associated
with closing wedge osteotomy of the tibia in patients with osteoarthritis
of the knee and finally a Cochrane review. Many of these trials
included comparative studies (opening wedge
We describe a new surgical technique for the
treatment of lacerations of the extensor tendon in zone I, which involves
a tenodesis using a length of palmaris longus tendon one-quarter
of its width. After exposing the dorsal aspect of the distal interphalangeal
joint and harvesting the tendon, a 1.5 mm drill bit is passed through
the insertion of the extensor tendon into the distal phalanx where
it penetrates through the skin of the pulp of the digit. The palmaris
longus tendon is threaded through the drill hole from dorsal to
ventral and the ventral end is tied in a simple knot and trimmed.
The palmaris longus tendon is then sutured to the extensor tendon
close to its insertion, and also at the middle of the middle phalanx. The operation was undertaken on 67 patients: 27 with an acute
injury and 40 patients with a chronic mallet deformity. One finger
(or the thumb) was involved in each patient. At a mean follow-up
of 12 months (6 to 18), 66 patients (98.5%) received excellent or
good results according to both the American Society for Surgery
of the Hand (ASSH) classification and Miller’s classification. Tenodesis using palmaris longus tendon after complete division
of an extensor tendon in zone 1 is a reliable form of treatment
for isolated acute or chronic ruptures.
We present the outcome of 47 Souter-Strathclyde replacements of the elbow with a mean follow-up of 82 months (12 to 129). The clinical results were assessed using a condition-specific outcome measure. The mean total score (maximum 100) before the operation was 47.21 and improved to 79.92 (p <
0.001). The mean pain score (maximum 50) improved from 21.41 to 46.70 (p <
0.001) and the mean functional component of the score (maximum 30) from 11.19 to 18.65 (p <
0.001). There was negligible change in the score for the range of movement although a significant improvement in mean flexion from 124° to 136° was noted (p <
0.001). Revision surgery was required in four patients, for dislocation, wound dehiscence and early infection in one, late infection in two and aseptic loosening in one. The cumulative survival was 75% at nine years for all causes of failure and 97% at ten years for aseptic loosening alone. Our study demonstrates the value of the Souter-Strathclyde total elbow arthroplasty in providing relief from pain and functional improvement in rheumatoid patients.
The August 2012 Wrist &
Hand Roundup360 looks at: the Herbert ulnar head prosthesis; the five-year outcome for wrist arthroscopic surgery; four-corner arthrodesis with headless screws; balloon kyphoplasty for Kienböck's disease; Mason Type 2 radial head fractures; local infiltration and intravenous regional anaesthesia for endoscopic carpal tunnel release; perilunate injuries; and replanting the amputated fingertip.
We reviewed the clinical details and radiographs of 52 patients with ballistic fractures of the femur admitted to the International Committee of the Red Cross Hospital in Kenya (Lopiding), who had sustained injuries in neighbouring Sudan. In all cases there had been a significant delay in the initial surgery (>
24 hours), and all patients were managed without stabilisation of the fracture by internal or external fixation. Of the 52 patients, three required an amputation for persisting infection of the fracture site despite multiple debridements. A further patient was treated by an excision arthroplasty of the hip, but this was carried out at the initial operation as a part of the required debridement. All of the remaining 48 fractures healed. Four patients needed permanent shoe adaptation because of limb shortening of functional significance. Although we do not advocate delaying treatment or using traction instead of internal or external fixation, we have demonstrated that open femoral fractures can heal despite limited resources.