The Essex-Lopresti injury (ELI) of the forearm
is a rare and serious condition which is often overlooked, leading
to a poor outcome. The purpose of this retrospective case study was to establish
whether early surgery can give good medium-term results. From a group of 295 patients with a fracture of the radial head,
12 patients were diagnosed with ELI on MRI which confirmed injury
to the interosseous membrane (IOM) and ligament (IOL). They were
treated by reduction and temporary Kirschner (K)-wire stabilisation
of the distal radioulnar joint (DRUJ). In addition, eight patients
had a radial head replacement, and two a radial head reconstruction. All patients were examined clinically and radiologically 59 months
(25 to 90) after surgery when the mean Mayo Modified Wrist Score
(MMWS) was 88.4 (78 to 94), the mean Mayo Elbow Performance Scores
(MEPS) 86.7 (77 to 95) and the mean disabilities of arm, shoulder
and hand (DASH) score 20.5 (16 to 31): all of these indicate a good outcome. In case of a high index of suspicion for ELI in patients with
a radial head fracture, we recommend the following: confirmation
of IOM and IOL injury with an early MRI scan; early surgery with
reduction and temporary K-wire stabilisation of the DRUJ; preservation
of the radial head if at all possible or replacement if not, and
functional bracing in supination. This will increase the prospect
of a good result, and avoid the complications of a missed diagnosis
and the difficulties of late treatment. Cite this article:
The October 2015 Shoulder &
Elbow Roundup360 looks at: Culture time important in propionibacterium acnes; Microvascularisation of the cuff footprint; Degenerative cuff tears: evidence for repair; Middle ground in distal humeral fractures?; Haste needed in elbow heterotopic ossification; Iatrogenic frozen shoulder; Salvage of failed humeral fixation
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:
Two types of fracture, early and late, have been
reported following limb lengthening in patients with achondroplasia (ACH)
and hypochondroplasia (HCH). We reviewed 25 patients with these conditions who underwent 72
segmental limb lengthening procedures involving the femur and/or
tibia, between 2003 and 2011. Gender, age at surgery, lengthened
segment, body mass index, the shape of the callus, the amount and
percentage of lengthening and the healing index were evaluated to determine
predictive factors for the occurrence of early (within three weeks
after removal of the fixation pins) and late fracture (>
three weeks
after removal of the pins). The Mann‑Whitney U test and Pearson’s
chi-squared test for univariate analysis and stepwise regression
model for multivariate analysis were used to identify the predictive factor
for each fracture. Only one patient (two tibiae) was excluded from
the analysis due to excessively slow formation of the regenerate,
which required supplementary measures. A total of 24 patients with
70 limbs were included in the study. There were 11 early fractures in eight patients. The shape of
the callus (lateral or central callus) was the only statistical
variable related to the occurrence of early fracture in univariate
and multivariate analyses. Late fracture was observed in six limbs
and the mean time between removal of the fixation pins and fracture
was 18.3 weeks (3.3 to 38.4). Lengthening of the tibia, larger healing
index, and lateral or central callus were related to the occurrence
of a late fracture in univariate analysis. A multivariate analysis
demonstrated that the shape of the callus was the strongest predictor
for late fracture (odds ratio: 19.3, 95% confidence interval: 2.91
to 128). Lateral or central callus had a significantly larger risk
of fracture than fusiform, cylindrical, or concave callus. Radiological monitoring of the shape of the callus during distraction
is important to prevent early and late fracture of lengthened limbs
in patients with ACH or HCH. In patients with thin callus formation,
some measures to stimulate bone formation should be considered as
early as possible. Cite this article:
Treatment for osteoarthritis (OA) has traditionally
focused on joint replacement for end-stage disease. An increasing number
of surgical and pharmaceutical strategies for disease prevention
have now been proposed. However, these require the ability to identify
OA at a stage when it is potentially reversible, and detect small
changes in cartilage structure and function to enable treatment
efficacy to be evaluated within an acceptable timeframe. This has
not been possible using conventional imaging techniques but recent
advances in musculoskeletal imaging have been significant. In this
review we discuss the role of different imaging modalities in the
diagnosis of the earliest changes of OA. The increasing number of
MRI sequences that are able to non-invasively detect biochemical
changes in cartilage that precede structural damage may offer a
great advance in the diagnosis and treatment of this debilitating
condition. Cite this article:
Sciatic nerve palsy following total hip arthroplasty
(THA) is a relatively rare yet potentially devastating complication.
The purpose of this case series was to report the results of patients
with a sciatic nerve palsy who presented between 2000 and 2010,
following primary and revision THA and were treated with neurolysis.
A retrospective review was made of 12 patients (eight women and
four men), with sciatic nerve palsy following THA. The mean age
of the patients was 62.7 years (50 to 72; standard deviation 6.9).
They underwent interfascicular neurolysis for sciatic nerve palsy,
after failing a trial of non-operative treatment for a minimum of
six months. Following surgery, a statistically and clinically significant
improvement in motor function was seen in all patients. The mean
peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1
to 5) (p <
0.001). The mean tibial nerve motor function score
improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean
improvement in sensory function was a clinically negligible 1 out
of 5 in all patients. In total, 11 patients reported improvement
in their pain following surgery. We conclude that neurolysis of the sciatic nerve has a favourable
prognosis in patients with a sciatic nerve palsy following THA.
Our findings suggest that surgery should not be delayed for >
12
months following injury. Cite this article:
The aim of this study was to determine whether there is any significant
difference in temporal measurements of pain, function and rates
of re-tear for arthroscopic rotator cuff repair (RCR) patients compared
with those patients undergoing open RCR. This study compared questionnaire- and clinical examination-based
outcomes over two years or longer for two series of patients who
met the inclusion criteria: 200 open RCR and 200 arthroscopic RCR
patients. All surgery was performed by a single surgeon. Objectives
Methods
The aim of this study was to determine the effect
of radial extracorporeal shock-wave therapy (rESWT) on patients with
chronic tendinitis of the rotator cuff. This was a randomised controlled
trial in which 82 patients (mean age 47 years (24 to 67)) with chronic
tendinitis diagnosed clinically were randomly allocated to a treatment
group who received low-dose rESWT (three sessions at an interval
10 to 14 days, 2000 pulses, 0.11 mJ/mm2, 8 Hz) or to
a placebo group, with a follow-up of six months. The patients and
the treating orthopaedic surgeon, who were both blinded to the treatment,
evaluated the results. A total of 44 patients were allocated to
the rESWT group and 38 patients to the placebo group. A visual analogue
scale (VAS) score for pain, a Constant–Murley (CMS) score and a simple
shoulder test (SST) score significantly improved in both groups
at three and six months compared with baseline (all p ≤ 0.012).
The mean VAS was similar in both groups at three (p = 0.43) and
six months (p = 0.262). Also, the mean CMS and SST scores were similar
in both groups at six months (p = 0.815 and p = 0.834, respectively). It would thus seem that low-dose rESWT does not reduce pain or
improve function in patients chronic rotator cuff tendinitis compared
with placebo treatment. Cite this article:
The recognition of hips at risk of displacement
in children with cerebral palsy (CP) is a difficult problem for
the orthopaedic surgeon. The Gross Motor Function Classification
System (GMFCS) and head–shaft angle (HSA) are prognostic factors
for hip displacement. However, reference values for HSA are lacking.
This study describes and compares the development of HSA in normal
hips and children with CP. We selected 33 children from a retrospective cohort with unilateral
developmental dysplasia of the hip (DDH) (five boys, 28 girls) and
50 children (35 boys, 15 girls) with CP with GMFCS levels II to
V. HSA of normal developing hips was measured at the contralateral
hip of unilateral DDH children (33 hips) and HSA of CP children
was measured in both hips (100 hips). Measurements were taken from
the radiographs of the children at age two, four and seven years.
The normal hip HSA decreased by 2° per year (p <
0.001). In children
with CP with GMFCS levels II and III HSA decreased by 0.6° (p =
0.046) and 0.9° (p = 0.049) per year, respectively. The HSA did
not alter significantly in GMFCS levels IV and V. Between the ages of two and eight years, the HSA decreases in
normal hips and CP children with GMFCS level, II to III but does
not change in GMFCS levels IV to V. As HSA has a prognostic value
for hip displacement, these reference values may help the orthopaedic
surgeon to predict future hip displacement in children with CP. Cite this article:
We compared the incidence of pseudotumours after
large head metal-on-metal (MoM) total hip arthroplasty (THA) with
that after conventional metal-on-polyethylene (MoP) THA and assessed
the predisposing factors to pseudotumour formation. From a previous randomised controlled trial which compared large
head (38 mm to 60 mm) cementless MoM THA with conventional head
(28 mm) cementless MoP THA, 93 patients (96 THAs: 41 MoM (21 males,
20 females, mean age of 64 years, standard deviation ( The incidence of pseudotumours, measured using a standardised
CT protocol was 22 (53.7%) after MoM THA and 12 (21.8%) after MoP
THA. Women with a MoM THA were more likely to develop a pseudotumour
than those with a MoP THA (15 Contrary to popular belief, pseudotumours occur frequently around
MoP THAs. Women with a MoM THA and an elevated cobalt level are
at greatest risk. In this study, pseudotumours had no effect on
the functional outcome after either large head MoM or conventional
MoP THA. Cite this article:
Metal artefact reduction (MAR) MRI is now widely
considered to be the standard for imaging metal-on-metal (MoM) hip
implants. The Medicines and Healthcare Products Regulatory Agency
(MHRA) has recommended cross-sectional imaging for all patients
with symptomatic MoM bearings. This paper describes the natural
history of MoM disease in a 28 mm MoM total hip replacement (THR)
using MAR MRI. Inclusion criteria were patients with MoM THRs who had
not been revised and had at least two serial MAR MRI scans. All
examinations were reported by an experienced observer and classified
as A (normal), B (infection) or C1–C3 (mild, moderate, severe MoM-related
abnormalities). Between 2002 and 2011 a total of 239 MRIs were performed
on 80 patients (two to four scans per THR); 63 initial MRIs (61%)
were normal. On subsequent MRIs, six initially normal scans (9.5%)
showed progression to a disease state; 15 (15%) of 103 THRs with
sequential scans demonstrated worsening disease on subsequent imaging. Most patients with a MoM THR who do not undergo early revision
have normal MRI scans. Late progression (from normal to abnormal,
or from mild to more severe MoM disease) is not common and takes
place over several years. Cite this article:
The April 2014 Shoulder &
Elbow Roundup360 looks at: arthroscopic capsular release successful after six months; MCIC in cuff surgery; analgesia following arthroscopic cuff repair; platelet-rich fibrin; and cuff tear and suprascapular nerve neuropathy?
The August 2015 Foot &
Ankle Roundup360 looks at: Is orthosis more important than physio in tibialis posterior deficiency?; Radiographic evaluation of ankle injury; Sciatic catheter quite enough!; A fresh look at avascular necrosis of the talus; Total ankle and VTE; Outcomes of posterior malleolar fracture; Absorbable sutures in the Achilles tendon; Lisfranc injuries under the spotlight
We performed a systematic review and meta-analysis
to compare the efficacy of intermittent mechanical compression combined
with pharmacological thromboprophylaxis, against either mechanical
compression or pharmacological prophylaxis in preventing deep-vein
thrombosis (DVT) and pulmonary embolism in patients undergoing hip
or knee replacement. A total of six randomised controlled trials,
evaluating a total of 1399 patients, were identified. In knee arthroplasty,
the rate of DVT was reduced from 18.7% with anticoagulation alone
to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03;
number needed to treat: seven). There was moderate, albeit non-significant,
heterogeneity (I2 = 42%). In hip replacement, there was
a non-significant reduction in DVT from 8.7% with mechanical compression
alone to 7.2% with additional pharmacological prophylaxis (RR 0.84)
and a significant reduction in DVT from 9.7% with anticoagulation
alone to 0.9% with additional mechanical compression (RR 0.17, p
<
0.001; number needed to treat: 12), with no heterogeneity (I2 =
0%). The included studies had insufficient power to demonstrate
an effect on pulmonary embolism. We conclude that the addition of intermittent mechanical leg
compression augments the efficacy of anticoagulation in preventing
DVT in patients undergoing both knee and hip replacement. Further
research on the role of combined modalities in thromboprophylaxis
in joint replacement and in other high-risk situations, such as fracture
of the hip, is warranted.
Lateral epicondylitis, or ’tennis elbow’, is
a common condition that usually affects patients between 35 and
55 years of age. It is generally self-limiting, but in some patients
it may continue to cause persistent symptoms, which can be refractory
to treatment. This review discusses the mechanism of disease, symptoms
and signs, investigations, current management protocols and potential
new treatments. Cite this article:
The early failure and revision of bimodular primary
total hip arthroplasty prostheses requires the identification of the
risk factors for material loss and wear at the taper junctions through
taper wear analysis. Deviations in taper geometries between revised
and pristine modular neck tapers were determined using high resolution
tactile measurements. A new algorithm was developed and validated
to allow the quantitative analysis of material loss, complementing
the standard visual inspection currently used. The algorithm was applied to a sample of 27 retrievals ( Cite this article:
The effects of disease progression and common tendinopathy treatments
on the tissue characteristics of human rotator cuff tendons have
not previously been evaluated in detail owing to a lack of suitable
sampling techniques. This study evaluated the structural characteristics
of torn human supraspinatus tendons across the full disease spectrum,
and the short-term effects of subacromial corticosteroid injections
(SCIs) and subacromial decompression (SAD) surgery on these structural
characteristics. Samples were collected inter-operatively from supraspinatus tendons
containing small, medium, large and massive full thickness tears
(n = 33). Using a novel minimally invasive biopsy technique, paired
samples were also collected from supraspinatus tendons containing
partial thickness tears either before and seven weeks after subacromial
SCI (n = 11), or before and seven weeks after SAD surgery (n = 14).
Macroscopically normal subscapularis tendons of older patients (n
= 5, mean age = 74.6 years) and supraspinatus tendons of younger
patients (n = 16, mean age = 23.3) served as controls. Ultra- and
micro-structural characteristics were assessed using atomic force
microscopy and polarised light microscopy respectively. Objectives
Methods
We investigated the changes seen on serial metal
artefact reduction magnetic resonance imaging scans (MARS-MRI) of
metal-on-metal total hip arthroplasties (MoM THAs). In total 155
THAs, in 35 male and 100 female patients (mean age 70.4 years, 42
to 91), underwent at least two MRI scans at a mean interval of 14.6
months (2.6 to 57.1), at a mean of 48.2 months (3.5 to 93.3) after
primary hip surgery. Scans were graded using a modification of the
Oxford classification. Progression of disease was defined as an
increase in grade or a minimum 10% increase in fluid lesion volume
at second scan. A total of 16 hips (30%) initially classified as
‘normal’ developed an abnormality on the second scan. Of those with
‘isolated trochanteric fluid’ 9 (47%) underwent disease progression,
as did 7 (58%) of ‘effusions’. A total of 54 (77%) of hips initially
classified as showing adverse reactions to metal debris (ARMD) progressed,
with higher rates of progression in higher grades. Disease progression
was associated with high blood cobalt levels or an irregular pseudocapsule
lining at the initial scan. There was no association with changes
in functional scores. Adverse reactions to metal debris in MoM THAs
may not be as benign as previous reports have suggested. Close radiological
follow-up is recommended, particularly in high-risk groups. Cite this article:
This study compared the clinical outcomes following
mini-open rotator cuff repair (MORCR) between early mobilisation
and usual care, involving initial immobilisation. In total, 189
patients with radiologically-confirmed full-thickness rotator cuff
tears underwent MORCR and were randomised to either early mobilisation
(n = 97) or standard rehabilitation (n = 92) groups. Patients were
assessed at six weeks and three, six, 12 and 24 months post-operatively.
Six-week range of movement comparisons demonstrated significantly
increased abduction (p = 0.002) and scapular plane elevation (p
= 0.006) in the early mobilisation group, an effect which was not
detectable at three months (p >
0.51) or afterwards. At 24 months
post-operatively, patients who performed pain-free, early active mobilisation
for activities of daily living showed no difference in clinical
outcomes from patients immobilised for six weeks following MORCR.
We suggest that the choice of rehabilitation regime following MORCR
may be left to the discretion of the patient and the treating surgeon. Cite this article: