Our aim was to compare the outcome of arthroscopic
release for frozen shoulder in patients with and without diabetes.
We prospectively compared the outcome in 21 patients with and 21
patients without diabetes, two years post-operatively. The modified
Constant score was used as the outcome measure. The mean age of
the patients was 54.5 years (48 to 65; male:female ratio: 18:24),
the mean pre-operative duration of symptoms was 8.3 months (6 to
13) and the mean pre-operative modified Constant scores were 36.6
(standard deviation ( Cite this article:
The outcomes of 261 nerve injuries in 100 patients
were graded good in 173 cases (66%), fair in 70 (26.8%) and poor in
18 (6.9%) at the final review (median 28.4 months (1.3 to 64.2)).
The initial grades for the 42 sutures and graft were 11 good, 14
fair and 17 poor. After subsequent revision repairs in seven, neurolyses
in 11 and free vascularised fasciocutaneous flaps in 11, the final
grades were 15 good, 18 fair and nine poor. Pain was relieved in
30 of 36 patients by nerve repair, revision of repair or neurolysis,
and flaps when indicated. The difference in outcome between penetrating
missile wounds and those caused by explosions was not statistically
significant; in the latter group the onset of recovery from focal
conduction block was delayed (mean 4.7 months (2.5 to 10.2)
Amputation was once widely practised for primary bone tumours of the limbs. Yet this situation has changed with limb salvage surgery becoming increasingly popular in the last 30 years. Many different techniques are now available. These include allografts, autografts, endoprostheses and allograft-prosthesis composites. This article reviews these methods, concentrating on the functional outcomes and complications that have been reported.
We present a review of litigation claims relating
to foot and ankle surgery in the NHS in England during the 17-year period
between 1995 and 2012. A freedom of information request was made to obtain data from
the NHS litigation authority (NHSLA) relating to orthopaedic claims,
and the foot and ankle claims were reviewed. During this period of time, a total of 10 273 orthopaedic claims
were made, of which 1294 (12.6%) were related to the foot and ankle.
1036 were closed, which comprised of 1104 specific complaints. Analysis
was performed using the complaints as the denominator. The cost
of settling these claims was more than £36 million. There were 372 complaints (33.7%) involving the ankle, of which
273 (73.4%) were related to trauma. Conditions affecting the first
ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective
practice. Overall, claims due to diagnostic errors accounted for
210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery
and 149 (13.5%) from alleged mismanagement. Our findings show that the incorrect, delayed or missed diagnosis
of conditions affecting the foot and ankle is a key area for improvement,
especially in trauma practice. Cite this article:
The October 2014 Oncology Roundup360 looks at: how best to reconstruct humeral tumours; not everything is better via the arthroscope; obesity and sarcoma; frozen autograft;
Of 48 consecutive children with Gartland III
supracondylar fractures, 11 (23%) had evidence of vascular injury,
with an absent radial pulse. The hand was pink and warm in eight
and white and cold in the other three patients. They underwent colour-coded
duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate
the patency of the brachial artery and arterial blood flow. In seven
patients with a pink pulseless hand, CCDS showed a displaced, kinked
and spastic brachial artery and a thrombosis was present in the
other. In all cases UV showed reduced blood flow in the hand. In
three patients with a white pulseless hand, scanning demonstrated
a laceration in the brachial artery and/or thrombosis. In all cases,
the fracture was reduced under general anaesthesia and fixed with
Kirschner wires. Of the seven patients with a pink pulseless hand
without thrombosis, the radial pulse returned after reduction in
four cases. The remaining three underwent exploration, along with
the patients with laceration in the brachial artery and/or thrombosis. We believe that the traditional strategy of watchful waiting
in children in whom the radial pulse remains absent in spite of
good peripheral perfusion should be revisited. Vascular investigation
using these non-invasive techniques that are quick and reliable
is recommended in the management of these patients. Cite this article:
The August 2014 Research Roundup360 looks at: Antibiotic loaded ceramic of use in osteomyelitis; fibronectin implicated in cartilage degeneration; Zinc Chloride accelerates fracture healing in rats; advertisements and false claims; Net Promoter Score: substance or rhetoric?; aspirin for venous thromboembolism prophylaxis and dissection, stress and the soul.
Despite a lack of long-term follow-up, there
is an increasing trend towards using femoral heads of large diameter
in total hip replacement (THR), partly because of the perceived
advantage of lower rates of dislocation. However, increasing the
size of the femoral head is not the only way to reduce the rate
of dislocation; optimal alignment of the components and repair of
the posterior capsule could achieve a similar effect. In this prospective study of 512 cemented unilateral THRs (Male:Female
230:282) performed between 2004 and 2011, we aimed to determine
the rate of dislocation in patients who received a 22 mm head on
a 9/10 Morse taper through a posterior approach with capsular repair
and using the transverse acetabular ligament (TAL) as a guide for the
alignment of the acetabular component. The mean age of the patients
at operation was 67 years (35 to 89). The mean follow-up was 2.8
years (0.5 to 6.6). Pre- and post-operative assessment included
Oxford hip, Short Form-12 and modified University of California
Los Angeles and Merle D’Aubigne scores. The angles of inclination
and anteversion of the acetabular components were measured using
radiological software. There were four dislocations (0.78%), all
of which were anterior. In conclusion, THR with a 22 mm diameter head performed through
a posterior approach with capsular repair and using the TAL as a
guide for the alignment of the acetabular component was associated
with a low rate of dislocation. Cite this article:
The April 2012 Trauma Roundup360 looks at fibula-pro-tibia plating, galeazzi fractures, distal radial fractures in the over 65s, transverse sacral fractures, acute dislocation of the knee, posterior malleolar fractures, immobilising the broken scaphoid, the terrible triad, lower limb amputation after trauma, and whiplash injuries
We present our experience of forearm lengthening
in children with various conditions performed by a single surgeon between
1995 and 2009. A total of 19 children with a mean age of 9.8 years
(2.1 to 15.9) at the time of surgery had 22 forearm lengthenings
using either an Ilizarov/spatial and Ilizarov circular frame or
a monolateral external fixator. The patients were divided into two
groups: group A, in whom the purpose of treatment was to restore
the relationship between the radius and the ulna, and group B, in
whom the objective was to gain forearm length. The mean follow-up after
removal of the frame was 26 months (13 to 53). There were ten patients (11 forearms) in group A with a mean
radioulnar discrepancy of 2.4 cm (1.5 to 3.3) and nine patients
(11 forearms) in group B. In group A, the mean lengthening achieved
was 2.7 cm (1.0 to 5.5), with a lengthening index of 11.1 weeks/cm.
Equalisation or overcorrection of the discrepancy was achieved in
seven of 11 forearms, but lengthening was only partially successful
at preventing subluxation or dislocation of the radial head. In
group B, the mean lengthening achieved was 3.8 cm (1.9 to 6.8),
with a lengthening index of 7.25 weeks/cm. Common complications
in both groups were pin-site infection and poor regenerate formation. Forearm lengthening by distraction osteogenesis is a worthwhile
procedure in children that can improve cosmesis and function, particularly
in patients with shortening of both radius and ulna.
The October 2014 Trauma Roundup360 looks at: proximal humeral fractures in children; quadrilateral surface plates in transverse acetabular fractures; sleep deprivation and poor outcomes in trauma; bipolar hemiarthroplasty; skeletal traction; forefoot fractures; telemedicine in trauma; ketamine infusion for orthopaedic injuries; and improved functional outcomes seen with trauma networks.
Between 1982 and 1997, 403 consecutive patients (522 elbows) with rheumatoid arthritis underwent Souter-Strathclyde total elbow replacement. By the end of 2007, there had been 66 revisions for aseptic loosening in 60 patients. The mean time of follow-up was 10.6 years (0 to 25) The survival rates at five-, ten, 15 and 19 years were 96% (95%, confidence interval (CI) 95 to 98), 89% (95% CI 86 to 92), 83% (95% CI 78 to 87), and 77% (95% CI 69 to 85), respectively. The small and medium-sized short-stemmed primary humeral components had a 5.6-fold and 3.6-fold risk of revision for aseptic loosening respectively, compared to the medium-sized long-stemmed component. The small and medium-sized all-polyethylene ulnar components had respectively a 28.2-fold and 8.4-fold risk of revision for aseptic loosening, compared to the metal-backed ulnar components. The use of retentive ulnar components was not associated with an increased risk of aseptic loosening compared to non-retentive implants.
The August 2014 Trauma Roundup360 looks at: On-table CT for calcaneal fractures; timing of femoral fracture surgery and outcomes; salvage arthroplasty for failed internal fixation of the femoral neck; screw insertion in osteoporotic bone; fibular intramedullary nailing on the ascendant; posterior wall acetabular fractures not all that innocent; bugs, plating and resistance and improving outcomes in olecranon tension band wiring.
The June 2014 Research Roundup360 looks at:Intraoperative irrigation a balance of toxicities; Ibandronate effective in bone marrow oedema; Risk stratification in damage control surgery; Osteoblast like cells potentially safe; Better wear and antibacterial?; Assessing outcomes in hip fracture.
Surgical repair of posterosuperior rotator cuff
tears has a poorer outcome and a higher rate of failure compared
with repairs of supraspinatus tears. In this prospective cohort
study 28 consecutive patients with an irreparable posterosuperior
rotator cuff tear after failed conservative or surgical treatment
underwent teres major tendon transfer. Their mean age was 60 years
(48 to 71) and the mean follow-up was 25 months (12 to 80). The
mean active abduction improved from 79° (0° to 150°) pre-operatively
to 105° (20° to 180°) post-operatively (p = 0.011). The mean active
external rotation in 90° abduction improved from 25° (0° to 70°)
pre-operatively to 55° (0° to 90°) post-operatively (p <
0.001).
The mean Constant score improved from 43 (18 to 78) pre-operatively
to 65 (30 to 86) post-operatively (p <
0.001). The median post-operative
VAS (0 to 100) for pain decreased from 63 (0 to 96) pre-operatively to
5 (0 to 56) post-operatively (p <
0.001). In conclusion, teres major transfer effectively restores function
and relieves pain in patients with irreparable posterosuperior rotator
cuff tears and leads to an overall clinical improvement in a relatively
young and active patient group with limited treatment options. Cite this article:
We reviewed 101 patients with injuries of the
terminal branches of the infraclavicular brachial plexus sustained between
1997 and 2009. Four patterns of injury were identified: 1) anterior
glenohumeral dislocation (n = 55), in which the axillary and ulnar
nerves were most commonly injured, but the axillary nerve was ruptured
in only two patients (3.6%); 2) axillary nerve injury, with or without
injury to other nerves, in the absence of dislocation of the shoulder
(n = 20): these had a similar pattern of nerve involvement to those
with a known dislocation, but the axillary nerve was ruptured in
14 patients (70%); 3) displaced proximal humeral fracture (n = 15),
in which nerve injury resulted from medial displacement of the humeral
shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension
of the arm (n = 11): these were characterised by disruption of the
musculocutaneous nerve. There was variable involvement of the median
and radial nerves with the ulnar nerve being least affected. Surgical intervention is not needed in most cases of infraclavicular
injury associated with dislocation of the shoulder. Early exploration
of the nerves should be considered in patients with an axillary
nerve palsy without dislocation of the shoulder and for musculocutaneous
nerve palsy with median and/or radial nerve palsy. Urgent operation
is needed in cases of nerve injury resulting from fracture of the
humeral neck to relieve pressure on nerves.
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:
Inability to actively supinate the forearm makes common activities of daily living and certain vocational activities awkward or impossible to perform. A total of 11 patients with deficient supination of the arm underwent transfer of the tendon of flexor carpi ulnaris to the split tendon of brachioradialis with its bony insertion into the radial styloid left intact. Active supination beyond neutral rotation was a mean of 37.2° (25° to 49.5°) at a minimum follow-up of three years, representing a significant improvement (95% confidence interval 25 to 50, p <
0.001). Functional evaluation of the hand after this transfer showed excellent and good results in ten patients and fair in one. The split tendon of brachioradialis as an insertion for transfer of the flexor carpi ulnaris appears to provide adequate supination of the forearm without altering the available pronation and avoids the domination of wrist extension sometimes associated with transfers of the flexor carpi ulnaris to the radial extensors of the wrist.
The April 2014 Wrist &
Hand Roundup360 looks at: diagnosis of compressive neuropathy; relevant reviews; the biomechanics of dorsal PIP fracture dislocation; the more strands the better; and state of mind the best predictor of outcome.