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Treatments of Chronic Acromioclavicular joint dislocation are controversial. Many procedures have been described in the past for the management of them. Treatment modalities have changed with increasing understanding of the nature of the problem, patient expectations and the biomechanics of the joint
Aim
To assess the functional outcome of the chronic AC joint dislocations treated by modified Weaver-Dunn procedure combined with Acromioclavicular joint augmentation.
Material and methods
We treated 54 patients with chronic AC joint dislocation by modified Weaver-Dunn procedure with additional AC joint augmentation. We used tight rope system in 20 patients, Mersilene tape in 22 patients and no 5 Ethibond in 12 patients.
Objective
The purpose of this study was to compare outcome of arthroscopic stabilization of the shoulder using knotted and knotless anchors and two rehabilitation regimes.
Method
This is a retrospective study of 58 patients who underwent arthroscopic shoulder stabilization over a five year period (2005–2009). There were two groups of patients. In group A stabilization was performed using absorbable anchors with a knotted technique using No.1 PDS suture. This group had an early mobilization regime. In group B a knotless anchor technique was used with PEEK anchors and nonabsorbable sutures. The patients in this group were immobilised in a sling for 6 weeks. There were a total of 58 patients, 37 in group A and 21 in group B. The mean age of patients undergoing the procedure was 35.7. There were a total of 23 males and 14 females in group A and 15 males and 6 females in group B. The number of dislocations prior to surgery ranged from 0 to multiple times a day. Patients had a mean follow up of 5 years (three to seven years - 2005 to 2009) and subjective shoulder function was evaluated using Oxford instability score and self-assessment questionnaire.
Introduction and Aim
The management of grade 4 articular cartilage defects of the knee is a great challenge and surgical techniques are evolving. This single surgeon series evaluated the results of articular cartilage implantation using matrix assisted autologous cartilage implantation (B Braun, Tetec, Reutlingen Germany) in 28 patients who had failed previous micro-fracture or chondroplasty.
Material and methods
Patients with a single chronic symptomatic full thickness defect either on the femoral condyle, trochlea or the patella were included. The defect size varied from 2.5 cm2 to 9.6 cm2. The mean age was 41.3 years and the mean duration of symptoms prior to surgery was 27 months (6–96).
Functional outcome was evaluated using the IKDC, KOOS, Tegner Lysholm and VAS pain scores. Patients also quantified their improvement in percentage or descriptive terms. Radiological assessment was carried out using MRI.
Introduction
The aim of this study is to analyse the effect of the degree of coverage of the Total Elbow implant with cement and the significance of cementation index as a predictor of failure.
Material/methods
Fifty elbows in forty seven patients who had undergone the Coonrad-Morrey TER were included in the study. The post-operative radiographs were evaluated for the cementation index. Failures and revisions were documented. Statistical analysis was done to evaluate the cementation index as a predictor of failure.
Introduction
Only a few studies have assessed the outcome of ulnar nerve decompression, most comparing various forms of decompression. A review of the case notes of patients undergone ulnar nerve decompressions was undertaken looking at the pre-op symptoms, nerve conduction studies, the co-morbidities, operative procedures and the post-operative outcomes.
Material/methods
We reviewed the case notes of ulnar nerve decompressions surgery performed over a period of six year period. Outcome grading was recorded as completely relieved, improved, unchanged or worse. The significance level was set at 5%.
Aim
To undertake a biomechanical study to determine the existence of any difference in the early tibial component fixation to bone, between two widely used techniques of cementation, which may confer an influence on implant survival.
Method
20 tibial saw bones were prepared by standard methods using extramedullary instrumentation to receive a fixed bearingtibial component (PFC, DePuy). Under controlled laboratory conditions, thetibial trayswere implanted with CMW cement using either of the two following cementation techniques (10 implants in each group): Full cementation–application of cement to the undersurface of the tibial tray, the keel, the cut surface of the tibia and its stem hole. Surface cementation – application of cement only to the undersurface of thetibial tray and the cut surface of the tibia. 72 hours after implantation, the fixation of the cemented components was assessed by determining the load to failure under controlled tensile stresses (using an Instron Electro-mechanical tensile tester).
Introduction
Extensor digitorum brevis (EDB) transfer is a useful method for treating chronic ankle instability in selected patients. It adds strength to the anterolateral capsule and provides proprioceptive feedback to functionally unstable ankles.
Method
A single surgeon of case series of patients undergoing EDB transfer for chronic ankle instability following sporting injuries between January 2003 and July 2011 was reviewed. All patients underwent arthroscopic procedures in a day case setting. Outcomes were measured using return to sporting activity and the Karlsson functional scoring system.
Percutaneous Achilles tenotomy is an integral part of the Ponseti technique. Though considered as a simple procedure, many authors have reported serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation. The authors describe the results of their new tenotomy technique, the ‘Posterior to Anterior Controlled’ (PAC) technique in an attempt to eliminate such complications.
This is a prospective study. Infants < 1 year of age with idiopathic clubfoot were taken up for the Ponseti technique of correction. Tenotomy was performed by the ‘PAC’ technique under local anaesthesia if passive dorsiflexion was found to be < 15 degrees. Outcome measures included completeness of the tenotomy (by ultrasonography), improvement in the equinus angle and occurrence of neurovascular complications.
40 clubfeet in 22 patients underwent ‘PAC’ tenotomy. The mean age was 3.5 months. The tenotomy was found to be complete in all cases. The equinus angle improved by an average of 78.5 degrees (range 70–95 degrees), which was statistically significant (p < 0.05, students t test). Mild soakage of the cast with blood was noted in 21 (52.5%) cases. No neurovascular complication was noted. The average follow-up was 12.2 months (range 9–18 months).
The ‘PAC’ tenotomy virtually eliminates the possibility of neurovascular damage, maintains the percutaneous nature of the procedure, is easy to learn and can be performed even by relatively inexperienced surgeons safely and effectively as an office procedure under local anaesthesia.
Introduction
Surgical fixation of greater tuberosity fractures in the shoulder is the choice of treatment even if the fragment is minimally displaced. This helps to reduce the incidence of impingement secondary to a malunited tuberosity fragment especially in younger patients. We evaluated the functional outcome of our patients treated with open reduction and internal fixation of these fractures using cancellous screws.
Materials and Methods
19 patients with a mean age of 57.1 years (range 27–84) with 19 isolated greater tuberosity fractures treated with cancellous screws were included. These patients were evaluated after an average follow up period of nearly four years (range 66–444 weeks) using the DASH score and the Constant and Murley score. They were also clinically assessed to check for signs of impingement.
Purpose of the study
To use a simple way of manipulating Taylor Spatial Frame to achieve soft tissue closure by acute intentional deformation and then gradually achieving anatomical alignment of the fracture without complex deformity and frame parameters.
Methods and end results
10 consecutive cases of Gustillo III B open fractures of tibia and of soft tissue defect due to infected implant were treated with a new technique of acute intentional deformation using Taylor Spatial frame to successfully close the soft tissue defect without plastic surgery. We describe a new simple technique of achieving anatomical alignment of the fracture after creating complex deformity to close the soft tissue defect. We achieved complete full thickness cover of the exposed bone in all cases without plastic surgery and restored the bone to anatomical alignment. Only one patient needed additional Taylor Spatial Frame total residual prescription to correct minor residual deformity.
Introduction
The outcome of periacetabular osteotomy in dysplastic hips is dependent on the absence of pre-operative osteoarthritis [OA]. The purpose of this study was to analyze whether Tonnis grading is a reliable predictor of OA in patients with hip dysplasia.
Methods
Thirty patients were identified who had undergone hip arthroscopy surgery to assess their suitability for periacetabular osteotomy. Radiographs were assessed for anterior centre edge angle, lateral centre edge angle, Tonnis angle and Tonnis grade for OA changes. The radiographic grading of OA was compared with arthroscopic findings.
Lunate or perilunate dislocations are common carpal injuries. Current treatment of these injuries by repair or reconstruction of intra-carpal ligaments is largely based on Mayfield's description of sequential failure of these ligaments.
We do treat significant number of these injuries. We have observed that dorsal wrist capsule is attached to dorsal aspect of proximal carpal row and its interosseous ligaments by vertically oriented identifiable fibres. This can be seen as carpal bones suspended from dorsal capsule, akin to cloths suspended from a washing line. We have also observed that in lunate or perilunate dislocations, dorsal capsule is peeled off from the dorsal aspect of lunate and distal radius, similar to a Bankart lesion in the shoulder. We believe that dorsal capsule plays a bigger role in the stabilising mechanism of carpal bone than the intercarpal ligaments. It has not been described before.
We dissected three cadaveric wrists and found vertical fibres running from dorsal wrist capsule/ligaments to the dorsal components of the scapholunate and lunotriquetralinterosseous ligaments. We have modified the Mayo approach to dorsal wrist capsule and use suture anchors to attach dorsal capsule/ligaments to scaphoid, lunate and triquetrum rather than repairing intra-carpal ligament. We have used this technique in 26 patients so far. Follow up for more than 4 years have shown satisfactory results and no significant recurrence of instability.
We present a novel, so far unreported, method of repairing the intracarpal injuries, using the dorsal capsule/ligaments, based on anatomic and intra-operative observations.
Introduction
The success of total hip replacement (THR) is closely linked to the positioning of the acetabular component. Malalignment increases rates of dislocation, impingement, acetabular migration, pelvic osteolysis, leg length discrepancy and polyethylene wear. Many surgeons orientate the cup to inherent anatomy of the acetabulum. Detailed understanding of the anatomy and orientation of the acetabulum in arthritic hips is therefore very important. The aim of this study was to describe the anteversion and inclination of the inherent acetabulum in arthritic hips and to identify the number that fall out with the ‘safe zone’ of acetabular position described by Lewinnek et al. (anteversion 15°±10°; inclination 40°±10°).
Materials and Methods
A series of 65 hips all with symptomatic osteoarthritis undergoing THR were investigated. Patients with dysplastic hips were excluded. All patients had a navigated THR as part of their normal clinical treatment. A commercially available non image based computer navigation system (Orthopilot BBraun Aesculap, Tuttlingen, Germany) was used. Anterior pelvic plane was registered using the two anterior superior iliac spines and pubic symphysis. Inner size of the empty acetabulum was sized with cup trials and appropriately size trial fixed with a computer tracker was then aligned in the orientation of the natural acetabulum as defined by the acetabular rim ignoring any osteophytes. The inclination and anteversion were calculated by the software.
The acetabular inclination in all hips was also measured on pre-operative anteroposterior pelvic digital radiographs. Acetabular inclination was measured using as the angle between a line passing through the superior and inferior rim of the acetabulum and a line parallel to the pelvis as identified by the tear drops, using the method described by Atkinson et al.
Background
Outcome of Type II and III (Sander's CT classification) fracture of the calcaneum who underwent open reduction and internal fixation was assessed.
Methods
Thirty-three type II and III fractures of the calcaneum (all unilateral) underwent open reduction and internal fixation using the ‘extensile lateral approach’. There were twelve Type II and twenty-one Type III fractures. Patients were followed up for a mean of 40.81 months (Range 28 to 62 months). Patients were assessed clinically by the Creighton Nebraska Health foundation score for assessment of fractures of the calcaneum. Radiologically assessment was done comparing the pre and post operativeBohler's and Gissane angles and measuring the calcaneal width on the axial xrays.
Introduction
The gamma nail is a cephalomedullary implant used in proximal femoral fracture management. Short gamma nails are technically less demanding, but there is concern over potentially higher complication rate.
Objectives
To determine differences in implant related complications between the short and long gamma nail.
Introduction
The dysplastic trochlear is a developmental condition characterized by an abnormally flat or dome-shaped trochlea and it is recognized as a significant cause of patella instability. Surgical correction of the shape of the Trochlear Groove is frequently performed. The described methods in the literature involve open arthrotomy to normalize and maintain the trochlear morphology achieving normal alignment and tracking of the patella.
Material, methods and results
Open procedures carries a significant risk of arthrofibrosis. We describe an arthroscopic procedure to create a neo-trochlea using gouges, spherical and conical hooded burrs. We studied prospectively a series of 4 consecutive patients with patello-femoral instability secondary to trochlear dysplasia, who were treated by an Arthroscopic trochleoplasty by a single surgeon between 2007 and 2008. Postoperatively the patients were rehabilitated in accordance with our routine Patello-Femoral microfracture protocol. CT scanning at one year showed a complete neo-cortex and cartilage sequenced MRI at 12 months showed complete fill with fibro cartilage.
Pre- and post-operative scores (KOOS, Kujala) were assessed by the patients and a satisfaction questionnaire was completed. The results showed a statistical improvement in the outcome at the 3 year follow up.
Background
There are no published studies investigating predictive values of psychological distress on effectiveness of epidural injection.
Aims
To evaluate response to epidural injection (EI) in patients with chronic lower back pain (CLBP) with and without psychological distress.
The Delta total shoulder replacement is a reversed, semi-constrained prosthesis and is recommended for the management of rotator cuff arthropathy and other difficult reconstructive shoulder problems. It was initially advised to use this prosthesis in patients older than 75. There were reports saying the complication rates of this prosthesis are high and patients' satisfaction and functional outcome is far from being satisfactory. In our study we wanted to evaluate results and complications of reverse shoulder arthroplasty in practice of single surgeon.
In our study we reviewed patients who had reverse shoulder arthroplasty performed between 2001 and 2009. We evaluated them clinically and radiologically. We measured functional outcome using Constant score, we used Oxford Shoulder score to measure patients' subjective outcome. We compared our results to pre-operative Oxford Shoulder score (unfortunately no pre-op constant score was done). X-rays were assessed by independent surgeon who was not involved in care of the patients.
Out of 36 reverse shoulder replacements performed by Mr. Sinha from 2001 to 2009 we managed to review in clinic 29 shoulders. 3 patients died from causes not related to surgery, 3 patients were too unwell to attend clinic, we lost 1 patient to follow up. Mean time from operation to follow up was 33 months (range 6 to 82 months). Average patients' age at time of surgery was 73,4 years (range: 44 to 90). Indications included rotator cuff arthropathy (86%), other indications were trauma (10%) and revision of failed hemiarthroplasty (4%). There were neither revisions nor infections in our group. There was 1 dislocation that occurred after operation, this was reduced under GA and never re-dislocated again. 12 patients (41%) were very pleased with result of surgery, 15 patients (52%) were satisfied and 2 patients said surgery did not meet their expectations. Mean Shoulder Oxford score improved from 20.8 (range 2 to 36) pre-operatively to 36.7 (range 20 to 48) during follow up. 3 patients had Oxford Shoulder score of 48 (maximum). Oxford shoulder score deteriorated in 2 cases (one in case when replacement was done to treat fracture). Post operative Constant score was 65.5. All patients but one declared overall improvement. 10 patients (34%) reported no pain at all. 5 patients who were 65 years old or younger at time of surgery did well and improved their shoulder function.
In our experience reverse geometry shoulder replacement is a very good solution for rotator cuff arthropathy. Results in proximal humeral fracture are worse, but the number of patients we had was small and our experience is limited. Mid term results are very satisfactory overall, even in younger and more demanding patients. The complications were rare and overall patients' satisfaction very high. We think more research needs to be done to asses long term results, especially in younger population.
Introduction/aims
Anterior cruciate ligament (ACL) reconstruction is now routinely performed arthroscopically. However, there are only a few centres in the UK which offer this procedure as a day case. We aimed to assess the clinical outcomes of day case ACL reconstruction using a tourniquet-less pump regulated procedure.
Material/methods
A retrospective analysis of day case ACL reconstructions by a single surgeon between January 2003 and December 2010 was undertaken. All reconstructions were performed without a tourniquet, instead, haemostasis was achieved using saline – epinephrine irrigation. Outcomes were measured using Lysholm knee scores, Mohtadi index and pain scores.
Reconstruction of an acetabulum following severe bone loss can be challenging. The aim of this study was to determine the outcome of acetabular reconstruction performed using trabecular metal shell for severe bone loss.
Between June 2003 and June 2006 a total of 29 patients with significant acetabular bone stock deficiency underwent revisions using trabacular metal shell. According to Paprosky classification, there were 18 patients with grade IIIA and 11 patients with grade IIIB defects. Nineteen patients required augments to supplement the defects. Functional clinical outcomes were measured by WOMAC and Oxford hip. Detailed radiological assessments were also made.
At most recent follow up (average 5.5 years, range 3.5–8.5) the mean Oxford hip score improved from 12 preoperatively to 27.11 postoperatively and WOMAC score from 17.57 preoperatively to 34.14 postoperatively The osseointegration was 83% according to Moore's classification. There were two reoperations; one was for instability, and one for aseptic loosening. One patient has a chronic infection and one had a periprosthetic fracture, both treated conservatively.
Despite challenges faced with severe preoperative acetabular defects the early results using this technique in Grade III A and B is encouraging.
Introduction
Soft tissue balancing is an important aspect of total knee replacement surgery. Traditionally sequential medial soft tissue release is performed for balancing in varus deformity. Its effects on kinematics and dynamic Femoro-Tibial-Mechanical-Angle (FTMA) have been described in extension and 90° flexion in coronal plane. However most studies have missed what happens when the knee flexes from 0 to 90 degrees This study is one of the first to describe its effects on knee kinematics throughout flexion. The aim was to look at deviation of FTMA in coronal plane with traditional sequential medial release with and without measured stress applied in varus and valgus at each point of measurement through the range of flexion.
Methods
12 cadaveric knees were studied using a computer navigation system. Rigid bodies were fixed to femur and tibia. The knee was exposed as per doing TKR surgery with medial parapatellar approach with no disturbance to the collateral ligaments. The anatomy was registered using a infra red waves based passive tracker navigation system. FTMA was studied in extension, 0°, 5°, 30°,45°,60°,90° and maximum flexion. Sequential medial release was performed in 7 steps as described by Luring et al. The sequential steps were Step 1: 2 cm release (antero medial tibial sleeve), Step 2: Postero-medial release, Step 3: 4 cm medial sleeve release, Step 4: 6 cm medial sleeve release, Step 5: Deep medial collateral ligament, Step 6: posterior cruciate ligament (PCL) medial half only, Step 7: entire PCL.
At each step FTMA was measured with and without stressing at each point of flexion. A 10 Newton Meter moment arm was applied for varus and valgus stress force.
Introduction
Recent studies have indicated that healthy and willing patients above 80 years have similar outcomes as younger patients following arthroplasty. We wished to investigate the outcomes in a cohort of patients above 80 years who underwent medial unicompartment knee replacement (UKA).
Material/methods
46 patients (51 knees) with UKA aged 80 or more formed the study group. For comparison rest of the UKA patients in the database were divided into groups according to their age. Patients were reviewed and KSS, complication rates and patient satisfaction information was collected. Revision for any cause was considered an endpoint. Significance was set at < 0.05.
Bone grafts are a useful option to treat large posteromedial defects in tibia which are usually seen in medial condyle of the tibia in severe varus knees and lateral condyle in valgus knees. Contained defects can be treated using cancellous bone chips/graft. Uncontained peripheral defects may be treated using cement with or without screw augmentation for small defects. Large defects > 25 % of tibial plateau and > 5 mm deep may need structural bone graft or impaction bone grafting or metal wedges. The use of bone grafts is a viable alternative for the treatment of massive bone loss.
For stable fixation of the components, we performed osseous reconstruction of tibial condyle using autologous structural bone grafts /impaction bone grafting. We used structural bone graft for 62 tibial defects in severe varus knees in 675 primary TKR. Grafts originating from the femoral condyles were fixed with screws. Morselised autograft supported by mesh, fixed with screws, were used in 8 patients. Bilateral bone grafting was done in 28 patients. Goal was to obtain firm seating of the tibial tray on a rim of viable bone along with rigid press fixation of the medullary stem.
We observed an average 70-point postoperative increase in knee function according to HSS score. Graft incorporation was seen in all patients at average seven year follow-up.
Autologous bone grafts can be successfully used for reconstruction of large osseous defects. It is available then and there, is biological and cost effective.
Introduction
Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty. We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban.
Methods
Both groups received mechanical prophylaxis. In the first group 89 patients were given 40 mg subcutaneous clexane once daily from the day prior to surgery until they were independently mobile. The second group comprised 99 patients who were given 10 mg of oral rivaroxaban.
Deep vein thrombosis (DVT) in shoulder operations is rare although a few case reports exist. No definite guidelines exist and therefore it is difficult for the surgeon to decide on thromboprophylaxis.
We prospectively evaluated the incidence of DVT following arthroscopic shoulder sub acromial decompression in 72 patients after obtaining local ethics committee approval. Patients with previous history of DVT and those on anticoagulants were excluded from the study. Pre and post-operative Doppler scans on 4 limbs were performed by a single consultant radiologist at an average of 3 weeks. All operations were performed by a single surgeon under GA in beach chair position as a day case procedure on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. No patient received any DVT prophylaxis.
The average age of 54.6 years, 47 were classified as ASA 1, 15 as ASA 2 and 10 ASA 3.58 patients had additional interscalene nerve blocks for pain relief. The average operating time was 43 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVTs on Doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients.
