Traumatic rotator cuff injury: does delayed surgery worsen functional outcomes?

PURPOSE

The optimal timing of surgery after traumatic rotator cuff tears (RCT) is unclear, with its impact on functional outcomes under debate. This study aimed to review functional outcomes after RCT repair in patients who underwent early vs delayed surgery at our unit.

METHODS

This was single-centre retrospective evaluation. Patients with an acute traumatic RCT that underwent repair between 2017 and 2019 and had local follow-up were included and placed into two groups: early surgery (within 6 months from injury) and delayed surgery (more than 6 months from injury). Patient demographics, RCT data and pre- and post-operative (after 12 months) Oxford Shoulder Score (OSS) were extracted from medical records. Data was analysed to compare OSS scores between groups, as well as the effect of cuff tear sizes on OSS scores.

RESULTS

Forty-nine patients were included in the analysis (15 early, 34 delayed). There were no significant differences in age, sex or cuff tear sizes between groups. No difference was identified in the mean post-operative OSS between early vs delayed groups (40.9 ± 6.34 vs 40.5 ± 7.65, p = 0.86). The mean improvement in OSS after surgery was also similar between groups (22.5 ± 7.81 vs 20.97 ± 7.19, p = 0.498). Having a large or massive RCT did not worsen OSS compared to small or medium RCT (p = 0.44), even when stratified by early or delayed surgery.

CONCLUSION

Delayed surgery for traumatic RCT greater than 6 months from injury did not negatively impact long-term functional outcomes at our unit. Patients should be reassured as applicable before surgery in the event of prolonged or unavoidable delays.

Patella Fracture Fixation Technique with Suture Anchors

Introduction

Patella fracture can occur due to direct injury to the knee or indirect eccentric contraction of the quadriceps tendon. These injuries can present in different configurations which require acceptable reduction and good fixation. Patients are at risk of not only losing their knee extensor mechanism but also having a defective patellofemoral articulation. Hence, the main aim in treating such fractures is to restore the knee extensor mechanism. Surgical options for treating patella fracture include tension band wiring, wiring through cannulated screws, fixation with plate, and suture anchor (SA) fixation.

Case Report

We demonstrate a new fixation technique for patella fracture with SAs in two of our patients. They presented with patella fracture following a fall and sustained closed injury with intact distal neurovascular status. The authors describe their technique using double-loaded SAs to obtain anatomical reduction and solid fixation. With three SAs, each inserted in a third portion of a distal fragment.

Conclusion

There are several modalities and techniques available for fixation of patella fracture. However, authors recommend that their described novel technique can provide more strength and satisfactory outcome. Furthermore, this technique uses a smaller incision compared to conventional suture tunnel repair as in this technique only the fracture that needs to be exposed distally.

Pseudoaneurysm - A Late and Rare Occurrence Following Shoulder Arthroscopy

Introduction

The incidence of vascular injuries from arthroscopic surgeries has been reported to be 0.005%. Pseudoaneurysms account for 11% of those injuries.

Case Report

In this case report, we discuss a 76-year-old female who presented with a pulsatile swelling in the right shoulder after 10 years following arthroscopic rotator cuff repair. Imaging confirmed the diagnosis of a posterior circumflex artery pseudoaneurysm. The patient was successfully embolised using a transradial approach with thrombosis of the pseudoaneurysm.

Conclusion

Vascular injuries following arthroscopic shoulder surgery are rare. However, a pseudoaneurysm should be considered in patients who present with swelling at the surgical site, regardless of the post-operative interval.

Effect of Implant Size, Version and Rotator Cuff Tendon Preservation on the Outcome of Reverse Shoulder Arthroplasty

Introduction: Functional outcomes following reverse geometry shoulder arthroplasty can vary. This study assessed the effects of glenosphere size, humeral stem version, posterior rotator cuff status and subscapularis repair on patient-reported outcome and range of motion. 

Methods: A consecutive series of 132 patients from two orthopaedic centres that use the same onlay system for reverse shoulder arthroplasty were reviewed over a six-year period. Outcome measures consisted of the Oxford Shoulder score (OSS) and range of motion (ROM) at one year following surgery. These were assessed against glenosphere sizes (small (36-38 mm) and large (40-42 mm)), humeral stem retroversion (less or more than 20 degrees), rotator cuff status (posterior rotator cuff present or absent) and subscapularis tendon (repaired or not) at the end of procedure.

Results: Larger glenospheres and less humeral stem retroversion yielded better ROM and OSS but this was not statistically significant. Subscapularis repair had no effect on outcomes. Preservation of posterior rotator cuff tendons improved functional outcomes. The number of tendons present at the end of procedure had a positive effect on outcome (best with two tendons and better with one compared to a completely bald humeral head).

Conclusion: Preservation of posterior rotator cuff tendons during reverse shoulder arthroplasty improves clinical outcomes unlike subscapularis repair which was found to be unnecessary. Implant size and version in reverse geometry arthroplasty have no significant effects on clinical outcome.

Assessing the required glenoid peg penetration in native scapula when bone graft is used during primary and revision shoulder arthroplasty

AIMS

Achieving purchase in native glenoid bone is essential for the stability of the glenoid baseplate when bone graft is used to address bone loss in both primary and revision shoulder arthroplasty procedures. The aim of this study is to assess the required depth of the baseplate peg in native bone when bone graft is used to result in satisfactory integration.

PATIENTS AND METHODS

The CT scans of patients who underwent either primary or revision arthroplasty procedures with bone graft using the SMR Axioma Trabecular Titanium (TT) Metal Backed glenoid system were assessed. We measured the depth of the glenoid peg in native glenoid bone. Measurements were taken by two authors separately.

RESULTS

The scans of 53 patients (mean age 68 years) with a minimum follow-up of two years were reviewed. Implants included 12 anatomical and 41 reverse geometry prostheses. There were 17 primaries and 36 revisions: hemiarthroplasties (20) total (14) and reverse (2) implants. Bone grafts were from humeral head (15), iliac crest (34) and allograft (4). The mean depths were 8.8 mm (first assessor) and 9.10 mm (second assessor). The glenoid peg violated the glenoid vault in 32 patients and this did not adversely affect the outcome. There were three failures of implants all of which were aseptic failures and had peg penetration of less than 6 mm.

CONCLUSIONS

The mean depth of glenoid peg in native bone was 9 mm (variation between 0.2 and 0.52 mm at 95% confidence interval). Aseptic loosening was seen with peg penetration less than 6 mm in native bone. Glenoid vault violation was not associated with loosening.

Range of Movement and Patient-Reported Outcomes in Shoulder Arthroplasty in the Elderly: A Comparison of Anatomical Versus Reverse Shoulder Replacements

Introduction Shoulder arthroplasty is in increasing demand in the elderly given the rising prevalence of glenohumeral osteoarthritis (OA) across the population. There is a dearth of evidence in the current literature comparing anatomical total shoulder arthroplasty and reverse total shoulder arthroplasty (RTSA) in the elderly population. This study compares patient-reported outcome measures and range of movement (ROM) between anatomical and reverse total shoulder replacements in matched patient cohorts over the age of 70 years. Materials and methods This retrospective cohort study compares range of movement and patient-reported outcomes between anatomical total shoulder arthroplasty and reverse total shoulder arthroplasty in matched cohorts over the age of 70 years at a single institution between 2011 and 2015. Overall, 75 patients were recruited, including 44 patients with anatomical total shoulder arthroplasty and 31 patients with reverse total shoulder arthroplasty. Cohorts were matched according to age, preoperative Oxford Shoulder Score (OSS), and preoperative range of movement. The minimum clinical follow-up was one year. Results At one year, range of movement metrics in flexion, abduction, and external rotation all demonstrated greater improvements in the anatomical total shoulder arthroplasty cohort in comparison to the reverse total shoulder arthroplasty cohort (p<0.0001). No statistical difference in Oxford Shoulder Score was evident between cohorts. Conclusion Anatomical total shoulder arthroplasty demonstrates a significant improvement in range of movement in comparison to reverse total shoulder arthroplasty in matched elderly patient cohorts. However, there was no statistical difference in functional assessment scores between reverse shoulder replacement and anatomical shoulder replacement.

Acromioclavicular Joint Pseudo-dislocations with Lateral end Clavicle Fracture: A Rare Injury and Proposed Technique of Fixation

Introduction:

Lateral end clavicle fractures are rare injuries in pediatric and adolescent population. Most of these injuries can be managed conservatively. However, in patients with acromioclavicular joint (ACJ) “pseudo-dislocations” associated with significant clinical deformity, some patients will benefit from operative intervention.

Case Report:

Our reported case is a young adolescent with a Type IV Dameron and Rockwood distal clavicle fracture and ACJ pseudo-dislocation, who underwent surgical fixation for this injury. We propose a novel technique of fixation with a suture anchor and endo button with temporary K wire stabilization. These are rare injuries and there are no standardized techniques for reconstruction and fixation. Stabilization with a suture anchor can provide a minimally invasive method of fixation for such injuries without the traditional plating and can lead to excellent final outcomes.

Conclusion:

ACJ pseudo-dislocations are rare injuries. There is limited evidence in guiding the management of such injuries. Our proposed technique of fixation with suture anchor, endo button and temporary stabilisation with K-wire can provide promising results.

Shoulder hydrodilatation for primary, post-traumatic and post-operative adhesive capsulitis

BACKGROUND

Adhesive capsulitis (frozen shoulder) is characterised by pain and loss of range of motion of the glenohumeral joint. It can be present as primary (idiopathic) or secondary to surgery, trauma or other conditions that restrict the use of the shoulder joint. Various treatment options have been adopted including physiotherapy, manipulation under anaesthetic, hydrodilatation and arthroscopic or open capsular release but the optimal form of management remains uncertain.

OBJECTIVES

The purpose of the study was to assess the clinical outcome of glenohumeral hydrodilatation in three cohorts of patients with different aetiologies with adhesive capsulitis.

STUDY DESIGN & METHODS

We carried out a retrospective study of patient who underwent hydrodilatation for adhesive capsulitis between 2013 and 2015. The procedure was performed by a specialist musculoskeletal radiologist under radiological guidance. The injection consisted of steroids, local anaesthetics and NaCl solution with a target volume around 35 mL. Our outcome measures were range of motion, and pre- and post-operative pain. Patients were divided into three groups based on the presumed cause of their stiffness: idiopathic, post-traumatic and post-surgical.

RESULTS

Two hundred fifty patients were included, with a mean age of 59 years (range: 20-79). Of these, 180 had idiopathic primary adhesive capsulitis (27 were diabetic), 23 were post-traumatic, and 20 following surgical procedures. Thirty-four required further intervention following initial hydrodilatation with 8 undergoing repeat hydrodilatation, and 26 requiring arthroscopic capsular release. The diabetic group accounted for 16 capsular releases and 4 repeat procedures, while the idiopathic group accounted for 9 and 4, respectively. One patient required capsular release in the surgical group. An improvement was recorded in ROM in all groups with mean abduction improving from 59° to 110°, flexion from 50° to 120° and external rotation from 20° to 50°. With regards to pain, the majority showed an improvement from severe or moderate pain to no or mild pain.

CONCLUSIONS

Results show that hydrodilatation resulted in an improvement in all outcome measures, with only a small number of patients, especially those with diabetes, needing further procedures or showing no improvement in range of motion and pain. There was no difference between the post-traumatic and post-surgical groups.

Fashioning Osteochondral Allograft for Humeral Head Defects in Reverse Hill-Sachs Lesions – A Proposed Surgical Technique

Introduction:

Posterior glenohumeral joint dislocations with associated bony lesions are challenging to treat; namely, reverse Hill-Sachs’s lesions increase humeral head excursion predisposing to recurrent dislocations. To add to the complexity of management, posterior shoulder dislocations are often missed on plain radiographs, leading to chronicity in presentation.

Case Report:

We describe here our technique in our case series of three patients. Case I, 32 years, gentleman, presented 3 days after injury. He had a locked posterior dislocation of shoulder which he sustained while he fell asleep and hit a glass table. Shoulder was not reducible in emergency department. Reverse Hill- Sachs’s lesion involved 40% of humeral head. Case II, a 54- years- old gentleman, a keen gym trainer . Following sudden withdrawal of diazepam, he woke up lying on the floor and started experiencing shoulder pain. He presented a week following the injury. The dislocated shoulder could not be reduced in emergency department. Bony defect involved 50% of humeral head. Case III, 45 years gentleman who fell off from bike, presented on the same day to the emergency department. The dislocated shoulder was reduced. Defect size was 40% of humeral head.

A thorough physical and radiological examination was performed to evaluate the lesion. Delto-pectoral approach was utilized for surgical exposure. Once fully assessed, the lesion is outlined and an oscillating saw is used to create uniform edges - – a regular “orange slice”- shaped defect. The prepared defect size is measured. Calcium phosphate cement is used to fill the defect and form a mould that represents the dimensions of allograft required to recreate the native sphericity of the humeral head. This mould then acts as a reference when fashioning the osteochondral femoral allograft to make sure this fits the defect anatomically. Once the graft is prepared, it is placed into the defect in the correct orientation and fixed in situ using headless screws. We utilized the same technique in all our patients.

Conclusion:

Reconstruction with osteochondral allograft is a promising technique to help shoulder surgeons achieve good outcomes for these patients. We propose a novel technique for fashioning allograft to anatomically fill the defects from bone loss, aiming to restores the native sphericity of the humeral head.

Arthroscopic Superior Capsular Reconstruction for Management of Massive Irreparable Rotator Cuff Tears: A Simple Alternative Technique

The use of acellular dermal allograft in arthroscopic superior capsular reconstruction is a promising treatment option for massive irreparable rotator cuff tears. However, indications are limited to a subset of patients, so it is not routinely performed. Therefore, the surgery is technically demanding, although it has evolved in recent years. The authors present a simple alternative technique that addresses common pitfalls. [Orthopedics. 2021;44(3):e458-e462.].

Evaluating Accuracy of Plain Magnetic Resonance Imaging or Arthrogram versus Wrist Arthroscopy in the Diagnosis of Scapholunate Interosseous Ligament Injury

Introduction Scapholunate interosseous ligament injury (SLIL) is the most common cause of wrist instability and a cause of morbidity in a proportion of patients with wrist injuries.

Aim To evaluate the accuracy of plain magnetic resonance imaging (MRI) and MR arthrogram (MRA) in the diagnosis of SLIL injury against the existing gold standard-wrist arthroscopy.

Materials and Methods We retrospectively reviewed 108 cases by comparing MRI/MRA reports and their wrist arthroscopy operation notes.

Results Overall MRI sensitivity to SLIL injuries was 38.5% (91.0% specificity). When broken down into plain MRI and MRA the results were: plain MRI sensitivity = 19.2% (91.4% specificity) and MRA sensitivity = 57.7% (90.5% specificity).

Conclusion Neither MRI nor MRA scanning is sensitive enough compared with the gold standard. Positive predictive value remains too low (62.5 and 88.2%, respectively) to consider bypassing diagnostic arthroscopy and treating surgically. The negative predictive value (60.4 and 63.6%, respectively) is inadequate to confirm exclusion of injury from MRI results alone.

Clinical Outcome of Transtendon Repair of Partial Articular Supraspinatus Tendon Avulsion Tear

Partial articular supraspinatus tendon avulsion (PASTA) tears are common. However, there is no consensus on the optimal surgical technique for the management of grade 3 tears (>50%). The authors report a retrospective consecutive case series of 64 patients with grade 3 PASTA lesions. The patients were treated by 2 surgeons from 2 centers with the same transtendon repair technique and implant system. The preoperative Oxford Shoulder Score (OSS) was compared with the postoperative OSS at final follow-up (mean, 28 months). Significant improvement in mean OSS occurred from 19.2 (SD, 7.5) preoperatively to 39.8 (SD, 7.8) postoperatively (P=.0001), and patient satisfaction rates were high (88%). The authors believe that transtendon repair of PASTA lesions of 50% or more is beneficial. High-quality randomized controlled trials are required to compare the benefit of repair vs debridement alone. [Orthopedics. 2020;43(6):e533-e537.].

Arthroscopic Superior Capsular Reconstruction of the Shoulder Using Dermal Allograft

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(4):215-220.].

How close is the axillary nerve to the inferior glenoid? A magnetic resonance study of normal and arthritic shoulders

INTRODUCTION

Axillary nerve injury is a major complication of shoulder surgery during glenoid exposure. The aim of this study was to measure the mean distance between the inferior glenoid and the axillary nerve in healthy shoulders and then to compare this distance between osteoarthritic and rotator cuff deficient glenohumeral joints.

METHODS

The magnetic resonance images of 50 patients with normal glenohumeral joints were reviewed. The infra-glenoid tubercle was determined as a fixed point and the distance to the axillary nerve was measured. Two separate assessors measured on the same sagittal sections. With a study power of 80%, the sample needed in each comparison group was 28 patients. Measurements were then performed on scans in patients with osteoarthritis and cuff tear arthropathy. The mean distance was compared between groups.

RESULTS

The mean distance between the infra-glenoid tubercle and axillary nerve was 12mm (standard deviation, SD, 5.6mm) in normal shoulders, 10.6mm (SD 5.4mm) in shoulders with osteoarthritis and 9.7mm (SD 3.7mm) in those with cuff tear arthropathy. For this sample size of 50 patients with a confidence interval of 95%, the mean range is 12mm (95% CI 10.4-13.6). A comparison between normal shoulder and osteoarthritis showed a p-value of 0.3, and between normal and cuff tear arthropathy a p-value of 0.06. This was not statistically significant.

CONCLUSIONS

The axillary nerve lies on average 12mm from the infra-glenoid tubercle. The presence of inferior osteophytes in glenohumeral osteoarthritis and the proximal migration of humeral head in cuff tear arthropathy does not seem to alter the course of the nerve significantly in relation to the inferior glenoid tubercle.

The Role of Clinical Examination in Predicting Relevant MRI Findings in Acute Knee Injuries: A Retrospective Study

The objective of this study was to delineate the usefulness of clinical examination and magnetic resonance imaging (MRI) in acute knee injuries. We aim to establish whether the time period post acute knee injury is related to the diagnostic accuracy of clinical examination and to investigate the strength of specific clinical examination findings in predicting a clinically relevant MRI abnormality. Seventy patients were referred to fracture clinic with an acute knee injury who subsequently went on to be investigated with MRI over 12 months. These patients were retrospectively analyzed looking at the time period they were reviewed, the components that were assessed at physical examination, and the results of their eventual MRI scan looking for any correlation. A greater proportion of patients who were examined at 2 weeks had relevant positive findings on MRI scan, p = 0.03. Range of movement and lateral joint line tenderness were not associated with a positive MRI scan at any period after injury. The presence of a moderate to large effusion was not associated with an MRI abnormality if the examination was within 2 weeks of injury but was if present 2 weeks after injury, p = 0.0001. Range of movement should not form part of the decision making on whether an injury should be investigated with MRI. Joint effusion in isolation within 2 weeks after injury should not be an indication for MRI but a repeat clinical examination in 2 weeks, where if still present, should be investigated with MRI.

Is it necessary to change instruments between sampling sites when taking multiple tissue specimens in musculoskeletal infections?

Introduction Surgical debridement of orthopaedic infections allows biopsy for microbiology and facilitates successful treatment. It is recommended that biopsy instruments are changed when taking multiple samples. This study compared assessed cross-contamination between biopsy sites when using same instruments to take tissue samples from multiple sites. Materials and methods During the surgical debridement, we defined five sampling sites and marked them with diathermy. Two sampling techniques were performed on same patient to minimise any potential bias arising from the type of host and the severity of infection. First, fresh instruments were used for each biopsy site. Titleond, the instruments used in the first sampling site were reused to take samples from the remaining sites. By comparing the microbiology results of the samples taken by each technique for each site we determined cross-contamination with microorganisms. Results Fifteen patients with foot and ankle infections (mean age 56 years) were included. Ten patients were diabetic and five had neuropathies. Cross-contamination between sampling sites occurred in eight cases when the same instruments were used to take biopsies (P = 0.002, Fisher's exact test). One or more microorganisms were involved in cross-contamination and the latter always occurred between two consecutive sites rather than sites that were further apart. Conclusion It is important to use fresh instruments for each biopsy site when taking multiple samples in musculoskeletal infection as cross-contamination might occur otherwise and affect microbiological studies.

Magnetic resonance imaging signal artefacts from invisible metal debris following surgery to the elbow

We report a case of exuberant artefacts on the magnetic resonance imaging scan of the elbow produced by invisible metal debris secondary to previous surgery.

The orthopaedic manifestation and outcomes of methicillin-sensitive Staphylococcus aureus septicaemia

AIMS

The aim of this paper was to present the clinical features of patients with musculoskeletal sources of methicillin-sensitive Staphylococcus aureus (MSSA) septicaemia.

PATIENTS AND METHODS

A total of 137 patients presented with MSSA septicaemia between 2012 and 2015. The primary source of infection was musculoskeletal in 48 patients (35%). Musculoskeletal infection was considered the primary source of septicaemia when endocarditis and other obvious sources were excluded. All patients with an arthroplasty at the time were evaluated for any prosthetic involvement.

RESULTS

The most common site of infection was the spine, which occurred in 28 patients (58%), and was associated with abscess formation in 16. Back pain was the presenting symptom in these patients, with a positive predictive value of 100%. A total of 24 patients had a total of 42 arthroplasties of the hip or knee in situ. Prosthetic joint infection occurred in six of these patients (25%). In five patients, the infection originated outside the musculoskeletal system. Three patients (6%) with MSSA septicaemia from a musculoskeletal sources died.

CONCLUSION

Amongst the musculoskeletal sources of MSSA septicaemia, the spine was the most commonly involved. We recommend an MRI scan of the whole spine and pelvis in patients with MSSA septicaemia with back pain, when the primary source of infection has not been identified or clinical examination is unreliable. Cite this article: Bone Joint J 2017;99-B:1545-51.

Tissue Biopsy in Infected Foot and Ankle Surgery

Category:

Basic Sciences/Biologics

Introduction/Purpose:

When performing surgical debridement to treat chronically infected orthopaedic cases our unit routinely samples 5 intraoperative specimens for microbiology. Best practice and achieving accurate sampling would suggest that a new scalpel and forceps for each sampling site would yield the most valid results.The alternate option would be to use the same instruments. The aim of this prospective study was to compare the two techniques in treating infected foot and ankle cases.

Methods:

Ten consecutive patients undergoing debridement for foot and ankle infection were prospectively included. Both techniques were performed on same patient to minimise any bias related to the type of host and severity of infection. This was achieved by collecting 5 tissue samples from 5 different sites initially using fresh instruments for each . We then used the first scalpel and forceps to sample the 2nd, 3rd, 4th, and 5th sites again. Samples were labelled from 1 to 9 where the 6th to 9th samples were from the same sites as the 2nd to 5th samples but taken by different technique. This allowed differentiating a genuine growth at a particular site from a contaminant carried on from another site.

Results:

In 7 patients the scalpel transferred microorganisms from one site to another as some of the 5 sites showed no organisms when biopsied by fresh instruments but showed growth when sampled by the re-used first scalpel. In the remaining 3 patients, the growth form the sites sampled by re-used first scalpel was consistent with the growth from those sites when ampled by fresh instruments .

Conclusion:

Our preliminary results showed that fresh scalpel and forceps are required for each sampling site to avoid transferring contamination from one site to another. This helps guide the extent of future debridement and also the type of antibiotics to be used.

Development and efficiency of dedicated upper limb trauma lists in a district general hospital

The aim of this audit was to assess the impact of dedicated upper limb trauma lists on the hospital stay and satisfaction of patients treated operatively for upper limb injuries. In first audit, we reviewed the data of 52 consecutive patients with upper limb injuries treated on the routine trauma lists. Accordingly, a new pathway of dedicated upper limb trauma lists was introduced whereby patients presenting with injuries were safely discharged home with written instructions regarding arrangements for surgery. The audit loop was then closed by collecting data of 78 consecutive patients treated using the new scheme. Dedicated upper limb trauma lists have reduced our in-patient stay without affecting the care and outcomes for our patients. The lists also improved patient satisfaction as arrangements for surgery were more convenient.

Comparison of the reconstruction trochanteric antigrade nail (TAN) with the proximal femoral nail antirotation (PFNA) in the management of reverse oblique intertrochanteric hip fractures

Reverse oblique intertrochanteric fractures have unique mechanical characteristics and are often treated with intramedullary implants. We compared the outcomes of the reconstruction trochanteric antegrade nail (TAN) with the proximal femoral nail antirotation (PFNA). Between July 2008 and February 2014, we reviewed all patients with reverse oblique intertrochanteric fractures treated at our hospital. Patients with pathological fractures and those who were treated with other than TAN and PFNA nailing systems were excluded. Preoperative assessment included the Abbreviated mental test score (AMT), the ASA grade, pre-injury mobility and place of residence. Postoperative outcome measures included the type of implant used, time to fracture union, failures of fixation and revision surgeries. Fifty-eight patients were included and divided into two groups based on the treatment: 22 patients treated with TAN and 36 patients treated with PFNA systems. The two groups were well matched with regards to demographics and fracture type. The overall union rate was similar in both groups but the time to union was shorter in the TAN group. There were 8 implant failures in the PFNA (22.2%) group compare to none in the TAN group. Implant failure was associated with the severity of fracture (AO 31.A3.3) but was not related to fracture malreduction or screw position (Tip-apex-distance). Our study suggests that the use of reconstruction system with two screws such as TAN may be more suitable implant for reverse oblique intertrochanteric hip fractures.

Lifting incise drapes off the skin during wound closure can cause contamination

Incise drapes adhere well to skin and reduce bacterial migration into the wound. We took skin swabs before and after the application of incise drapes during 49 hip and knee arthroplasty procedures. Contamination was detected under incise drapes in four cases (8.1%) and consisted mainly of skin flora. We conclude that it is important to clean the skin again with antiseptics if the incise drape is removed by the surgeon.

A prospective study on the risk of glove fingertip contamination during draping in joint replacement surgery

INTRODUCTION

The aim of this prospective study was to investigate the risk of contamination of surgical gloves during preparation and draping in joint replacement surgery.

METHODS

During 46 hip and knee replacement procedures, the gloves of orthopaedic consultants (n=5) and registrars (n=3) were assessed for contamination immediately after draping by impression of gloved fingers on blood agar. Contamination was evaluated by the surgeon's grade, the type of procedure, the role of the assistant and the dominance of the hand.

RESULTS

A total of 125 pairs of top gloves were examined (79 pairs from registrars and 46 pairs from consultants). Bacterial contamination was isolated on 19 pairs (15.2%) (16 pairs from registrars and 3 pairs from consultants, p=0.04). Coagulase negative staphylococci were the main isolates and contamination was considered low in all cases (1-5 colonies). Contamination was seen more on the dominant hand (16 gloves from dominant hands and 6 from non-dominant hands, p=0.04), on the index finger and thumb. More contaminated gloves were seen in hip arthroplasty procedures (16 pairs from total hip replacements vs 3 pairs from total knee replacements, p=0.02).

CONCLUSIONS

Contamination of glove fingertips during draping in joint replacement procedures is more likely to occur among junior surgeons, in hip rather than knee arthroplasty procedures and on the dominant hand. It is therefore essential that surgeons of different grades replace gloves used in draping to avoid exposing patients to the risk of infection.

Effect of surgical approach on the early outcome of total hip replacement for femoral neck fractures

We reviewed the short-term outcome of 171 patients treated with total hip replacement for femoral neck fractures using the lateral (94 patients) or posterior approach (77 patients). The Sernbo score and the Abbreviated Mental Test Score were used to assess patients' pre-injury functional and cognitive status respectively. Patients were uniformly treated with regard to the type of prosthesis, size of femoral head and rehabilitation. They were followed up to a mean of 25 months (range : 13-42 months). The dislocation rate in the lateral group was 2.1% versus 0% in the posterior group. There was no difference with regards to leg length discrepancy and the restoration of medial offset. Our results were attributed the standardised patients' selection and adequate soft tissue repair.

Intraoperative radiation use by trainees during ankle fracture fixation

Orthopedic trainees are assessed during training regarding their use of radiological screening during operative procedures. The authors investigated whether orthopedic trainees' use of fluoroscopic screening during ankle fixation operations varied with the 2 variables of consultant supervision and trainee experience. Data from operative fixation of isolated Weber B ankle fractures were reviewed. The intraoperative radiation dose was retrieved from radiographers' data. Operations performed by consultants were used as a control group (n=25 patients). Trainee supervision was assessed as "trainer in operating room (OR)" and "trainer out of OR." Regarding experience, the patients were divided into those operated on primarily by trainees in their first (n=36 patients) and in their last (n=34 patients) 3 years of formal specialist training. All trainee groups used more radiation than consultants. Supervision did not affect the radiation use of senior trainees (P<.05). Senior trainees used less radiation than their junior peers (P<.02). Junior trainees supervised by a trainer in the OR used less radiation than junior trainees supervised by a trainer outside of the OR (P<.05). During open reduction and internal fixation of ankle fractures, junior orthopedic trainees use less intraoperative radiation when they are supervised by a trainer in the OR. The more experience a surgeon has, the less fluoroscopic screening is used during operative ankle fixation.

Addition of an anti-rotation screw to the dynamic hip screw for femoral neck fractures

The authors investigated the use of an anti-rotation screw with the dynamic hip screw (DHS) during internal fixation of Garden I and II femoral neck fractures. Sixty-five patients with Garden I and II femoral neck fractures (mean age, 70 years) were treated with internal fixation at the authors' institution. In 31 patients, a 2-hole DHS was used alone (group 1), and in 34 patients, the DHS was combined with an anti-rotation screw placed in the cranial part of femoral head and neck (group 2). Patients' preinjury function and mental level were assessed using the Barthel index and the Abbreviated Mental test, respectively. The outcome measures included cost implications, operative time, and intraoperative radiation dose. The modified Harris Hip Score and a radiological assessment were performed at a mean of 11 months (range, 8-24 months) postoperatively. The use of the anti-rotation screw was associated with a longer operative time (mean, 44.54 minutes in group 1 vs 51.52 minutes in group 2; P<.0001) and more fluoroscopy screening (mean dose area product, 28.39 cGy/cm(2) in group 1 vs 44.33 cGy/cm(2) in group 2; P=.03). The additional cost of using an anti-rotation screw was £106 ($170) per case. No difference existed between the 2 groups with regard to radiological union, onset of avascular necrosis, and rate of revision surgeries. An anti-rotation screw, used with the dynamic hip screw, involves extra costs, prolongs operative time, and requires more intraoperative fluoroscopy screening but offers no advantages with regard to fracture union.

Dynesys dynamic stabilization: less good outcome than lumbar fusion at 4-year follow-up

Dynamic semirigid stabilization of the lumbar spine was introduced in 1994 in an attempt to overcome the drawbacks of fusion. It is supposed to preserve motion at the treated levels, while avoiding hypermobility and thus spondylosis at the adjacent levels. Although the early reports showed promising results, the long term effects are still debated. We retrospectively compared outcomes of Dynesys dynamic stabilization with those of the traditional fusion technique. Thirty-two patients who had undergone Dynesys between 2004 and 2006 (group 1) were compared to 32 patients who had been treated with fusion between 2005 and 2006 (group 2). VAS for back and leg pain, and ODI improved significantly in both groups (p < 0.001). These scores were all better in the fusion group, and even significantly so as far as VAS for back pain was concerned (p = 0.014). Similarly, more patients were satisfied or very satisfied after fusion than after Dynesys: 87.5% versus 68.8% (p = 0.04). Interestingly, in the Dynesys group scatter plot graphs showed a positive correlation between older age and improvement in the two VAS scores and in ODI. Dynamic stabilization with Dynesys remains controversial. Older patients are relatively more satisfied about it, probably because of their low level of demands.

Efficacy of corticosteroid injection versus size of plantar interdigital neuroma

BACKGROUND

The aim of this prospective study was to assess the effectiveness of a single ultrasound-guided steroid injection in the treatment of Morton's neuromas and whether the response to injection correlates with the size of the neuroma.

METHODS

Forty-three patients with clinical features of Morton's neuroma underwent ultrasound scan assessment. Once the lesion was confirmed in the relevant web space, a single corticosteroid injection was given using 40 mg of methylprednisolone along with 1% lidocaine. All scans and injections were performed by a single musculoskeletal radiologist. Patients were divided into two groups on the basis of the size of the lesion measured on the scan. Group 1 included patients with neuromas of 5 mm or less and group 2 patients had neuromas larger than 5 mm. A visual analog scale (VAS) for pain (scale 0 to 10), the American Orthopaedic Foot and Ankle Society (AOFAS) score, and the Johnson satisfaction scale were used to assess patients before injection and then at 6 weeks, 6 months, and 12 months following the injection. Thirty-nine patients had confirmed neuromas. Group 1 (lesion ≤ 5 mm) included 17 patients (mean age, 30 years) (7 males, 10 females) and group 2 (lesion >5 mm) had 22 patients (mean age, 33 years) (8 males, 14 females).

RESULTS

VAS scores, AOFAS scores, and Johnson scale improved significantly in both groups at 6 weeks (p < .0001). At 6 months postinjection, this improvement remained significant only in group 1 with all scores (p < . 001). At 12 months, there was no difference between both groups and outcome scores nearly approached preinjection scores. At the final review, two patients in group 1 and four patients in group 2 had severe recurrent symptoms and therefore underwent surgical excision of the neuroma after they rejected the offer for a repeat injection (p = 0.6).

CONCLUSION

A single ultrasound-guided corticosteroid injection resulted in generally short-term pain relief for symptomatic Morton's neuromas. The effectiveness of the injection appears to be more significant and long-lasting for lesions smaller than 5 mm.

The efficacy of patient information sheets in wrist arthroscopy: a randomised controlled trial

PURPOSE

To evaluate the effects of perioperative information for wrist arthroscopy on postoperative pain, return to daily activities, and patient satisfaction.

METHODS

34 women and 21 men aged 19 to 54 (mean, 35) years underwent diagnostic wrist arthroscopy to explore the radiocarpal and midcarpal joints. They were randomised to receive specific preoperative information on the procedure (pictures of the wrist joint anatomy, portal entry sites, and the arthroscope) and written instructions on postoperative care (n=28) or only standard preoperative information and verbal instructions on postoperative care (n=27). The visual analogue score (VAS) for pain and the Quick Dash score for return to daily activities of each patient were recorded before and after wrist arthroscopy. Analgesic intake after wrist arthroscopy was recorded.

RESULTS

The mean post-arthroscopic VAS from days 2 to 6 was significantly lower in the experimental group than controls. This was reflected by the decrease in analgesic intake. The mean post-arthroscopic Quick Dash score was significantly lower in the experimental group than controls (40 vs. 47, p=0.02), indicating earlier return to daily activities.

CONCLUSION

Patients who received specific preoperative information on the procedure and written instructions on postoperative care experienced less pain, consumed less analgesics, and had an earlier return to daily activities.

Osteosynthesis of displaced intra-articular fractures of the calcaneum: a long-term review of 47 cases

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders' classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler's angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders' classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler's angle.

Osteosynthesis of displaced intra-articular fractures of the calcaneum: a long-term review of 47 cases

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders' classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler's angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders' classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler's angle.

Septic trochanteric bursitis in an adolescent

Trochanteric bursitis, whether septic or inflammatory in origin, is a condition that affects middle-aged patients. Here we report the rare case of an adolescent with septic trochanteric bursitis (treated successfully with intravenous antibiotics), review the available literature on septic bursitis, illustrate the importance of prompt recognition and treatment of this condition in any age group, and describe the clinical presentation and the radiologic findings.

Single photon emission computerized tomography (SPECT) scan-positive facet joints and other spinal structures in a hospital-wide population with spinal pain

BACKGROUND CONTEXT

The current criterion standard for zygapophyseal (facet) joint pain diagnosis is placebo-controlled triple comparative local anesthetic facet joint or medial branch blocks. Single photon emission computerized tomography (SPECT) scanning is a less invasive modality that has been widely used in patients with spinal pain for the diagnosis of facet joint arthritis. Previous studies have shown that SPECT results correlate well with response to facet joints steroid injections.

PURPOSE

To evaluate the prevalence of SPECT scan-positive facet joints and other spinal areas in different age groups in a hospital-wide population with spinal pain.

STUDY DESIGN

Retrospective study.

METHODS

This study included 534 patients who underwent a SPECT scan for spinal pain over 7.5 years in our hospital. All referrals from all doctors for any cervical or lumbar spinal pain were included, and the results were reviewed.

RESULTS

A total of 486 patients (91.1%) had at least one positive abnormality on SPECT scan; 81.3% had increased uptake in different structures and regions of the spine. This included 42.8% increased uptake in the facet joint 29.8% in the vertebral bodies/end plates, and 5.9% in sacroiliac joints. The prevalence of increased uptake in the lumbosacral and cervical spine was 44% and 37%, respectively. When patients were divided into five age groups (below 40, 40-49, 50-59, 60-69, and 70 years and older), there was a significantly higher increased prevalence in advancing age groups.

CONCLUSIONS

In a hospital-wide population with spinal pain, there is a 42.88% prevalence of increased uptake in the facet joint on SPECT. The incidence increases significantly with advancing age. SPECT can play a role in investigating patients with spinal pain.

Double- versus single-incision technique for open carpal tunnel release

A prospective, randomized, controlled trial was performed comparing the double incision technique to the conventional open method used in carpal tunnel decompression surgery, with pillar pain, scar sensitivity, and recovery of grip strength each assessed independently. Forty patients (40 hands) were operated on, 21 hands with the standard single-incision technique and 19 hands with the double-incision technique. Patients were assessed throughout 6 months of follow-up. The results showed that the double-incision technique caused less pillar pain and scar sensitivity compared to the single-incision technique. No difference in recovery of grip strength was noted between the 2 techniques. The limited open technique using the double incision in carpal tunnel decompression surgery is advantageous over the standard technique in tackling scar-related morbidities.