A review of Marcel Lemaire's original work on lateral extra-articular tenodesis

This classic discusses Marcel Lemaire's original publications in the context of modern surgical practice, including a description of his original lateral extra-articular tenodesis. Previously published in French, these translations shed light on his revelations regarding the anterior cruciate ligament's role in knee stability and his detailed insights into the ressaut rotatoire or the pivot shift phenomenon. We track the evolution of Lemaire's procedure since the publication of his original technique in 1967 which used a nylon cord superficial to the lateral collateral ligament followed by cast immobilisation for one month. We report his patient outcomes as he refines his methods through experiential learning. Lemaire's fundamental concepts in relation to anterior cruciate ligament deficiency remain relevant in contemporary clinical practice. Furthermore, the "modified Lemaire technique" has emerged as one of the preferred methods for lateral extra-articular tenodesis. We hope that disseminating his thoughts to a wider audience will help enlighten the ongoing debate regarding the management of rotatory instability. LEVEL OF EVIDENCE: V - Expert Opinion.

Mechanical outcomes of the TFNA, InterTAN and IMHS intramedullary nailing systems for the fixation of proximal femur fractures

INTRODUCTION

Hip fractures have become a major public health priority due to their increasing incidence. Intramedullary (IM) nailing has gained popularity as a surgical technique for managing these fractures. However, comparative studies with extramedullary devices indicate potentially increased mechanical complications associated with IM nailing. Specifically, there have been recent reports of early implant fracture associated with the TFNA system. This study compares the rate of mechanical complications between 3 implants. Secondarily, we analysed the factors associated with implant fracture and all other mechanical complications.

METHODS

This retrospective study included 803 IM nails performed between 2008-2021 for the fixation of proximal femur fractures at a level 1 trauma centre. We recorded patient demographics, AO fracture classification, implant specification and intra-operative parameters such as tip-apex distance, Cleveland index, reduction quality, presence of medial calcar integrity, neck-shaft angle. The outcomes analysed included implant fracture, lag screw cut-out, >10 mm backing out, autodynamisation, periprosthetic fracture, non-union at 6 months and time to revision surgery.

RESULTS

The overall implant fracture rate was 3.1 % (25/803), with no statistically significant difference between the three devices (p = 0.51). The TFNA group included 183 patients with a median follow-up of 1.6 years. The TFNA fracture rate was 2.2 % (4/183) which occurred at 207 +/- 16.66 days post-operatively. The rate of all mechanical complications was 4.9 % in the TFNA group, 12.9 % in the InterTAN group and 17 % in the IMHS group. Non-union (p < 0.001) and increasing lag screw length (p < 0.02) were identified as risk factors for implant fracture and other mechanical complications. The reverse oblique fracture pattern (AO 31 A3.1) was associated with mechanical complications only (p < 0.01). The cumulative survival rates without revision for the TFNA, InterTAN, IMHS groups were 97.8 %, 95.5 % and 87.9 % respectively at 2.5 years.

DISCUSSION

The rates of implant fracture were comparable between the three nailing systems. The TFNA provides effective fixation for proximal femur fractures using a traditional screw without cement augmentation. The TFNA was associated with an overall reduction in mechanical complications compared to the InterTAN and IMHS. Previously reported mechanical complications associated with IM Nails may relate to older device designs.

A standardised communication tool reduces radiation exposure associated with intraoperative fluoroscopy

BACKGROUND

The widespread use of intraoperative fluoroscopy in orthopaedic procedures has revolutionised surgical practice. However, there are risks associated with using ionising radiation. Efforts to reduce radiation exposure include low-dose imaging protocols and lead protective equipment. Current communication during fluoroscopic procedures can be inefficient and lead to excessive radiation exposure for patients and staff.

AIMS

This study aims to implement a communication tool with standardised commands to reduce radiation exposure in an Irish orthopaedic department.

METHODS

Radiation exposure was evaluated using dose-area product (DAP) measured in uGy/m2. A control group was recorded before implementing the communication tool. Training sessions were conducted and posters of the standardised commands were displayed. Feedback was collected from surgeons and radiographers via surveys. Statistical analysis was performed to compare pre- and post-intervention groups.

RESULTS

A total of 673 surgical cases were included over 6 months. The post-intervention group showed a mean reduction in radiation exposure from 59.8 to 36.4 uGy/m2 (p < 0.011). Subset analyses revealed reduced radiation exposure for ORIF of the distal radius, ankle, humerus, and phalanges. Surgeons and radiographers recognised the need for improved communication and expressed willingness to learn the new tool.

CONCLUSIONS

Implementation of a standardised communication tool effectively reduced patient and staff radiation exposure. It was also believed to have a positive effect on theatre staff morale. Incorporating a universal language tool into training programmes could be beneficial. Surgeons and radiographers provided several suggestions to improve the effectiveness and implementation of this tool into other units.

Acetabular cup size trends in total hip arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is a common procedure for end stage osteoarthritis. The learning curve for THA is complex and challenging. One of the most difficult skills to master is acetabular reaming. We wish to identify if experience in arthroplasty leads to preservation of more bone stock.

AIM

To investigate if increasing surgeon experience will predict an ever decreasing acetabular cup size.

METHODS

A retrospective case series of four attending orthopaedic surgeons was completed. All uncemented elective total hip arthroplasties since appointment were selected for inclusion. The size of acetabular cup used was noted and logistic regression was used to identify if a trend to smaller cups existed.

RESULTS

A total of 1614 subjects were included with a mean age of 64 years. Overall cups were on average 0.18mm smaller per year (95% confidence interval -0.25 to -0.11, P < 0.001). Individual surgeon trends showed cup sizes to decrease 0.27 mm/year for surgeon A, 0.02 mm/year for surgeon B, 0.15 mm/year for surgeon C and 0.29 mm/year for surgeon D. Three of the four surgeons had a more pronounced trend to smaller cups for male subjects than their female counterparts.

CONCLUSION

We found increasing surgeon experience to be associated with an ever-decreasing acetabular cup size. Smaller acetabular cup size may act as a surrogate marker of surgical proficiency by virtue of decreased acetabular reaming.

Surgical helmet systems in total joint arthroplasty: assessment of hood sterility and donning technique

BACKGROUND

The incidence of prosthetic joint infection (PJI) is increasing, coincident with the rising volume of joint arthroplasty being performed. With recent controversy regarding the efficacy of surgical helmet systems (SHS) in preventing infection, the focus has turned to the correct donning techniques and usage of surgical hoods. The aim of this study was to compare the bacterial contamination of the operating surgeon's gloves after two common donning techniques of SHS hoods. We also evaluated the baseline sterility of the SHS hoods at the beginning of the procedure.

METHODS

The bacterial contamination rate was quantified using colony-forming units (CFUs), with 50 trials performed per donning technique. Samples were cultured on 5% Columbia blood agar in ambient air at 37 °C for 48 h and all subsequent bacterial growth was identified using a MALDI-TOF mass spectrometer. In Group 1, the operating surgeon donned their colleague's hood. In Group 2, the operating surgeon had their hood applied by a non-scrubbed colleague. After each trial, the operating surgeon immediately inoculated their gloves onto an agar plate. The immediate sterility of 50 SHS hoods was assessed at two separate zones-the screen (Zone 1) and the neckline (Zone 2).

RESULTS

There was no significant difference in contamination rates between the two techniques (3% vs. 2%, P = 0.99) or between right and left glove contamination rates. Immediately after donning, 6/50 (12%) of SHS hoods cultured an organism. Contamination rates at both the face shield and neckline zones were equivalent. The majority of bacteria cultured were Bacillus species.

DISCUSSION

We found no significant difference in the operating surgeon's glove contamination using two common SHS hood-donning techniques when they were performed under laminar airflow with late fan activation. We suggest the SHS hood should not be assumed to be completely sterile and that gloves are changed if it is touched intraoperatively.

Does lucency equate to revision? A five-year retrospective review of Attune and Triathlon total knee arthroplasty

PURPOSE

The Attune® total knee arthroplasty system was introduced in 2013 to address lingering issues of patient dissatisfaction. However, recent literature reports concerns of early tibial tray debonding. The aim of this study was to compare the incidence of radiolucent lines, survivorship and patient reported outcome-measures between the Attune® system and the well-established Triathlon® system.

METHODS

This retrospective database review was conducted at a single institution in Cork, Ireland. All primary Attune® (N = 445) and Triathlon® (N = 285) systems implanted between 2015 and 2016 were reviewed. Radiolucent lines were assessed for those with a minimum two-year radiological follow-up (Attune® = 338; Triathlon® = 231). X-rays were taken post op, at 6 months, 2 years and 5 years. Radiolucent lines were documented using the Modern Knee Society Radiographic System. Five-year survival was assessed using Kaplan-Meier analysis with the Log Rank method to determine statistical significance. The Oxford Knee Score and EQ-5D-5L, were collected pre-op, at 6 months, 2 years and 5 years post-operatively and compared using the Kruskal-Wallis Test.

RESULTS

The Attune® had a higher proportion of radiolucent lines at the tibial tray [87.1% (54/62) vs 61.4% (27/44); p = 0.001] and at the implant-cement interface [62.9% (39/62) vs 43.2% (19/44); p = 0.02]. Conversely, the Triathlon® had a higher proportion AT the femur [38.6% (17/44) vs 12.9% (8/62); p = 0.001] and at the cement-bone interface [56.8% (25/44) vs 37.1% (23/62); p = 0.02]. The overall frequency of radiolucent lines was similar in both the Attune® and Triathlon® groups [17.8%, (60/338) vs 17.7%, (41/231); p = 0.49]. There was no difference in revision-free survival analysis at 5 years (Attune® 97.8% vs Triathlon® 95.8%; p = 0.129). The Attune® performed better at 5 years in the Oxford Knee Score [Attune® = 42.6 (SD 5.2) vs Triathlon® = 41 (SD 6.4); p = 0.001] and in the EQ-5D [Attune® = 0.773 (SD 0.187) vs Triathlon® = 0.729 (SD 0.218); p = 0.013]. There was no difference at 5 years in the EQ-VAS [Attune® = 80.4 (SD 13.7) vs Triathlon® = 78.5 (SD 15.3); p = 0.25].

CONCLUSION

The Attune® system exhibited a higher incidence of  radiolucent lines at the tibial tray. However, this did not lead to decreased survivorship at medium term follow-up compared to the Triathlon®. Furthermore, improvements in patient reported outcomes modestly favoured the Attune® system.

LEVEL OF EVIDENCE

III.

Kocuria rhizophila prosthetic hip joint infection

We present the first case report of prosthetic joint infection (PJI) caused by Kocuria rhizophila. Our patient is a 74-year-old male who underwent primary total hip replacement for right hip pain. His recovery was uneventful until 6 weeks postoperatively when he presented to his routine outpatient appointment with significant erythema, swelling, and tenderness over his right hip wound. Based on the acuity of his symptoms and the radiological findings, it was determined that the patient should undergo debridement, antibiotics, and implant retention (DAIR procedure). A consensus decision was also made at our PJI multidisciplinary meeting to treat him with 12 weeks of IV antibiotics. After completing this 12 weeks course of IV Vancomycin, his inflammatory markers returned to normal limits. At 6 months follow-up, our patient was mobilizing independently without any signs of infection recurrence. His radiographs showed the implant was in a satisfactory position with no evidence of loosening. This case adds to an emerging body of literature describing invasive infections associated with Kocuria species. We have demonstrated the effectiveness of managing this condition with debridement, implant retention, and IV Vancomycin therapy for 12 weeks.

Sustainable orthopaedic surgery: Initiatives to improve our environmental, social and economic impact

In response to appeals from the WHO and The Lancet, a collaborative statement from over 200 medical journals was published in September 2021, advising international governments to combat the "catastrophic harm to health" from climate change. Healthcare, specifically surgery, constitutes a major contributor to environmental harm that remains unaddressed. This article provides practical guidance that can be instituted at a departmental, hospital and national level to institute transformative, sustainable efforts into practice. We also aim to provoke healthcare leaders to discuss policy-making with respect to this issue and highlight the necessity for sustainability to become a core domain of quality improvement. The average orthopaedic service produces 60% more waste than any other surgical specialty. Fortunately, simple measures such as a comprehensive education programme can decrease waste disposal costs by 20-fold. Other simple and effective "green" measures include integrating carbon literacy into surgical training, prioritising regional anaesthesia and conducting recycling audits. Furthermore, industry must take accountability and be incentivised to limit the use of single-item packaging and single-use items. National policymakers should consider the benefits of reusable implants, reusable surgical drapes and refurbishing crutches as these are proven cost and climate-effective interventions. It is crucial to establish a local sustainability committee to maintain these interventions and to bridge the gap between clinicians, industry and policymakers.

Recurrent chondroblastoma of the talus: A case report and literature review of recurrent lesions in the foot and ankle

INTRODUCTION AND IMPORTANCE

Chondroblastoma is a benign cartilaginous tumour that usually presents in the epiphysis of long bones in patients aged 10-20 years old. Only 4 % of primary chondroblastoma occur in the talus. Recurrence is rare, especially in the foot and ankle and there is no consensus regarding how it is best managed. This unique case and literature review add to a limited evidence base.

CASE PRESENTATION

A 21-year-old male was referred to our elective orthopaedic clinic with persistent anterior ankle pain exacerbated by weight-bearing. Radiographs and MRI revealed a 2.5 cm non-homogenous mass in the anteromedial talus with expansion of overlying bone consistent with chondroblastoma-ABC. Our patient was initially managed by intralesional curettage and autologous bone grafting but had recurrence 4.5 months postoperatively. Subsequent en bloc resection of the talar neck with talonavicular and calcaneocuboid joint fusion resulted in excellent functional outcomes and disease-free survival at 2 years follow-up.

CLINICAL DISCUSSION

There are few reports discussing treatment options for recurrence in the foot and ankle. Successful treatment of primary and recurrent lesions depends on complete local resection. Repeat curettage or en bloc resection are effective options depending on tumour size and location. Type of bone graft or void filler should be considered on a case-by-case basis. Novel therapies (e.g. phenol instillation) may be beneficial.

CONCLUSION

This case details successful management of recurrent chondroblastoma with en bloc resection of the talar neck and hindfoot reconstruction. We review the efficacy and outcomes of all previously reported recurrent chondroblastoma in the foot and ankle. We highlight multiple potential treatment options.

Bilateral patellar tendon rupture following low-energy trauma in a young patient without predisposing risk factors

We describe the case of a 25 year old male who presented with a bilateral patellar tendon ruptures without any of the identified risk factors for tendon injuries. Our patient is the youngest adult reported to date with confirmed bilateral, unprovoked, patellar tendon ruptures. We accompany our case with an up-to-date literature review on this topic. A degree of clinical suspicion is required for emergency room physicians as well as orthopaedic surgeons assessing such patients to avoid missing bilateral injuries. Point of care ultrasound may be utilised when there is doubt regarding the diagnosis. Prompt surgical management and a specific rehabilitation programme are both required to ensure maximum recovery of these patients.

Paediatric major trauma in the setting of the Irish trauma network

BACKGROUND

The construction of a new tertiary children's hospital and reconfiguration of its two satellite centres will become the Irish epicentre for all paediatric care including paediatric trauma. Ireland is also currently establishing a national trauma network although further planning of how to manage paediatric trauma in the context of this system is required. This research defines the unknown epidemiology of paediatric major trauma in Ireland to assist strategic planning of a future paediatric major trauma network.

METHODS

Data from 1068 paediatric trauma cases was extracted from a longitudinal series of annual cross-sectional studies collected by the Trauma Audit and Research Network (TARN). All paediatric patients between the ages of 0-16 suffering AIS ≥2 injuries in Ireland between 2014-2018 were included. Demographics, injury patterns, hospital care processes and outcomes were analysed.

RESULTS

Children were most commonly injured at home (45.1%) or in public places/roads (40.1%). The most frequent mechanisms of trauma were falls <2 m (36.8%) followed by RTAs (24.3%). Limb injuries followed by head injuries were the most often injured body parts. The proportion of head injuries in those aged <1 year is double that of any other age group. Only 21% of patients present directly to a children's hospital and 46% require transfer. Consultant-led emergency care is currently delivered to 41.5% of paediatric major trauma patients, there were 555 (48.2%) patients who required operative intervention and 22.8% who required critical care admission. A significant number of children in Ireland aged 1-5 years die from asphyxia/drowning. The overall mortality rate was 3.8% and was significantly associated with the presence of head injuries (p < 0.001).

CONCLUSION

Paediatric Trauma represents a significant childhood burden of mortality and morbidity in Ireland. There are currently several sub-optimal elements of paediatric trauma service delivery that will benefit from the establishment of a trauma network. This research will help guide prevention strategy, policy-making and workforce planning during the establishment of an Irish paediatric trauma network and will act as a benchmark for future comparison studies after the network is implemented.

Bilateral Mechanically-Assisted Crevice Corrosion Resulting in Femoral Stem-Head Dissociation in Metal-on-Polyethylene Total Hip Arthroplasty

There are emerging reports of complications related to corrosion in modular femoral components. We report a unique case describing an 83-year-old man with bilateral mechanically-assisted crevice corrosion in hip replacements performed 10 years previously, by the same surgeon using the same size 3 Accolade TMZF stem and same 44-mm CoCr LFIT V40 head (Stryker Orthopedics, Mahwah NJ). Our patient presented with complete femoral stem-head complex dissociation of his right hip and elevated serum cobalt and chromium levels. He subsequently underwent right hip revision arthroplasty while his contralateral hip is monitored closely as an outpatient. This case helps to define the poorly understood mechanisms and component design factors implicated in this emerging issue. We also hope to provoke discussions about guidelines for monitoring and revising failing metal-on-polyethylene arthroplasty systems.

Thyroid radiation shields: A potential source of intraoperative infection

Introduction

Thyroid radiation shields are often uncovered by the surgical gown and may represent a preventable source of wound contamination. The aims of this study are to define the common pathogens found on thyroid radiation shields and evaluate the effectiveness of a simple cleaning method.

Methods

Samples were obtained from 29 community thyroid shields collected from the operating theatres of 3 teaching hospitals. Each shield was swabbed under strict sterile technique using a separate swab for each of 4 designated zones. After sampling, shields were cleaned with a readily available disinfectant and sampling was repeated after 5 min. All swabs were cultured in ambient air at 37 °C on 5% sheeps blood agar for 48 hrs and subsequent growth was identified by a MALDI-TOF Walkaway mass spectrometer.

Results

Before cleaning, 100% of thyroid shields (29/29) and 68% of shield zones (79/116) grew at least 1 type of bacteria. Coagulase negative staphylococci, including S. epidermidis, S. capitis, S. cohnii, S. haemolyticus and S. hominis, were most commonly isolated. Enterobacteriaceae and S. aureus were also cultured. After cleaning, culturable contamination was reduced by 86.3% and 64.5%, respectively (p < 0.001).

Conclusion

The most common pathogens associated with SSIs can be isolated on thyroid radiation shields. Appropriate cleaning of thyroid shields with readily available disinfectant can significantly reduce the bacterial burden as detectable by culture. Hospitals should facilitate staff education and reinforce their policies on cleaning these shields which may often be overlooked.

Posteriorly displaced salter halter fracture-dislocation at the sternoclavicular joint with associated thoracic outlet syndrome: A case report

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Posterior sternoclavicular joint fracture-dislocations are a rare and often-missed injury in trauma.

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Posterior displacement at the SCJ is a true emergency and can be associated with compression of vital structures and thoracic outlet syndrome.

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Closed or open reduction of these injuries is generally advised but is associated with considerable risk.

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Conservative management can be successful in the presence of physeal injury but has never been described in the setting of thoracic outlet syndrome.

Introduction

Posterior sternoclavicular joint fracture-dislocations are a rare and often missed diagnosis. They represent <1% of shoulder girdle injuries and are nine times less common than anterior dislocations. These injuries can be associated with life-threatening complications such as compression of the superior mediastinal structures including the great vessels and brachial plexus.

Presentation of Case

This case describes a 23-year-old woman who was initially discharged from the emergency department but represented 8 days later with symptoms of venous and neurogenic thoracic outlet syndrome as a result of posterior displacement of a Salter 2 fracture-dislocation at the sternoclavicular joint. Multidisciplinary consensus and patient preference resulted in the conservative management of her injuries with intensive rehabilitation and close outpatient follow-up.

Discussion

The evidence regarding this rare injury is evolving. It currently suggests all posteriorly displaced fracture-dislocations at the sternoclavicular joint are reduced. Closed reduction is often unsuccessful and open reduction is high risk and must be undertaken in the presence of a cardiothoracic surgeon which may not always be appropriate or in line with patient preferences. There are limited reports of successful conservative management of these injuries and none in the setting of thoracic outlet syndrome.

Conclusion

This unique case report is the first to describe outcomes of a conservatively managed, posteriorly displaced fracture-dislocation at the sternoclavicular joint with associated venous and neurogenic thoracic outlet syndrome. This information will benefit select patients.

Foot and ankle service adaptation in response to COVID-19 and beyond

The disruption to healthcare provision as a result of the COVID-19 pandemic has compelled us to streamline healthcare delivery. This has given us an opportunity to implement healthcare technology, reform inter-disciplinary collaboration and ultimately enhance patient care. We discuss some of the advances made by the foot and ankle department at our hospital. These innovations have broad applicability and will hopefully ignite discussion amoung a number of healthcare teams about improving the future care of their patients.