Refractory patella tendinopathy with failed conservative treatment-shock wave or arthroscopy?

AIM

To identify whether the location of refractory patella tendinopathy (PT) has an effect on treatment modality (radial extracorporeal shock wave therapy (rESWT) or arthroscopic debridement).

METHODS

Between 2012 and 2014, 40 patients with PT underwent a magnetic resonance imaging (MRI) scan. This confirmed the diagnosis as either involving the tendon itself (group A, 20) or with retropatella fat pad extension (group B, 20). All patients underwent rESWT. If there was no improvement patients proceeded with surgery in the form of arthroscopic debridement (by senior authors CW and AG). Outcomes were assessed before and after treatment using the Victorian Institute of Sports Assessment-Patella (VISA-P) score.

RESULTS

There were 18 males and 2 females in group A and 15 males and 5 females in group B. The mean age was 41.4 years in group A (23-59) and 34.7 in group B (19-52). Seventeen of 20 in group A reported good or excellent outcomes and did not require surgical intervention (remaining three improved after second course of ESWT). All patients in group B failed to improve with rESWT, resulting in arthroscopic debridement and reported good or excellent outcomes. After 6 months, group A mean VISA-P score increased from 50.2 to 65.0 ( p = 0.01) and group B from 39.6 to 78.4 ( p = <0.001).

CONCLUSION

An MRI should be performed to determine the precise location of tendinosis in patients with refractory PT who fail standard conservative management. If the MRI scan shows intratendon changes only, ESWT should be performed and those with extension into the fat pad should proceed to arthroscopic debridement without rESWT.

A Controlled Clinical Trial of Postoperative Hand Elevation at Home Following Day-Case Surgery

Although elevation of the upper limb is considered valuable for the prevention and of the reduction of swelling following major surgery or severe injuries to the hand, it is not clear how much elevation, if any, is required following minor surgery such as carpal tunnel decompression. We investigated this by randomizing patients undergoing carpal tunnel decompression into two groups – one having high elevation at home and one being treated with a simple sling. Volumetric analysis of the swelling of the hand 5 days postoperatively showed no significant difference between the two groups. In the trial group, the mean increase in volume of the operated hand was 11 ml (95% CI +4 to +17) or 2.7%. In the control group, the mean swelling was 13 ml (95% CI +4 to +21) or 3.6%. The findings of this study do not support the use of routine high arm elevation following day-case surgery of the hand.

Condylar fractures of the proximal and middle phalanges

We describe the treatment of 74 patients with phalangeal condylar fractures. Twelve patients presenting with undisplaced fractures were initially treated nonoperatively; of these, five displaced, requiring fixation. The remaining seven patients, all children, united uneventfully. Sixty-two patients presenting with displaced fractures were treated with internal fixation using a single lag screw through a lateral approach. The patients were treated semi-electively on a day surgery unit. Twenty-seven patients with unicondylar fractures, all operated on within 2 weeks of injury, regained full range of movement. Thirty-eight patients had loss of extension (range 10-35°) with fixed flexion contractures at the proximal interphalangeal and thumb interphalangeal joints and extensor lag at the distal interphalangeal joints (overall mean extension loss 10°). Although fixation was technically easier during the first week, a delay of 2 weeks before fixation made little difference to the outcome. In our experience, fractures can be taken down and fixed internally even 8 weeks after injury. If nonoperative treatment is initially embarked upon, close monitoring is required with weekly radiographs up to 3 weeks, as these fractures will frequently displace.

Two-stage revision for infected total knee arthroplasty: our experience with interval prosthesis

INTRODUCTION

To review our practice of performing two-stage revision for infected total knee arthroplasty using articulating interval prosthesis and to compare the incidence of the recurrence of infection and re-operation rate in patients undergoing two-stage revision as planned with the group of patients who choose not to proceed to the second stage.

METHOD

This study is a retrospective review of 60 consecutive patients undergoing a two-stage revision for infected total knee arthroplasty using articulating interval prosthesis. All cases managed by a single surgeon using a uniform peri-operative protocol, and short-course parenteral antibiotic therapy.

RESULT

Thirty-four patients (57%) (Group 1) underwent the two-stage revision as planned. However, twenty-six patients (43%) (Group 2) opted not to have a second-stage procedure as the first-stage and interval prosthesis had eradicated the infection, resolved the pain and achieved good functional outcome. There were five cases of recurrent infection in the 60 patients (8%) at a mean follow-up 5 years. In those completing the two-stage revision, two patients had recurrent infection. Of the patients who retained the interval prosthesis, there were three recurrent infections. There was no statistically significant difference between the groups in terms of recurrence of infection or re-revision.

CONCLUSION

Two-stage revision with interval prostheses represents a safe and reliable method of treating infected knee prosthesis; however, there may be a role for one-stage revision in selected cases.

Does it matter whom you see? - a fracture clinic audit

INTRODUCTION

A consultant-led service for trauma in the UK has become the accepted norm. Practice in fracture clinics may vary widely between consultants and has an impact on the number of patients seen and, therefore, the time devoted to each patient.

PATIENTS AND METHODS

A total of 945 patients attending our unit's fracture clinics were analysed over a 6-week period, representing one complete cycle of our trauma system.

RESULTS

The overall discharge rate was 38% but this differed significantly between consultants. Patients re-presenting for the same complaint were evenly distributed between those discharging aggressively and those re-reviewing regularly.

CONCLUSIONS

Re-reviewing patients has a significant impact on the number of patients seen in future clinics and, therefore, the time that can be devoted to each patient, individual consultant workload and teaching of junior staff. Since the re-presentation rate between those discharging aggressively and those re-reviewing more frequently was the same, discharge protocols are recommended for common trauma conditions to standardise the process. Specialist clinics are recommended for more complex trauma cases.

A review of wound healing following Maquet osteotomy

Maquet osteotomy can be associated with an unacceptably high incidence of wound complications that may be as high as 37%. A consecutive series of 42 Maquet osteotomies has been performed between 1990 and 2002 by a single surgeon without a single wound problem or infection and this series is the subject of this report. The use of an anterolateral incision reduces the damage to the major lymphatics minimising the risk of wound oedema. Identification and preservation of the feeding musculocutaneous vessels on the lateral and medial sides facilitates extensive but safe mobilisation of the skin flaps permitting an easy closure over a substantially elevated tibial tubercle. The use of an anterolateral incision with knowledge of the blood supply of the leg has eliminated the wound complications associated with the standard anteromedial incision reported previously in the literature. This approach, preserving the blood supply and lymphatic drainage, avoids skin necrosis and wound dehiscence, obviates any requirement for plastic surgical procedures such as releasing incisions or skin grafts and minimises the risk of infection and osteomyelitis.