Acute surgical management of traumatic knee dislocations--Average follow-up of 10 years.

BACKGROUND: Traumatic knee dislocations have been managed historically by means of either delayed reconstruction or non-operative methods. More recently, there has been a trend towards early reconstruction. There is no clear consensus in the literature as to how such patients should be managed and in what time frame. OBJECTIVE: The aim of this study was to establish the long-term outcome of patients who underwent acute surgical management of their traumatic knee dislocation. METHODS: Thirty-six patients with traumatic knee dislocations were treated by multi-ligament reconstruction. All surgical interventions occurred within 21 days of presentation. The collateral ligament complexes were primarily repaired where possible and reconstructions were performed with either autograft, allograft or the ligament augmentation and reconstruction system (LARS) synthetic graft. RESULTS: The mean time to surgery was 12 days (1 to 21) with a mean follow-up of 10.1 years (7 to 19). The International Knee Documentation Committee (IKDC) assessment demonstrates that 56% of patients went on to have "nearly normal" knee function and the average Tegner-Lysholm score of 80 (57 to 91), is consistent with good function. The Knee Outcome score (KOS) was 84% for Activities of Daily Living and 74% for Sports. CONCLUSION: This study demonstrates a high level of overall knee function following the acute surgical reconstruction of traumatic knee dislocations. LEVEL OF EVIDENCE: Level 2B: Cohort Study with Outcome Measures.

27 year survival of Maney Watt unicondylar hemi knee replacement for fixation of a lateral tibial plateau fracture--a case report.

We report the case of a 62-year-old gentleman who underwent a novel treatment for a lateral tibial plateau fracture 27 years ago. The patient presented to an elective knee outpatient clinic with new onset knee pain. Further investigation revealed that this was a Maney Watt prosthesis (Zimmer UK) for use in the management of unicompartmental osteoarthritis. This mode of fixation gave this patient over 20 years of good functional outcome. Following revision, the patient was followed up at 5 years, reporting a satisfactory outcome.

Early failure of a mobile-bearing unicompartmental knee replacement.

Concerned by a perceived high revision rate, we retrospectively reviewed the survivorship of a series of 43 cemented, medial, mobile-bearing Preservation unicompartmental knee replacements implanted during a 2-year period at a single institution. The initial post-operative AP and lateral radiographs were independently assessed to test the hypothesis that suboptimal implantation of the prosthesis was responsible for early failure. An X-ray scoring system based on the criteria for assessing the Oxford mobile-bearing unicompartmental knee replacement was devised. The components of this score included assessment of prosthesis alignment, sizing and cementation. Nine (21%) LCS Preservation mobile-bearings prostheses had required revision at a mean of 22 months post-implantation. The commonest causes for failure were pain (44%) and tibial component loosening (33%). Analysis of post-operative radiographs showed no difference (n.s.) between the compound error scores for the revised and the surviving prostheses. No particular surgical error was identifiable leading to subsequent need for revision. The high failure rates shown in this study have led us to cease using this implant. The clinical relevance of this study is that the captive running track of the LCS mobile-bearing prosthesis may over constrain the meniscal component leading to early failure.

Biodegradable rods in adult osteochondritis dissecans of the knee.

Symptomatic osteochondritis dissecans of the knee in skeletally mature patients does not follow a predictable natural history and there has been a trend toward internal fixation of the unstable fragment(s) where possible. Biodegradable implants are enticing for intraarticular use: implant removal is unnecessary and its degradation potentially allows a gradual shift of loading stress to the fracture site. Nine patients with a mean age of 18.6 years (range, 14-23 years) deemed skeletally mature by plain film radiography underwent internal fixation of fragments by 2-mm self reinforced polylactic rods. Six procedures were completed arthroscopically and three required arthrotomy. All fragments were of the medial femoral condyle. The procedure was tolerated well although three patients had early postoperative serosanguinous effusions develop that did not recur after one aspiration. At a mean followup of 33 months (range, 24-54 months), eight fragments radiographically were united whereas one remained ununited at 26 months, accounting for the one poor result in this series. Seven patients had good to excellent results according to Hughston's criteria and were satisfied with the procedure. One of these seven patients had a spontaneous effusion develop at 5 months that did not recur after aspiration and intraarticular steroid injection. Severe, unremitting synovitis did not occur in any patient. Internal fixation of osteochondritis dissecans of the knee with biodegradable polylactic rods provided satisfactory control of symptoms in the short term and resulted in radiographically stable lesions in eight of nine patients. These rods may be suited best for fragmented lesions with intact articular cartilage as an adjunct to drilling.

Behavior of sutures used in anterior cruciate ligament reconstructive surgery.

This study was performed to determine the material properties of sutures commonly used in orthopedic surgery in order to allow selection of the most appropriate one for securing a hamstring or quadriceps tendon graft in anterior cruciate ligament (ACL) reconstruction. Three suture materials (number 5 Ticron, number 5 Ethibond, and 5 mm Mersilene tape) were tested. The ultimate tensile load (UTL) with and without a knot, modulus of elasticity, effect of conditioning on the behavior of the suture, and plastic deformation were determined for each suture. Prior conditioning significantly improved the plastic deformation characteristics of all three sutures. Mersilene possessed the highest UTL both with and without knots, and its plastic deformation was significantly lower than that of Ticron or Ethibond. We feel that these characteristics make it the best suture for use in securing hamstring or tendon grafts in ACL surgery. Because of the high UTL achieved by Mersilene tape in the knotted surgical loop construct (nearly 500 N), it may be possible to achieve fixation integrity approaching that of interference fixation with bone blocks.

The influence of a diastasis screw on the outcome of Weber type-C ankle fractures.

We performed a retrospective study of the factors affecting the outcome of Weber type-C ankle fractures in 43 patients reviewed at two to nine years after injury. We determined the functional result in relation to the use of a diastasis screw, the accuracy of reduction, the presence of tibiotalar dislocation, and of injury to the medial side of the ankle by medial malleolar fracture or deltoid ligament rupture. We assessed the use of a diastasis screw as appropriate or inappropriate on the basis of an anatomical study performed by Boden et al (1989). The diastasis screw was used unnecessarily in 19 of the 31 patients so treated, but this did not appear to affect the final functional result. The worse functional results were in ankles dislocated at the initial injury, and in those with medial malleolar fractures as opposed to those with deltoid ligament ruptures. The best results were after accurate reduction of the fibula and the syndesmosis, and greater increase in the width of the syndesmosis was associated with a worse result. Our results suggest that an increase of more than 1.5 mm in syndesmosis width is unacceptable. We recommend that when the deltoid ligament is ruptured, a diastasis screw should be used if the fibular fracture is more than 3.5 cm above the top of the syndesmosis. When a medial malleolar fracture has been rigidly repaired a diastasis screw is required if the fibular fracture is more than 15 cm above the syndesmosis.

Urinary tract infection and hip fracture.

A routine audit revealed that in 25 per cent of patients with proximal femoral fracture, hospital stay was complicated by urinary tract infection (UTI). A prospective study was undertaken to investigate the relationship of UTI to fracture type, timing of surgery and the effect of perioperative antibiotics. Eighty-eight patients were investigated over a 4-month period with urine specimens obtained at time of operation and 48 h from operation. Of the patients, all female, 12.5 per cent had positive urine cultures at the time of operation. Of all patients, 42 per cent had positive urine cultures 48 h after operation. Females with intra-capsular fractures were more likely to have positive cultures both pre- and post-operatively (P < 0.005). Age (P < 0.05) and operative delay beyond 48 h (P < 0.05) were also found to predispose to infection. All patients except one who had urinary infection at the time of surgery had post-operative urine infection with the same organism. Present audit methods have significantly under estimated the presence of UTI in these patients. Fracture type and operative delay would appear to be the most significant determinants of a positive urine culture 48 h after operation. Prophylactic antibiotics appear to be ineffective in eradicating pre-existing or preventing early post-operative infection.

MRI of the knee: its cost-effective use in a district general hospital.

In the first year of magnetic resonance imaging (MRI) scanning of the knee in the East Berkshire Health District, 175 patients were scanned and 79 of these subsequently had an arthroscopy performed. We found that MRI accurately demonstrated the pathology present in the knee, particularly for meniscal lesions, although it was less accurate for anterior cruciate and cartilage lesions. The relative costs of MRI scanning, arthroscopy and conservative treatment are compared. On the basis of this analysis we have worked out a protocol for the cost-effective use of MRI in imaging the knee. This protocol has reduced the number of arthroscopies performed, allowing us to expend resources on patients who would definitely benefit from arthroscopic surgery.

Syme's amputation: a neglected procedure.

Over a 9-year period nine patients underwent Syme's amputation, one patient undergoing a staged bilateral procedure. Six of the ten amputations were carried out for the complications of peripheral vascular disease, including one with Buerger's disease who had bilateral amputations. Three patients had amputations for infected diabetic gangrene and one amputation was performed as a result of trauma. Five patients had previously undergone surgery to improve their peripheral circulation. Two patients required a subsequent below knee amputation. The indications for and technique of Syme's amputation are discussed.

External fixator pin placement in the forearm: how safe is it? An anatomical study.

An anatomical study was undertaken using cadaveric forearms to identify the best technique and angle of pin placement for external fixator pins. We have found that inserting pins through stab incisions risks transfixion of the underlying structures and leads to an increased morbidity. We conclude that inserting pins under direct vision is much safer and that the optimum angle of pin insertion is in the coronal plane, parallel to the plane of the metacarpals.

Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly.

In order to determine the factors influencing outcome following craniotomy for trauma in patients over the age of 65 and to establish criteria for surgical intervention, the authors carried out a retrospective analysis of the hospital and general practice records of all head injury patients over the age of 65 who underwent a craniotomy for evacuation of a post-traumatic haematoma within 7 days of injury at Frenchay Hospital during a 10-year period (1980-89). Outcome was measured using the Glasgow Outcome Scale and patients were allotted to a good outcome group (good recovery or moderate disability but independent) or a poor outcome group (severe disability, vegetative state of death). There were 35 men and 31 women with a mean age of 72.5 years (range 65-85 years). The mortality rate was 61% and 9% of patients survived in a severely disabled or vegetative state. All 20 (30%) patients with a good outcome had a Glasgow Coma Score (GCS) of 5 or more immediately before surgery. All 18 (27%) patients with a GCS of 4 or less and all 22 (33%) patients with unilateral or bilateral pupillary dilatation had a poor outcome. Outcome was significantly worse in the older patients (75-85 years) compared with the younger patients (65-74 years) and in those patients requiring craniotomy within 24 hours of injury, but the mechanism of injury (fall or road traffic accident), the presence or absence of skull fractures and limb fractures and the pre-operative CT scan appearances did not influence outcome. This study confirms the high probability of poor outcome following surgical evacuation of traumatic intracranial haematomas for elderly head-injured patients with pupillary dilatation or extensor motor responses. Craniotomy under these circumstances is not justified.

Thermographic assessment of burns using a nonpermeable membrane as wound covering.

Infrared thermography is a useful technique for the investigation of disorders which affect skin blood flow. The damage to skin blood vessels caused by thermal injury is a major determinant of the capacity of the wound to heal. Thermographic assessment of this damage has been found to correlate with the healing time of burn wounds. However, the application of thermography to the assessment of burns for early surgery has been limited because of the difficulties involved in correcting for cooling artefacts resulting from the effect of evaporative water loss (EWL) at the wound surface. A water impermeable polyvinylchloride film (sold in the USA as Saran Wrap, in Australia as Glad Wrap and in the UK as Clingfilm (CF)) was investigated as a wound covering to avoid this cooling effect. It was found that the CF abolished the cooling effect of EWL and did not significantly interfere with the measurement of surface temperature. This material provides a solution to the problems of thermographic examination of wounds such as burns where damage to the skin surface allows exudation or EWL to occur.