Neck of femur fracture: Previous history of malignancy is not an indication to send femoral head for routine histology.

BACKGROUND: Neck of femur fractures is the most common fractures associated with low-velocity injury in the elderly. Some patients may require further histological examination of the femoral head due clinical suspicion of malignance as a cause of fracture. OBJECTIVES: To review whether standard screening question(s) could be used to identify patients that require histological examinations following neck of femur fracture. STUDY DESIGN AND METHODS: Femoral heads sent for histological examination over a period of 5 years were identified from hospital database. All patients presenting acutely with neck of femur fracture above the age of 70 were included, and their case notes were retrospectively reviewed. Reason for histopathological examination were categorised into three screening questions: (Q1) clinical suspicion based on history alone, i.e. neck of femur fracture with no clear history of fall or trauma or preceding hip pain, (Q2) radiological evidence of suspicious abnormality on admission radiographs, (Q3) previous history of malignancy or concurrent malignancy or (Q4) combination of above. RESULTS: In total, 119 samples of femoral head were sent and 18 patients had a positive histology. The sensitivity and specificity of these questions individually showed very poor correlation to positive histology with lowest for (Q3) previous history of malignancy (0.39 and 0.51, respectively). However, combining Q1 and Q2 the sensitivity is improved to 1.0 (95% CI 1.0-1.0) and specificity to 0.35 (95% CI 0.25-0.44) with a positive predictive value of 0.21 (95% CI 0.13-0.30) and negative predictive value of 1.00 (95% CI 1.00-1.00). CONCLUSION: History of previous malignancy poorly correlates with positive histology. Routine request based on these screening criteria is not cost-effective in patient management. LEVEL OF EVIDENCE: Prognostic level III.

The course and distribution of the infra patellar nerve in relation to ACL reconstruction.

INTRODUCTION: A common complication after ACL (anterior cruciate ligament reconstruction) is injury to the infra-patellar branch of the saphenous nerve (IPBSN). Very little about its origin and course of this nerve has been described. The aim of this study was to understand the course of IPBSN in relation to surgery around the knee. MATERIALS AND METHOD: The course of the nerve was dissected and traced in 25 knees from 14 cadaveric knees (10 males; four females). An incision was made posterior to the medial condyle of the tibia and continued deeper towards the saphenous nerve which is located under the sartorius muscle. The saphenous nerve branch was then followed to distally supply the anterior leg (IPBSN). The relationship of saphenous nerve and IPBSN to each other and the hamstrings were recorded. RESULTS: Four paths of IPBSN, in relation to the sartorius muscle, were identified: (1) posterior--inferior posterior border of the muscle, (2) transmuscular--penetrating through the muscle, (3) anterior--anterior border of the muscle, (4) posterior patellar--posterior of the muscle at the level of the patellar bone and (5) combined. The posterior pathway of IPSBN was the most common (57%) and had the closest proximity to the tendons of semitendinosus and gracilis muscles. The terminal branches of the IPSBN crossed over the patellar tendon in every dissection. CONCLUSIONS: A posterior path IPBSN is more prone to damage during a tendon harvest due to its proximity to the gracilis and semitendinosus muscle tendons.

Elbow dislocation with complete triceps avulsion.

Radio-ulnar Fracture dislocation of the elbow is a high-energy trauma which can be associated with significant ligamentous injury in adults. We report an unusual triad of injury in a patient with avulsion injury of the triceps. This injury can be thought of as a variant of "terrible triad" with dislocation of radio-ulnar joint, radial head fracture, and medial collateral ligament injury with avulsion of the triceps. Elbow has to be stabilized with early repair of the ligaments for a successful outcome.

Skin necrosis associated with thromboprophylaxis after total knee replacement.

Thromboprophylaxis are routinely given to prevent venous thromboembolism (VTE) in patients after total hip and knee replacement surgeries. Low molecular weight heparin (LMWH) (fractioned heparin) is effective in the prevention and treatment of VTE. The predicable effect of LMWH has popularized it for routine clinical use. Although LMWH has lesser complication rate, compared to unfractioned heparin (UFH), sporadic clinical complication has been reported. We report a rare case of skin necrosis secondary to use of LMWH tinzaparin used for routine thromboprophylaxis after total knee replacement.

Metallosis in a total knee arthroplasty.

A 70-year-old woman presented with right knee pain and a 'grinding' sensation 6 months after a total knee replacement for osteoarthritis. Clinical examination revealed a valgus deformity, patellofemoral crepitus and a reduced knee flexion. Radiographs revealed distinctive findings including the 'bubble sign', 'cloud sign' and the 'metal line sign', which are diagnostic of metallosis. Metallosis is an uncommon complication of total joint replacements, where bone and periprosthetic soft tissues are infiltrated by metallic debris from wearing of the prostheses. This usually occurs in high-wear joints such as hips and knees. Treatment for patients diagnosed with metallosis is synovectomy and a revision surgery. Our patient underwent revision surgery 5 years after her initial surgery.

Investigating the potential advantages of a new design metacarpophalangeal joint.

This paper investigates a new metacarpophalangeal joint design aimed at treating patients with moderate to severe forms of arthritis affecting the index, long, ring, and little fingers. Current small joint arthroplasty designs, including those for the metacarpophalangeal joint of the hand, have had limited success owing to mechanical failures and can be divided into two main families: single-piece elastomer implants and surface articulating implants. The design proposed in this study involves combining the principles of a surface weight-bearing articulating implant with those of a spanning elastomeric implant. The design consists of metacarpal and proximal phalangeal articulating housings and a central flexible spanning elastomer rod that maintains the alignment of the metacarpal and proximal phalangeal components. A preliminary finite element analysis was used to investigate the stresses in the design, the wear of the articulating bearing surfaces for different material combinations, and the stresses between the central elastomer rod and the articulating housings. This preliminary analysis shows that the design should withstand the probable loading conditions experienced within the human body and that the wear rates of the articulating surfaces and the central elastomer are acceptable.

The mortality, morbidity and cost benefits of elective total knee arthroplasty in the nonagenarian population.

With the increasing life expectancy, a greater number of elderly patients are being referred to an orthopaedic department to have elective total knee arthroplasty (TKA). Total knee arthroplasty should be considered in the very elderly only after carefully balancing the benefits of surgery against the risks of surgery. The aim of this study was to analyse the mortality, morbidity and cost benefits of elective TKA in a cohort group of the nonagenarian population. Between 1990 and 2006, 42 patients >or=90 years of age had TKA surgery. Patient's notes were retrospectively analysed. A cost-benefit analysis was carried out by comparing the surgical costs against nursing home placement. The mean age at surgery was 90.4 years (range: 90-90.6). There was one major and 11 minor postoperative complications with no immediate or late postoperative deaths. The Knee Society Scores improved from 25 points (range: 8-44) to 81 points (range: 60-95), and the WOMAC Scores improved from 62 points (range: 54-73) to 41 points (range: 34-46) (p<0.002). The calculated cost-benefit savings for 42 patients at 5 years after TKA was estimated to be pound 2,746,839. Total knee arthroplasty in the nonagenarian population is safe, beneficial and cost-effective.

The safety of hip injection with corticosteroid in the diagnosis and treatment of osteoarthritis.

INTRODUCTION: Injection of steroid and local anaesthetic into hip and knee joints has been a recommended treatment for osteoarthritic pain for decades. There have been recent studies showing a higher incidence of infection leading to early revision of joint prostheses in patients who have had corticosteroid injections prior to joint replacement surgery. OBJECTIVE: The aim of our study was to determine if there is any risk of infection in patients undergoing total hip arthroplasty (THA) after a hip joint injection. PATIENTS AND METHODS: A retrospective search was conducted using the hospital computer database to identify patients who underwent hip injection and subsequent THA between 2000 and 2004. The study included a review all case notes to specifically identify prosthetic infection or early joint replacement surgery. RESULTS: One hundred and twenty-eight patients had hip joint injections and subsequently underwent successful total hip replacement. In this study there was no evidence of associated risk of prosthetic infection or early revision of total hip arthroplasty after hip joint injection with corticosteroids (average time of follow-up 3.2 years). CONCLUSIONS: Hip injection is safe provided a strict aseptic protocol is maintained. The time period of pain relief with hip injection is limited (average 2 months). For diagnostic purposes injections with local anaesthetic only is recommended. A large randomised control study would probably further substantiate these findings.