The technique of delivery of peri-operative analgesia does not affect the rehabilitation or outcomes following total knee arthroplasty.

AIMS: This non-blinded randomised controlled trial compared the effect of patient-controlled epidural analgesia (PCEA) versus local infiltration analgesia (LIA) within an established enhanced recovery programme on the attainment of discharge criteria and recovery one year after total knee arthroplasty (TKA). The hypothesis was that LIA would increase the proportion of patients discharged from rehabilitation by the fourth post-operative day but would not affect outcomes at one year. PATIENTS AND METHODS: A total of 242 patients were randomised; 20 were excluded due to failure of spinal anaesthesia leaving 109 patients in the PCEA group and 113 in the LIA group. Patients were reviewed at six weeks and one year post-operatively. RESULTS: There was no difference in the proportion of patients discharged from rehabilitation by the fourth post-operative day, (77% in the PCEA group, 82% in the LIA group, p = 0.33), mean length of stay (four days in each group, p = 0.540), day of first mobilisation (p = 0.013) or pain (p = 0.278). There was no difference in mean Oxford Knee Scores (41 points in each group, p = 0.915) or the rate of complications in the two groups. CONCLUSION: Both techniques provided adequate pain relief, enabled early mobilisation and accelerated rehabilitation and good patient-reported outcomes up to one year post-operatively. PCEA and LIA are associated with similar clinical outcomes following TKA. Cite this article: Bone Joint J 2016;98-B1189-96.

The efficacy and safety of epidural filter catheters when used for post-operative intra-articular anaesthesia.

UNLABELLED: There are concerns about the risk of iatrogenic infection when employing local anaesthetic techniques with post-operative intra-articular infusions in total knee arthroplasty. This study aimed to determine the efficacy of intact epidural filters in preventing transit of bacteria and to develop a technique of administration which would prevent membrane rupture. Filter efficacy was assessed using a standardised test suspension of Pseudomonas aeruginosa. Twenty millilitres of suspension was injected through isolated epidural filters (n=10) or filters with 40cm of catheter tubing attached (n=30). For each filter, injections were carried out at 0, 8 and 24h. Filtrates were collected, incubated, sub-cultured onto Columbia horse blood agar and examined for bacterial growth. Three delivery techniques were tested: manually controlled syringe with 5ml of water at 20ml/min, forced administration syringe with 5ml of water at >240ml/min and an automated syringe driver delivering 40ml of water at 6.7ml/min. For the two techniques using syringes, three syringe sizes, 5ml, 10ml and 20ml, were tested. Each test condition was carried out on 10 filters (total n=70). Filters were examined for rupture. Intact epidural filters prevented bacterial transit in all cases. Manual controlled and automated syringe driver administration generated no filter ruptures. Manual forced administration generated 93% filter rupture. Ruptures occurred at peak pressures of approximately 620kPa. Epidural filters can be used to prevent bacterial transit. These results suggest automated devices remove the risk of filter rupture. This study is relevant to all specialties that utilise these filters during infiltration such as epidurals or other regional anaesthetic techniques. CLINICAL RELEVANCE: This study identified that filters are prone to rupture with high infusion rates and that manual techniques are particularly vulnerable. From these results, it is recommended that pumps are used to minimise risk of filter rupture.

Intra-operative deviation in limb alignment occurring at implantation in total knee arthroplasty.

BACKGROUND: Long-term survival of knee replacement depends on accurate alignment. Despite improvements in cut accuracy mal-alignment of 3° or more is still seen. All methods share common implantation techniques. This study examines the effect of implantation on overall limb alignment relating it to cut alignment and trial alignment. METHODS: A retrospective review of navigated primary knee replacements was undertaken (n=113). Overall coronal limb alignments for the aggregated cuts, trial and final implanted components were examined. RESULTS: All 113 knees had coronal aggregated cut alignment within 2° of neutral (range: 2° varus to 2° valgus). With trial components 99 knees (88%) had an overall coronal limb alignment within 2° of neutral (range: 3° varus to 4° valgus). After final implantation 106 knees (94%) were within 2° of neutral (range: 4° varus to 4° valgus). Forty eight knees (42%) showed no alignment deviation occurring between trial and the final implanted prostheses and 16 knees (14%) shoed a deviation of 2° or more. There was a correlation of both aggregated cut (r=0.284, p=0.002) and trial (r=0.794, p<0.001) with final alignment. There was no significant difference between the final alignment and the aggregated cut alignment(mean difference=-0.15°, p=0.254) or trial alignment (mean difference -0.13°, p=0.155). CONCLUSIONS: Even when the aggregated alignment produced by the bone cuts is accurate, inaccuracy in final alignment can result from the implantation process. It may be productive for surgeons to concentrate on the implantation process to improve alignment and reduce outliers.

The role of retraction in direct nerve injury in total hip replacement: an anatomical study.

OBJECTIVES: Acetabular retractors have been implicated in damage to the femoral and obturator nerves during total hip replacement. The aim of this study was to determine the anatomical relationship between retractor placement and these nerves. METHODS: A posterior approach to the hip was carried out in six fresh cadaveric half pelves. Large Hohmann acetabular retractors were placed anteriorly, over the acetabular lip, and inferiorly, and their relationship to the femoral and obturator nerves was examined. RESULTS: If contact with bone was not maintained during retractor placement, the tip of the anterior retractor had the potential to compress the femoral nerve by passing superficial to the iliopsoas. If pressure was removed from the anterior retractor, the tip pivoted on the anterior acetabular lip, and passed superficial to the iliopsoas, overlying and compressing the femoral nerve, when pressure was reapplied. The inferior retractor pierced the obturator membrane in all specimens medial to the obturator nerve, with subsequent retraction causing the tip to move laterally, making contact with the nerve. CONCLUSION: Iliopsoas can only offer protection to the femoral nerve if the retractor passes deep to the muscle bulk. The anterior retractor should be reinserted if pressure is removed intra-operatively. Vigorous movement of the inferior retractor should be avoided. Cite this article: Bone Joint Res 2014;3:212-6.

An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom--follow up at one year.

The concepts of Enhanced Recovery Programmes (ERP) are to reduce peri-operative morbidity whilst accelerating patient's rehabilitation resulting in a shortened hospital stay following primary joint arthroplasty. These programmes should include all patients undergoing surgery and should not be selective. We report a consecutive series of 1081 primary total knee arthroplasties undergoing an enhanced recovery programme with a one year follow up period. A comparative cohort of 735 patients from immediately prior to the enhanced recovery programme implementation was also reviewed. The median day of discharge home was reduced from post-operative day six to day four (p<0.001) for the ERP group. Post-operative urinary catheterisation (35% vs. 6.9%) and blood transfusion (3.7% vs. 0.6%) rates were significantly reduced (p<0.001). Within the ERP group median pain scores (0 = no pain, 10 = maximal pain) on mobilisation were three throughout hospital stay with 95% of patients ambulating within 24h. No statistical difference was found in post-operative thrombolytic events (p=0.35 and 0.5), infection (p=0.86), mortality rates (p=0.8) and Oxford Knee Scores (p=0.99) at follow up. This multidisciplinary approach provided satisfactory post-operative analgesia allowing early safe ambulation and expedited discharge to home with no detriment to continuing rehabilitation, infection or complication rates at one year.

A prospective clinical audit of a new dressing design for lower limb arthroplasty wounds.

An audit of wound healing in patients undergoing total hip or knee arthroplasty in a Scottish hospital found that use of a barrier film made no difference to the effectiveness of a new Hydrofiber/hydrocolloid dressing combination.

A quantitative method of effective soft tissue management for varus knees in total knee replacement surgery using navigational techniques.

Total knee replacement (TKR) has become the standard procedure in management of degenerative joint disease with its success depending mainly on two factors: three-dimensional alignment and soft-tissue balancing. The aim of this work was to develop and validate an algorithm to indicate appropriate medial soft tissue release during TKR for varus knees using initial kinematics quantified via navigation techniques. Kinematic data were collected intraoperatively for 46 patients with primary end-stage osteoarthritis undergoing TKR surgery using a computer-tomography-free navigation system. All patients had preoperative varus knees and medial release was made using the surgeon's experience. Based on these data an algorithm was developed. This algorithm was validated on a further set of 35 patients where it was used to define the medial release based on the kinematic data. The post-operative valgus stress angles for the two groups were compared. These results showed that the algorithm was a suitable tool to indicate the type of medial release required in varus knees based on intra-operatively measured pre-implant valgus stress and extension deficit angles. It reduced the percentage of releases made and the results were more appropriate than the decisions made by an experienced surgeon.

Long-term results of the modified Hoffman procedure in the rheumatoid forefoot. Surgical technique.

BACKGROUND: Rheumatoid arthritis commonly affects the forefoot, causing metatarsalgia, hallux valgus, and deformities of the lesser toes. Various types of surgical correction have been described, including resection of the lesser-toe metatarsal heads coupled with arthrodesis of the great toe, resection arthroplasty of the proximal phalanx or metatarsal head, and metatarsal osteotomy. We report the results at an average of five and a half years following thirty-seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique involving resection of all five metatarsal heads. METHODS: All patients were treated with the same technique of resection of all five metatarsal heads through three dorsal incisions. All surviving patients were asked to return for follow-up, which included subjective assessment (with use of visual analogue pain scores, AOFAS [American Orthopaedic Foot and Ankle Society] foot scores, and SF-12 [Short Form-12] mental and physical disability scores), physical examination, and radiographic evaluation. RESULTS: All results were satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was 22.3 degrees. There were no reoperations. CONCLUSIONS: Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.

Long-term results of the modified Hoffman procedure in the rheumatoid forefoot.

BACKGROUND: Rheumatoid arthritis commonly affects the forefoot, causing metatarsalgia, hallux valgus, and deformities of the lesser toes. Various types of surgical correction have been described, including resection of the lesser-toe metatarsal heads coupled with arthrodesis of the great toe, resection arthroplasty of the proximal phalanx or metatarsal head, and metatarsal osteotomy. We report the results at an average of five and a half years following thirty-seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique involving resection of all five metatarsal heads. METHODS: All patients were treated with the same technique of resection of all five metatarsal heads through three dorsal incisions. All surviving patients were asked to return for follow-up, which included subjective assessment (with use of visual analogue pain scores, AOFAS [American Orthopaedic Foot and Ankle Society] foot scores, and SF-12 [Short Form-12] mental and physical disability scores), physical examination, and radiographic evaluation. RESULTS: All results were satisfactory to excellent in the short term (six weeks postoperatively), and no patient sought additional surgical treatment for the feet. A superficial infection subsequently developed in two feet, and two feet had delayed wound-healing. At an average of 64.9 months postoperatively, the average AOFAS forefoot score was 64.5 points and the average hallux valgus angle was 22.3 degrees . There were no reoperations. CONCLUSIONS: Resection of all five metatarsal heads in patients with metatarsalgia and hallux valgus associated with rheumatoid arthritis can be a safe procedure that provides reasonable, if rarely complete, relief of symptoms.

Iatrogenic nerve injury with the Russell-Taylor humeral nail.

The first consecutive 51 humeral shaft fractures treated with the Russell-Taylor intramedullary nail at Glasgow Royal Infirmary were reviewed in a retrospective study. There were eight iatrogenic nerve injuries- three to the radial nerve which settled spontaneously and five to the lateral cutaneous nerve of forearm of which three have failed to recover completely. The authors feel that the insertion of the distal interlocking screw in the antero-posterior direction puts this nerve at risk. We believe that iatrogenic injury to the lateral cutaneous nerve of forearm during humeral nailing has not been previously reported.

Dorsal wedge osteotomy in the treatment of hallux rigidus.

The results of 18 dorsal wedge osteotomies in the treatment of hallux rigidus are presented. Patients were retrospectively interviewed and examined, and an assessment was made in a number of key functional areas. Good or excellent results were obtained in 14 or 18 cases at a mean follow-up time of 4 years with only one patient requiring further surgery. Pain (p = 0.00014), activity levels (p = 0.0019), footwear difficulties (p = 0.0016), and joint range of motion (p = 0.0001) were all significantly improved; tiptoeing was the only activity assessed (p = 0.23) for which the improvement was not significant. These results compare well with other published series. We recommend dorsal wedge osteotomy as a useful alternative in the treatment of hallux rigidus.

Three cases of prolapsed disc presenting as 'twisted ankles'.

We have recorded three cases of patients who initially were referred to the orthopaedic department with ankle problems. One of these was actually being managed with a full below-knee walking plaster. All of these patients proved to have prolapsed intervertebral discs with appropriate symptoms, and signs at examination and on computerized tomography (CT). Incorrect management protocols resulted in possible morbidity or at least in a delay in correct diagnosis. In summary, it is recommended to remember nerve root compression as a cause for ankle pain and for lack of abductor control of the ankle joint. This emphasizes the need for an adequate history and examination.

Bier's block: a change of injection site.

Bier's block or intravenous regional anesthesia is a well-proven technique that is useful in the traumatic setting to provide upper limb anesthesia in the manipulation of distal radial fractures. In this situation, the traditional injection site in the dorsum of the hand can present difficulties with subsequent plaster application and with venous access caused by swelling or pain. One hundred patients were randomly allocated into two groups of 50. The first group was injected into the dorsum of the hand and the second into the antecubital fossa, in each case on the injured side. Effectiveness of anesthesia at both the fractures site and the cuff was assessed using a visual analog scale. Results analyzed using Student's t test, showed no difference in anesthesia between the two groups. In addition, there were fewer technical problems associated with venous access and subsequent plaster application in the antecubital fossa group.

External fixation of the distal radius. A biomechanical study.

External fixation is a useful method of treating unstable fractures of the distal radius. There is a lack of information regarding the behaviour of mini-fixation systems, particularly under cyclical loading, which would be expected to occur at the wrist. This laboratory study was designed to investigate the mechanical characteristics of nine current fixation systems. A programme of loading was devised to mimic forces acting on the distal radius. Wooden dowel was used to mount the fixator. Distraction and compression forces were applied in an Instron rig. Displacement was monitored throughout the load programme. No fixator failed at the loads tested. The small Hoffman rectangular frame proved stiffest in compression and extension, but was heavier than other devices. A trend of progressive, permanent deformation became apparent in those fixators which contain plastic or composite materials. This feature has implications for loss of fracture reduction in the clinical setting.

Full face protection in orthopaedics: a practical appliance for use in high risk cases.

A clear plastic, full-face visor is described which gives face, eye and neck protection during surgery. It has proved comfortable and light to wear, providing excellent, unobstructed vision and, unlike protective goggles and spectacles, it is not prone to condensation.

A complication of the buried suture.

A buried suture used in the repair of the central slip of a digital extensor resulted in an erosive lesion of the proximal interphalangeal joint of the long finger. In a review of the literature I can find no other reports describing this unusual complication.

A study of age-related changes of the articular disc of the wrist in Hong Kong Chinese.

A cadaveric study of age-related changes in the triangular fibrocartilage of the wrist in Hong Kong Chinese confirms the high incidence of tears with increasing age. There appears to be two distinct types, linear and degenerate, with no clear evidence that the former is simply a precursor of the latter.

Ligamentotaxis and bone grafting for comminuted fractures of the distal radius.

The conventional treatment of comminuted fractures in the distal radius has been unsatisfactory. We therefore made a prospective study using the principle of ligamentotoxis and primary cancellous bone grafting as the uniform method of treatment. Ligamentotaxis was maintained by using an external fixator for three weeks only, after which a carefully monitored programme of rehabilitation was given. We have reviewed 72 consecutive distal radial fractures after a follow-up of 7 to 40 months (average 11 months). Reduction had been maintained during healing and over 80% of patients regained full range of movement in hands, wrists and forearms with strong and pain-free wrist function. Complications were infrequent and gave no real problems. We conclude that distraction, external fixation and bone grafting appears to be an excellent method of treating comminuted fractures of the distal radius.

Vibrio vulnificus necrotizing fasciitis presenting with compartmental syndrome of the hand.

Vibrio vulnificus necrotizing fasciitis is an unusual clinical problem. When it presented as a compartment syndrome, the picture was obscured. We report a rare case of such a presentation. A below-elbow amputation was performed and the patient recovered.