Heterotopic ossification after surgery for distal humeral fractures.

We retrospectively reviewed 89 consecutive patients (45 men and 44 women) with a mean age at the time of injury of 58 years (18 to 97) who had undergone external fixation after sustaining a unilateral fracture of the distal humerus. Our objectives were to determine the incidence of heterotopic ossification (HO); identify risk factors associated with the development of HO; and characterise the location, severity and resultant functional impairment attributable to the presence of HO. HO was identified in 37 elbows (42%), mostly around the humerus and along the course of the medial collateral ligament. HO was hazy immature in five elbows (13.5%), mature discrete in 20 (54%), extensive mature in 10 (27%), and complete bone bridges were present in two elbows (5.5%). Mild functional impairment occurred in eight patients, moderate in 27 and severe in two. HO was associated with less extension (p = 0.032) and less overall flexion-to-extension movement (p = 0.022); the flexion-to-extension arc was < 100º in 21 elbows (57%) with HO compared with 18 elbows (35%) without HO (p = 0.03). HO was removed surgically in seven elbows. The development of HO was significantly associated with sustaining a head injury (p = 0.015), delayed internal fixation (p = 0.027), the method of fracture fixation (p = 0.039) and the use of bone graft or substitute (p = 0.02).HO continues to be a substantial complication after internal fixation for distal humerus fractures.

Controversies relating to the management of acromioclavicular joint dislocations.

The aim of this review is to address controversies in the management of dislocations of the acromioclavicular joint. Current evidence suggests that operative rather than non-operative treatment of Rockwood grade III dislocations results in better cosmetic and radiological results, similar functional outcomes and longer time off work. Early surgery results in better functional and radiological outcomes with a reduced risk of infection and loss of reduction compared with delayed surgery. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Although non-controlled studies report promising results for arthroscopic coracoclavicular fixation, there are no comparative studies with open techniques to draw conclusions about the best surgical approach. Non-rigid coracoclavicular fixation with tendon graft or synthetic materials, or rigid acromioclavicular fixation with a hook plate, is preferable to fixation with coracoclavicular screws owing to significant risks of loosening and breakage. The evidence, although limited, also suggests that anatomical ligament reconstruction with autograft or certain synthetic grafts may have better outcomes than non-anatomical transfer of the coracoacromial ligament. It has been suggested that this is due to better restoration horizontal and vertical stability of the joint. Despite the large number of recently published studies, there remains a lack of high-quality evidence, making it difficult to draw firm conclusions regarding these controversial issues.

Two-stage revision for the treatment of the infected total elbow arthroplasty.

We report our experience of staged revision surgery for the treatment of infected total elbow arthroplasty (TEA). Between 1998 and 2010 a consecutive series of 33 patients (34 TEAs) underwent a first-stage procedure with the intention to proceed to second-stage procedure when the infection had been controlled. A single first-stage procedure with removal of the components and cement was undertaken for 29 TEAs (85%), followed by the insertion of antibiotic-impregnated cement beads, and five (15%) required two or more first-stage procedures. The most common organism isolated was coagulase-negative Staphylococcus in 21 TEAs (62%). A second-stage procedure was performed for 26 TEAs (76%); seven patients (seven TEAs, 21%) had a functional resection arthroplasty with antibiotic beads in situ and had no further surgery, one had a persistent discharge preventing further surgery. There were three recurrent infections (11.5%) in those patients who underwent a second-stage procedure. The infection presented at a mean of eight months (5 to 10) post-operatively. The mean Mayo Elbow Performance Score (MEPS) in those who underwent a second stage revision without recurrent infection was 81.1 (65 to 95). Staged revision surgery is successful in the treatment of patients with an infected TEA and is associated with a low rate of recurrent infection. However, when infection does occur, this study would suggest that it becomes apparent within ten months of the second stage procedure.

Age-specific incidence of first and second fractures of the hip.

We determined the age-specific incidence of a second fracture of the hip and compared it with that of a primary fracture in a study population drawn from 6331 patients admitted to Nottingham University Hospital with a primary fracture of the hip over a period of 8.5 years. The incidence of a second fracture was determined using survival analysis. The mean age-specific incidence rates of primary hip fracture were calculated using census data. The overall incidence of a second fracture was 2.7% at one year and 7.8% at 8.5 years. That of a primary fracture was 50 per 100 000 in women aged 55 to 64 years rising to 3760 in those aged 84 years and over. The incidence of a second fracture in women aged 55 to 64 years was 2344 per 100 000. Patients of this age had a relative risk of 45 (95% confidence interval 13 to 155) for further fracture when compared with the population at risk of a first fracture. The incidence of a second fracture in women aged > 84 years was 2451 per 100 000 (relative risk 0.7, 95% confidence interval 0.5 to 0.9). A similar trend was seen in men. Patients sustaining a primary fracture of the hip between the ages of 55 and 64 years have a much greater risk of further fracture than the normal population, whereas those over 84 years have a similar risk. These findings have important implications for the provision of fracture prevention services in primary and secondary care.

Tension band suturing for the treatment of displaced type 2 lateral end clavicle fractures.

INTRODUCTION: Non-operative treatment of Neer type 2 lateral end clavicle fractures presents a difficult problem due to the high incidence of non-union, delayed union and resulting shoulder girdle instability. Operative techniques described may require extensive soft tissue reconstruction, implant removal or lead to implant failure. MATERIALS AND METHODS: We report a modified tension band suturing technique for the treatment of these lateral end displaced clavicle fractures that avoids these problems of extensive soft tissue dissection, implant removal or implant failure. Ten patients were reviewed clinically, radiologically and with Constant assessment score outcomes using the tension band suture for the treatment of these fractures. RESULTS: All the fractures had healed at a mean follow-up of 9.2 weeks (range 6-16 weeks) with a mean Constant score of 91 and the power was comparable to the normal shoulder using the Nottingham Myometer. CONCLUSION: The results of this pilot study for treatment of Neer's type 2 lateral end clavicle fractures are very encouraging. We do recommend the need for a prospective larger study of this technique for the treatment of Neer type 2 lateral end clavicle fracture to evaluate this technique further.

Preservation of the ulnar bursa within the carpal tunnel: does it improve the outcome of carpal tunnel surgery? A randomized, controlled trial.

BACKGROUND: It was hypothesized that preserving a layer of gliding tissue, the parietal layer of the ulnar bursa, between the contents of the carpal tunnel and the soft tissues incised during carpal tunnel surgery might reduce scar pain and improve grip strength and function following open carpal tunnel decompression. METHODS: Patients consented to randomization to treatment with either preservation of the parietal layer of the ulnar bursa beneath the flexor retinaculum at the time of open carpal tunnel decompression (fifty-seven patients) or division of this gliding layer as part of a standard open carpal tunnel decompression (sixty-one patients). Grip strength was measured, scar pain was rated, and the validated Patient Evaluation Measure questionnaire was used to assess symptoms and disability preoperatively and at eight to nine weeks following the surgery in seventy-seven women and thirty-four men; the remaining seven patients were lost to follow-up. RESULTS: There was no difference between the groups with respect to age, sex, hand dominance, or side of surgery. Grip strength, scar pain, and the Patient Evaluation Measure score were not significantly different between the two groups, although there was a trend toward a poorer subjective outcome as demonstrated by the questionnaire in the group in which the ulnar bursa within the carpal tunnel had been preserved. Preserving the ulnar bursa within the carpal tunnel did, however, result in a lower prevalence of suspected wound infection or inflammation (p = 0.04). CONCLUSIONS: In this group of patients, preservation of the ulnar bursa around the median nerve during open carpal tunnel release produced no significant difference in grip strength or self-rated symptoms. We recommend incision of the ulnar bursa during open carpal tunnel decompression to allow complete visualization of the median nerve and carpal tunnel contents.

An assessment of the tensile properties and technical difficulties of two- and four-strand flexor tendon repairs.

This study compares the mechanical properties of locking Kessler and four-strand flexor tendon repairs and examines for difficulties related to technical ability. Two trainee surgeons each carried out 10 locking Kessler and 10 four-strand single-cross flexor tendon repairs on an in vitro porcine model. Outcome measures included gap formation and ultimate forces, operative time and repair bulk. Ultimate force was 81% greater for the four-strand repair compared to the Kessler (52 N, SD 5, versus 29 N, SD 6). Operating times were similar between the two techniques (Kessler 10.0 minutes, four strand 10.1 minutes). Rupture force and operating times improved slightly during the study for the Kessler repairs, but in the four strand repairs results remained stable throughout the study. We conclude that the single-cross four-strand repair tolerates superior loads yet is no more technically demanding than the modified Kessler, and can be reliably performed without additional operating time.

Topical anaesthesia to reduce pain associated with carpal tunnel surgery.

This randomized, double-blinded study assessed the effectiveness of a topical anaesthetic, eutectic mixture of local anaesthetics (EMLA), in reducing pain associated with carpal tunnel release performed under local anaesthetic. Fifty-six patients undergoing carpal tunnel release under local anaesthetic were randomized into either EMLA (n = 29) or placebo (n = 27) groups. Visual analogue pain scores were obtained for needle insertion, injection of anaesthetic and surgery itself. Pain scores were significantly less for needle insertion (P = 0.001) and injection of anaesthetic (P = 0.0005). Scores related to surgery were also lower in the EMLA group, but this did not reach statistical significance.

Components of adult Class II open-bite malocclusion.

In an effort to identify the frequency and distribution of the dental and skeletal components of adult Class II malocclusion with and without open-bite, 124 adults, half of whom had an anterior open-bite, were evaluated. Significant differences (P less than 0.05) between the open-bite and non-open-bite groups were found for the following measurements: the posterior maxilla exhibited vertical excess in the open-bite group; the maxillary occlusal plane was less steep in the open-bite group; the mandibular occlusal plane was more steep in the open-bite group; the gonial angle was higher in the open-bite group; the mandibular plane angle was higher in the open-bite group; the mandibular ramus was positioned in a more downward and backward (clockwise) location in the open-bite group; the total and lower anterior facial height were increased in the open-bite group; and the mandible was less protrusive in the open-bite group. No significant intergroup differences were noted in the cranial base, the anteroposterior position of the maxilla or of the upper and lower incisors, the palatal plane, posterior facial height, mandibular ramus height, or mandibular body length. The results of this analysis indicate that the average Class II open-bite malocclusion is characterized by aberrations in both the maxilla and the mandible. Therapy, therefore, may frequently require surgical intervention in both jaws to successfully correct this deformity.