Case Report: Kingella kingae causing prosthetic joint infection in an adult.

Introduction: Kingella kingae is a Gram-negative micro-organism that is rarely isolated as a pathogen in the adult population. Although widely reported to affect prosthetic heart valves, there have been no previously reported cases of K. kingae infecting prosthetic joints in adults. Case Presentation: A 61-year-old patient with a history of rheumatoid arthritis presented with insidious onset of pain and swelling in her right shoulder, which had progressed to a discharging sinus. The patient had undergone a total shoulder replacement 11 years previously and had not developed any prior post-operative infections. She had been taking anti-TNF medication for 5 years prior to review for her rheumatoid disease. The patient underwent a two-stage revision replacement procedure, including implant removal, sinus excision and debridement. Deep tissue samples grew K. kingae post-operatively. The patient was commenced on intravenous ceftriaxone for 14 days, followed by a further 28 days of oral ciprofloxacin. A second-stage custom shoulder replacement was undertaken 10 months following the first stage and the patient made a good functional recovery. Conclusion: The authors suggest that clinicians should be attuned to K. kingae as a potential pathogen for prosthetic joint infection, particularly in patients who are immunosuppressed. Two-stage revision procedures can ensure a favourable outcome and eradication of this pathogen from the joint. Beta lactams remain the principal antibiotic of choice.

Determining the ideal osteotomy for stemless total shoulder replacement: a cadaveric study.

HYPOTHESIS: We sought to determine the angle of osteotomy that produces a circular humeral cut surface. METHODS: A total of 49 cadaveric shoulders, from 25 cadavers, underwent sequential humeral head osteotomy from 180° (vertical, in line with the humeral diaphyseal shaft), in 10° increments, until the rotator cuff insertion was encountered. At each stage, the anteroposterior (AP) and superoinferior (SI) distances were recorded. The data were analyzed for normality and then assessed to determine the optimum cut angle. RESULTS: The AP/SI ratio is an indication of roundness. Plotting values of 1 - AP/SI (ie, error) vs. cut angle allowed us to plot the likelihood of producing a circular cut surface using a third-order curve that created the best fit to the data set (R2 = 0.99). The results from this study suggest that the optimum osteotomy angle that produces a circular cut surface is 23° from the vertical. The cohort data illustrated that at this angle, the average roundness error was 1% with a 95% confidence limit of <1%. There was no significant difference (P > .05) between sexes. CONCLUSION: The humeral head shape changes from oval to circular and then to an oval cut surface as the osteotomy angle increases from the vertical toward the horizontal. The range of angles within which the cut surface is circular, within a 10% error margin, is 18°-27° from the vertical, which is much less than the traditional osteotomy angle of 45°.

Immediate Fixation Versus Late Osteotomy for an Unusual Scapula Body Fracture: A Report of 2 Cases.

CASE: We present 2 unusual scapula fractures that do not meet published thresholds for surgical intervention; 1 initially managed surgically with a good functional result and 1 conservatively with a poor outcome. The second patient subsequently underwent osteotomy and fixation with good effect. CONCLUSION: Despite not reaching published levels of displacement or angulation usually considered for surgical intervention, these cases demonstrate that combined patterns of scapula injury can cause functional disability if managed conservatively. The authors believe that combination patterns of injury should be considered for early surgery to avoid loss of function caused by healing of the fracture(s) in malposition.

Medium- to long-term results of acromioclavicular joint stabilisation using the Ligament Augmentation Reconstruction System (LARS) ligament.

BACKGROUND: Opinion is divided as to optimum management of grade III acromioclavicular joint injuries that have failed conservative management. We objectively investigated the radiological and functional outcome of acromioclavicular joint reconstruction using the Ligament Augmentation Reconstruction System (LARS®). METHODS: Retrospective review of patients with LARS reconstruction of acromioclavicular joint dislocations with minimum six-year follow-up. Functional assessment was performed using the constant score, Disability of Arm Shoulder and Hand score and simple satisfaction score. Radiological assessment was undertaken using plain radiographs. Results were compared with the uninjured limb. RESULTS: Twenty-four of 25 patients were included. Mean constant score for the injured shoulder was 87.0, Disability of Arm Shoulder and Hand score was 11.6. All patients indicated that they would have the operation again. There were five complications including two patients that suffered small cracks in the clavicle. Coracoid erosion was frequently seen but was most often minor. In two cases, this resulted in a complete dissociation of the coracoid tip but without functional detriment. DISCUSSION: LARS is a safe and effective method of acromioclavicular joint reconstruction producing good results, and we recommend its use for these injuries. We also caution clinicians who use cerclage methods to be aware of coracoid erosion when following up their patients.

Effect on Hospital Length of Stay of Tourniquet Use During Internal Fixation of Ankle Fractures: Randomized Controlled Trial.

Approximately 50% of ankle fractures require internal fixation. A tourniquet is often used to create a bloodless operative field, but its effect on hospital length of stay (LOS) is unclear. This article reports a parallel-group observer-blinded randomized trial of the effect of tourniquet use on LOS. One hundred eighty-eight adult patients requiring internal fixation of ankle fracture were randomized to surgery with or without a tourniquet. LOS was analyzed on intention-to-treat principles using Poisson regression. As a secondary outcome, duration of operation was analyzed by analysis of covariance. Mean LOS was 1.79 ± 1.50 days in the tourniquet group and 1.65 ± 1.11 days in the no-tourniquet group. The covariate-adjusted rate ratio for LOS (reference group: no tourniquet) was 1.084 (95% confidence interval 0.871, 1.348; p = .470). Sensitivity analyses (unadjusted intention-to-treat analysis and as-treated analysis) gave similar nonsignificant results. The covariate-adjusted mean difference in duration of operation was 3.03 minutes (95% confidence interval -4.96, 11.02; p = .455), favoring the tourniquet group; sensitivity analyses again gave similar results. Adverse events did not differ significantly between groups. In conclusion, the use of a tourniquet during internal fixation does not significantly influence hospital LOS, of which preinjury medical condition of the patient appears to be the most important determinant.

Relocation of a dislocated long head of biceps tendon is no better than biceps tenodesis.

A displaced Long Head of Biceps (LHB) tendon is commonly encountered in association with subscapularis rotator cuff tears. Management options for the displaced tendon consist of tenotomy, tenodesis or relocation with reconstruction of the biceps pulley. We present 16 patients in whom LHB relocation and reconstruction of the biceps pulley, was performed in association with subscapularis rotator cuff repair. During follow-up ultrasound scanning was used to assess LHB mobility and location. Eight of the 16 patients had a static LHB tendon at an average follow-up of 26 months. Four of the 6 patients who had a groove deepening procedure combined with the tendon relocation had a static tendon on ultrasound scanning. Relocation of the LHB and reconstruction of the biceps pulley appears to offer no advantage over tenotomy or tenodesis alone when managing the displaced LHB tendon in conjunction with subscapularis tears.

The anatomy of the quadrilateral space with reference to quadrilateral space syndrome.

Quadrilateral space syndrome is a rare condition in which the contents of the quadrilateral space, the axillary nerve and the posterior circumflex humeral artery, are compressed, leading to vague symptoms of shoulder pain, tenderness over the quadrilateral space on palpation, and teres minor and deltoid denervation. Fibrous bands within the quadrilateral space are often cited in the literature as a cause of compression in quadrilateral space syndrome; however, Cahill and Palmer did not see these bands in cadaveric dissection. These are postulated to cause compression of the quadrilateral space contents in abduction and external rotation of the shoulder. To clarify the anatomic features that may predispose the development of quadrilateral space syndrome, 16 cadaveric shoulders were studied. Dissection revealed that fibrous bands are a common finding in the quadrilateral space, being present in 14 of 16 shoulders. The most common site for a fibrous band was between the teres major and the long head of the triceps. Where the bands were present, both internal and external rotation of the shoulder caused a reduction in the cross-sectional area of the quadrilateral space.

Cement venogram--a risk of satisfactory cement pressurization.

Longevity of cemented femoral components is dependent upon many factors. It is certainly related to the cementing technique. A dilemma exists between adequate cement pressurization and risk of embolic events. A cementation pressure above bleeding pressure, to allow optimum cement bone interdigitation but not high enough to produce embolic or cardiorespiratory events, is the ideal situation. We present a case where cement pressurization resulted in the appearance of a cement venogram on the routine postoperative x-ray.

Rate of return to work and driving following arthroscopic subacromial decompression.

BACKGROUND: The aim of the present paper was to evaluate the return to work and return to driving of a cohort of patients undergoing arthroscopic subacromial decompressions +/- arthroscopic acromioclavicular joint excision. METHODS: Arthroscopic subacromial decompressions +/- arthroscopic acromioclavicular joint excision were performed in 68 patients between February 2000 and November 2000. All patients had symptoms of subacromial impingement +/- acromioclavicular joint arthrosis for more than 6 months that had not settled with conservative treatment. All had positive local anaesthetic injection tests. All patients were followed up at 3 weeks and 3 months postoperatively. Their Constant-Murley score was measured preoperatively and at 3 weeks and 3 months postoperatively. Patients were asked to record when they had returned to work and when they had returned to driving. RESULTS: Only one non-manual worker did not return to work within 6 weeks. Eighty-five per cent of manual workers returned to manual work within 3 months. Fifty-one patients held driving licences. The average time to return to driving was 28.9 days. Average preoperative Constant-Murley scores were 47.5 (20-67). At 3 weeks postoperation average Constant-Murley scores were 66.8 (40-92), and at 3 months 76.5 (48-99).

Metasynchronous bilateral Achilles tendon rupture.

Although Achilles tendon ruptures are a common occurrence, bilateral ruptures of the Achilles tendon are not. We present the case of a 33-year-old female who sustained metasynchronous (i.e., very close in time) bilateral ruptures of her Achilles tendons with no obvious predisposing factors. She was treated using a percutaneous technique and six months following surgery has returned to her normal activities.