Is there a need for early post-operative x-rays in primary total knee replacements? Experience of a centre in the UK.

INTRODUCTION: Early post-operative x-rays are often taken in total knee replacements (TKRs). Patient mobilisation may be delayed until these x-rays are obtained and this may prolong discharge. The aim of this study was to assess the value of such early x-rays and whether they influenced the early post-operative management of these patients. METHODS: A total of 624 consecutive TKRs performed at the Blackpool Victoria Hospital over a 34-month period were evaluated. Plain anteroposterior and lateral x-rays were examined. RESULTS: Two patients were found to have significant abnormalities: an undisplaced periprosthetic tibial fracture and a partial inferior pole patellar avulsion. Neither of these required further treatment or influenced mobility. No other complications were noted that changed routine post-operative management. CONCLUSIONS: These results question the need for immediate x-rays in primary TKRs.

The current practice of the management of little finger metacarpal fractures--a review of the literature and results of a survey conducted among upper limb surgeons in the United Kingdom.

Little finger metacarpal fractures are the most common type of metacarpal fractures and the treatment is quite variable as it is a multifactorial entity comprised of subcapital, metacarpal shaft and base fractures. These fractures are common presentations in the fracture clinics and the general orthopaedic surgeons treat them until a complex case warrants specific decision making by a hand surgeon. The management of many of these fractures is still a matter of debate and differ widely in the various parts of the United Kingdom. The aim of this study was to investigate the current practice of little finger metacarpal fractures among upper limb surgeons in the UK. We conducted an online survey among 278 upper limb orthopaedic specialist surgeons throughout the UK. Our response rate was 58%. There are various factors which dictate the treatment as suggested by these respondent upper limb consultants. For example, for fifth metacarpal neck fractures, it was generally recognised that 43% of upper limb surgeons prefer neighbour strapping alone for non-operative management of little finger metacarpal fractures. For little finger metacarpal shaft fractures, 39.3% of surgeons suggested that they would contemplate intervention, i.e. manipulation under anaesthesia/surgery if beyond 30° of volar angulation is present. For little finger metacarpal neck fractures, 33.7% would only consider surgical intervention beyond 60° of volar angulation. 91.6% of upper limb specialists agreed that they would operate on little finger metacarpal base fractures only if it was a fracture dislocation, while 71.8% suggested that they would proceed to operate on even a pure dislocation. We have illustrated the various permutations and combinations of these fractures with the results of our survey in this article in detail. The vast majority of metacarpal bone fractures are stable and treated conservatively. The different types of injury patterns must be recognised by the orthopaedic surgeons and appropriate treatment then should be executed to serve the patient optimally in due course.

Reoperation for metalwork complications following the use of volar locking plates for distal radius fractures: a United Kingdom experience.

Volar locking plates are increasingly used in the management of distal radius fractures. As with any new implant, understanding the rate and type of potential metalwork related complications is important. In this study, we reviewed 114 distal radius fractures treated with volar locking plating. Our aim was to determine the type and rate of metalwork complications requiring reoperation. In our series, 12 cases (10%) underwent further surgery for metalwork related complications mainly for screw protrusion into the radiocarpal joint following fracture collapse. Our results suggest that volar locking plates are associated with a high rate of metal work related complications requiring further surgery. Technical aspects to reduce such complications are discussed.

The low contact stress patellofemoral replacement: high early failure rate.

The low contact stress patellofemoral replacement consists of a trochlear component and a modular patellar component which has a metal-backed mobile polyethylene bearing. We present the early results of the use of this prosthesis for established isolated patellofemoral arthritis in 51 consecutive patellofemoral replacements in 35 patients. The mean follow-up was 25 months (5 to 60). The estimated survival rate at three years was 63% (95% confidence interval 47 to 80) with revision as the endpoint and 46% (95% confidence interval 30 to 63) with revision and ongoing moderate or severe pain as the endpoint. The early results of the use of the low contact stress patellofemoral replacement are disappointing with a high rate of revision. We cannot therefore recommend its use.

Distal radial and ulnar landmarks used in percutaneous pin fixation: anatomical relationship to the superficial radial and ulnar nerves.

BACKGROUND: The radial and ulnar styloids as well as Lister's tubercle are important surgical landmarks in the surgical treatment of distal forearm fractures. There have been limited studies assessing their relative safety in terms of their distance from superficial nerves which are in danger during surgical procedures. The aim of this cadaveric study was to assess and compare the distance of superficial nerves to these important surgical landmarks. METHODS: Twenty embalmed cadaveric upper limbs were dissected exposing the nerves and tendons around the wrist. The radial styloid, Lister's tubercle, ulnar styloid and nerve branches were marked with pins. The distance of the nearest nerve branch to each landmark was measured with a digital calliper. Statistical analysis of the data was performed using SPSS for Windows 11.5 (SPSS Inc., Chicago, IL) using Friedman Tests and Wilcoxon Signed Ranks tests. RESULTS: The median distance of the nearest nerve branch to the radial styloid was 5.42 mm, to the Lister's tubercle was 16.68 mm and to the ulnar styloid was 13.56 mm. There was unequal safety for these three surgical landmarks regarding proximity to nerve branches (p < 0.00001). Paired comparison using Wilcoxon Signed Ranks Test showed that the Lister's tubercle was safer than the radial styloid (p < 0.0001) and ulnar styloid (p = 0.04). In addition, the ulnar styloid was safer than the radial styloid (p < 0.001). CONCLUSIONS: There is a higher risk of injury to superficial nerves when operating near the radial styloid as it is significantly closer to nerve branches as compared to Lister's tubercle and ulnar styloid.

Bone-cement interface strength in distal radii using two medullary canal preparation techniques: carbon dioxide jet cleaning versus syringed saline.

PURPOSE: Loosening is an important cause of failure of upper limb arthroplasty and improvement in cementation techniques may limit this. The currently accepted medullary canal preparation techniques use saline washing and gauze drying. Another method of bone preparation uses carbon dioxide compression gas jet which blows debris from the canal, whilst simultaneously drying the bone. We compared the push out strengths of cement plugs in sections of human cadaveric radii that had been prepared using either syringed saline or carbon dioxide jet cleaning. METHODS: Following bone preparation, four radii in each group, were cemented in a standardised fashion, and cut into 1 cm sections. An Instron materials testing machine was used to measure the force needed to push the cement plug out of the bone section. RESULTS: The force needed to push out the cement plug was significantly higher in the carbon dioxide jet (median 580.61, IQR 429.10-650.05) as compared to the saline group (median 366.57N, IQR 271.05-502.23), P = 0.009. The mechanism of failure of the bone-cement interface also differed between the two groups, with 100% of the sectioned cortices fracturing prior to cement extrusion in the carbon dioxide jet group, but only 23% of the sectioned cortices doing so in the saline group. CONCLUSION: Our results suggest that there is a statistically stronger macro-interlock at the bone-cement interface after preparation of the medullary canals of radii using a carbon dioxide compression gas jet as compared to saline irrigation.

Accessory bands of the hamstring tendons: A clinical anatomical study.

Gracilis and semitendinosus tendons are commonly used as grafts in ligamentous reconstruction. Awareness of accessory bands of these tendons is essential in preventing inadvertent diversion of the tendon harvester into the main tendon resulting in premature tendon amputation and inadequate tendon graft. The aim of this study was to describe the characteristics of these accessory bands. Twenty five patients undergoing arthroscopic anterior cruciate ligament reconstruction using hamstring tendons were included. The number of accessory bands and distance of the most proximal band from the distal periosteal insertion point on the tibial crest was recorded for both gracilis and semitendinosus. In most cases gracilis had two accessory bands; the average distance of the most proximal band from the tibial crest insertion being 5.1 cm. Semitendinosus had three bands in most cases, the average distance of the most proximal band from the tibial crest insertion being 8.1 cm. Five (20%) semitendinosus but no gracilis tendons had an accessory band originating greater than 10 cm from the tibial crest insertion. Semitendinosus had more accessory bands compared to gracilis. A significant proportion (20%) of semitendinosus and none of the gracilis tendons had bands originating greater than 10 cm proximal to the tibial crest insertion. This knowledge about the accessory bands of the hamstrings can guide toward safe harvesting of these tendons.

Gradual distraction using an external fixator followed by open reduction in the treatment of chronic lunate dislocation.

Chronic lunate dislocation is a difficult problem to deal with. We describe a surgical technique whereby gradual wrist distraction is applied using an external fixator followed by open repositioning of the lunate. We have successfully used this technique in a rugby player with an undiagnosed chronic lunate dislocation. Our case was able to return to competitive rugby playing.

The tag test for Dupuytren's surgery.

Digital nerve injury is a well-recognised complication of surgical treatment for Dupuytren's disease. We describe a simple test, the Tag test, that can be used intra-operatively to help identification of the digital nerves.

Applied kinesiology for treatment of women with mastalgia.

To determine whether an applied kinesiology technique was of benefit to women with breast pain, an open pilot study was conducted in which 88 newly presenting women with self-rated moderate or severe mastalgia were treated by applied kinesiology. This involved a hands-on technique consisting of rubbing a series of 'lymphatic reflex points' while touching painful areas of the breasts. The women were predominantly pre-menopausal, and patients with both cyclical and non-cyclical pain were included in the study. Patients' self-rated pain scores, both before and immediately after applied kinesiology were compared, together with a further score 2 months later. Immediately after treatment there was considerable reduction in breast pain in 60% of patients with complete resolution in 18%. At the visit after 2 months, there was a reduction in severity, duration and frequency of pain of 50% or more in about 60% of cases (P<0.0001). This preliminary study suggests that applied kinesiology may be an effective treatment for mastalgia, without side-effects and merits testing against standard drug therapies.

Platelet aggregometry on whole blood: the use of the ELT 8/ds blood cell counter in the investigation of bleeding disorders.

A method is described for measuring platelet aggregation by serial counting of platelets in whole blood, using the Ortho ELT 8/ds blood cell counter. The method is simple, rapid, reproducible and more sensitive to low concentrations of ADP and other agonists than conventional aggregometry on platelet-rich plasma. It can be used as a diagnostic test for disorders of platelet function using as little as 2 ml of whole blood: results in thrombasthenia, Hermansky-Pudlak and Bernard Soulier syndromes and von Willebrand's disease are shown.