Outcomes following revision of the revision total elbow arthroplasty.

BACKGROUND: There is very little information in the literature on the outcomes of revision of revision total elbow arthroplasty (RRTEA). Our aim was to report the outcomes of this rarely performed procedure. METHODS: We retrospectively identified all patients who had undergone RRTEA between 2007 and 2016. Outcomes were assessed clinically using a number of validated systems, and radiographs were reviewed for prosthesis alignment, cementation by Morrey grading, and heterotopic ossification. RESULTS: We identified 22 patients who underwent RRTEA. Of these patients, 14 were available for assessment (2 died of unrelated causes, 2 could not be contacted, 2 declined to participate because of travel difficulties, and 2 had incomplete data). At the final review, the median age was 73 years (range, 57-83 years), with a median follow-up period of 4.5 years (range, 2-7 years) since the last surgical procedure. The median number of previous revision arthroplasty procedures per patient was 3 (range, 2-6). The indications for RRTEA were aseptic loosening (60%), bushing wear (16%), fracture (14%), and infection (10%). Of the patients, 30% required extra-long or custom-made implants and 50% needed allograft augmentation. At final clinical assessment, 56% of patients had triceps insufficiency, the median flexion-extension arc was 90°, and the median prono-supination arc was 95°. The functional elbow scores revealed good outcomes in the majority of patients (median visual analog scale score, 5; median Oxford Elbow Score, 22; median Mayo Elbow Performance Index score, 55; and median QuickDASH [short version of Disabilities of the Arm, Shoulder and Hand questionnaire] score, 63). Eighty-one percent of patients were satisfied with their RRTEAs. Complications included infection in 2 patients (1 superficial and 1 deep), symptomatic aseptic humeral component loosening in 1, sensory ulnar nerve symptoms in 2, and radial nerve injury in 1. One patient required ulnar nerve release. Radiologic review revealed asymptomatic loosening in 1 patient (humeral component), and overall prosthesis alignment with cementation was adequate in 81%. Heterotopic ossification was present in 38% of cases. CONCLUSIONS: RRTEA is a satisfactory treatment option in these complex cases, with good short- to mid-term survival rates but a relatively high complication rate.

Isolated suprascapular nerve palsy following childbirth: A case study and literature review.

We report a case of 30-year-old lady presenting with a suprascapular nerve (SSN) injury in the postpartum period. Two days following normal delivery, the patient experienced progressive weakness in her left shoulder, of spontaneous onset. Initially thought to be a rotator cuff tear, further imaging indicated a lesion in the SSN. Isolated SSN palsy is a rare occurrence. Previously reported cases of brachial plexus nerve injuries are due to trauma, traction, iatrogenic and the positioning of the patient during surgery. To our knowledge this is the first case report of SSN injury following normal delivery. In addition to the unusual presentation, our patient completely recovered from the SSN nerve injury without any operative management.

Infection and failure rates following total hip arthroplasty for septic arthritis: a case-controlled study.

INTRODUCTION: Total hip arthroplasty (THA) is performed as a 2-stage or single stage procedure in patients with a history of septic arthritis of the native hip joint. The decision is based on whether the infection is active or quiescent in the joint. The aim of this study was to compare the outcomes of total hip arthroplasty for septic arthritis of the native hip to a control series of patients treated for primary osteoarthritis of the hip with standard THA. METHODS: Between March 2000 and March 2013, 18 cases of septic arthritis of the hip treated with THA were retrospectively identified. During the same time period, 18 control cases of THA for degenerative osteoarthritis were identified. Cases and controls were comparable in age, gender, body mass index, type of anaesthesia and American Society of Anesthesiologists score. RESULTS: 11 and 7 cases received 2-stage and single stage total hip arthroplasty respectively for septic arthritis. There was a mean interval of 4 months between 1st and 2nd-stage operations. Cases and controls were followed up for a mean of 70 and 72 months respectively. There was no reinfection or implant failure in the cases, and comparable functional outcomes between cases and controls. CONCLUSIONS: Two-stage and single-stage THA for active and quiescent native hip infection respectively, achieved similar outcomes to THA for primary osteoarthritis in controls.

The use of recombinant morphogenic protein-2(rhBMP-2) in children undergoing revision surgery for persistent non-union.

The purpose of the study was to evaluate the safety and efficacy with the use of BMP-2 for treating persistent non-unions in children with underlying complex conditions. Between October 2006 and November 2010 in our unit, 15 patients were treated with rhBMP-2 to enhance bone union. There were nine females and six males with a mean age of 9.5 years (range 4-15) at time of surgery. Seventy-five per cent of the patients required revision of internal fixation with insertion of rhBMP-2 to the non-union site, and the reminder had freshening of the non-union site with rhBMP-2 application. Patients had undergone a mean of 2 (1-5) operations prior to implantation of rhBMP-2. All the patients in the study group were available for review with mean follow-up of 44 months (range 21-70). The mean time to union was 16 weeks (range 10-28 weeks). No adverse events related to BMP-2 application were noted in our study group. Healing occurred clinically and radiographically in 16 of the 17 sites. Our study demonstrates that BMP-2 enhances healing of the persistent non-unions without any adverse events.

Long-term follow up outcome results of Knifelight carpal tunnel release and conventional open release following a departmental randomized controlled trial. A prospective study.

BACKGROUND: Carpal tunnel syndrome is traditionally treated with open release through a long palmar incision, which leaves some patients with pillar pain and scar tenderness. The Knifelight (Stryker, Kalamazoo, MI) is an exciting new instrument that allows minimally invasive release of the transcarpal ligament without subjecting the patient to the traditional problematic open palmar incision. However, no long-term data has been published in the literature so far. MATERIAL AND METHODS: A modified QuickDASH score questionnaire was used to assess long-term results and patient satisfaction 10 years following our department's original randomized control trial comparing open carpal tunnel release (43 patients) to carpal tunnel release using the Knifelight method (39 patients). RESULTS: The mean modified QuickDASH score was 33.71 (SD 23.27) for the open group and 13.22 (SD 13.62) for the Knifelight group (P-value=0.0024). Patients from the open group complained of pillar pain (30%), scar tenderness (25%) and recurrence of carpal tunnel symptoms (18%). Three patients had symptoms so severe that they could not perform their jobs. In the Knifelight group there were no reports of any pain, recurrence or scar-related problems and a high level of general satisfaction was observed with this group of patients. CONCLUSIONS: Our study results show that the minimally invasive Knifelight carpal tunnel release was associated with better clinical outcomes, less complications and overall better quality of life when compared to the conventional open carpal tunnel release.

Cementless surface replacement arthroplasty of the shoulder for osteoarthritis: results of fifty Mark III Copeland prosthesis from an independent center with four-year mean follow-up.

PURPOSE: Few studies have reported the outcome of cementless surface replacement (CSRA). We initiated this study to analyze results of the Mark III Copeland prosthesis used as a hemiarthroplasty in patients with glenohumeral osteoarthritis. MATERIALS AND METHODS: We retrospectively reviewed 53 consecutive Mark III Copeland CRSA hemiarthroplasties in 46 patients (30 women, 16 men) with glenohumeral osteoarthritis from an independent institution by a single surgeon. Patients were a mean age of 69 years (range, 45-94 years). Mean follow-up was 4.2 years (range, 2-8 years). Fifty uncemented hemiarthroplasties were available for review. RESULTS: Mean (range) age-adjusted Constant and Oxford scores improved from 38.5 (15-61) and 22 (9-31) to 75.1 (38-87) and 42 (18-48), respectively. Anterosuperior escape of the humeral head developed in 1 patient who had an oversized humeral component due to progressive rotator cuff failure at 2 years. Moderate glenoid erosion was present in 12% and correlated with oversizing of the humeral component. There was one revision to a stemmed cemented hemiarthroplasty for periprosthetic fracture. No patients have required revision for aseptic loosening, rotator cuff failure, or glenoid erosion to date. CONCLUSIONS: Copeland surface replacement hemiarthroplasty for glenohumeral osteoarthritis can provide functional results similar to modular stemmed prostheses, with a relatively low revision rate at 4.2 years of follow-up; however, there is high rate of glenoid erosion that may complicate future revision surgery, and we did not achieve the same functional improvement as that achieved from the designer's institution.

How to read a postoperative knee replacement radiograph.

Knee replacement surgery is the most common joint replacement surgery in England and Wales. Postoperative radiographs are associated with long-term outcome at both early and late stages, and their correct interpretation is therefore vital. These radiographs will commonly be assessed by surgical trainees, emergency doctors, orthopaedic surgeons, nurse practitioners, and radiologists. The aim of this paper is to provide the reader with a systematic approach to assessing these radiographs, whether it be in the immediate postoperative period or during subsequent follow-ups, and to provide sufficient knowledge to critique the procedure. An outline of prostheses and their indications alongside a comprehensive review of the assessment of important angles, alignment, and correct positioning of femoral and tibial components is presented.

Concurrent palmar lunate dislocation and posterior elbow dislocation: a case report.

We report a rare case of concurrent palmar lunate dislocation of the left wrist combined with a posterior dislocation of the left elbow joint in a 40-year-old man. He sustained both injuries after falling onto his outstretched left hand. The elbow was reduced by the closed method. The wrist was treated with open reduction with carpal tunnel decompression and fixation with a Kirschner wire through the volar approach. Both the scapholunate and radioscaphocapitate ligaments were also repaired. At month 3, the patient had no pain in his elbow and minimal pain in his wrist on heavy lifting and had resumed his work as a porter.

Femoral neuropraxia after vaccination in a 3-month-old infant: a case report.

We report an incidence of a 3-month-old infant who developed femoral neuropraxia after vaccination (diphtheria, tetanus and acellular pertussis/inactivated poliovirus/haemophilus influenzae type B vaccine) in the thigh. To the best of our knowledge, femoral nerve injury after vaccination has not been reported in the literature before. However, this baby made good neurological recovery within 8 weeks after vaccination.

Promises and difficulties with the use of femoral intra-medullary lengthening nails to treat limb length discrepancies.

Limb lengthening using external fixation may be associated with problems such as pin-track infections, poor patient acceptance, muscle transfixation, secondary axial deformity and re-fractures. Intramedullary lengthening nails have been designed to address these issues. We present our results for femoral limb lengthening in adults managed by intramedullary lengthening nails. A retrospective review was undertaken for 8 femoral lengthening procedures performed in adults using intra-medullary lengthening nails over a three-year period. The average age of our patients was 34 years; the average duration of follow-up was 26.5 months (range: 8 to 40 months). An Albizzia nail was used in 5 procedures, an Intra-medullary Skeletal Kinetic Distractor (ISKD nail) in 3 procedures. Target lengthening was achieved in 6 out of 8 femurs with an average of 38.77 mm (range: 0 to 70 mm) length gained. The distraction index (length gained per day) was 0.58 on average (range: 0-1.25) and the consolidation index average was 5039 (range: 0-79) days/cm. Premature consolidation was noted in 4 cases, runaway acute lengthening in one patient; prominent metalwork--noted in 4 patients--and a bent nail were frequent obstacles and meant multiple visits to theatre. Femoral lengthening with an intramedullary lengthening nail is a reasonable alternative to external fixators, thereby avoiding problems associated with callotasis using external fixation methods. It is however, important to counsel patients regarding possibilities of significant obstacles including failure and multiple visits to theatre during the process.

Quality of consent form completion in orthopaedics: are we just going through the motions?

Consent plays a vital role in every aspect of medicine and surgery, facilitating the patient in making informed decisions about their treatment. The recently published Reference Guide to Consent, by the Department of Health (DH), notes that, although not a legal requirement, the completion of consent forms is good practice, particularly in interventions such as surgery. In addition, the Parliamentary and Health Service Ombudsman noted that a significant number of complaints about consent involved the complainant feeling that they did not fully understand what was going to happen. It was often found that there was no documentation to clarify what the patient was told, when and by whom. We have performed an audit of 71 randomly selected consent forms, elective and trauma cases within our district general hospital orthopaedics department. Our data demonstrate that a significant number of consent forms were incorrectly or insufficiently completed. This could not only leave the patient confused about their procedure but also leaves the doctor open to litigation, with little in the way of documentation support. Minor changes in consenting methods and more precise documentation could significantly improve patient experience and satisfaction.

Post-traumatic calcific myonecrosis of flexor hallucis longus. A case report and literature review.

Calcific myonecrosis is a rare, late complication of compartment syndrome in the lower extremity. In this condition an entire single muscle of the leg is replaced by a fusiform mass with central liquefaction and peripheral calcification. Calcific myonecrosis presents a diagnostic dilemma to the clinician; it has to be considered in the differential diagnosis of a calcifying soft tissue tumour in the lower extremity. The purpose of this report is to highlight the importance of recognition of the lesion and its key clinico-pathological presenting features leading to appropriate management. We describe the unique presentation, diagnosis and surgical management of calcific myonecrosis involving only the flexor hallucis longus muscle of the leg in a middle-age adult. We found MRI Scan as the most useful method of investigation. Diagnosis can be confirmed by yellow-brown paste like material within the lesion intra-operatively or by aspiration and further by histology. We recommend complete excision of the lesion and closure of the wound with compression dressing, to avoid secondary infection.