A national questionnaire survey on knee manipulation following total knee arthroplasty.

BACKGROUND: Adequate range of knee motion is critical for successful total knee arthroplasty. While aggressive physical therapy is an important component, manipulation may be a necessary supplement. There seems to be a lack of consensus with variable practices existing in managing stiff postoperative knees following arthroplasty. Hence we aim to determine the current practice and trend among knee surgeons throughout the United Kingdom. MATERIALS AND METHODS: Postal questionnaires were sent out to 100 knee surgeons registered with British Association of Knee Surgeons, ensuring that the whole of United Kingdom was well represented. The questions included whether the surgeon used Manipulation Under Anaesthaesia (MUA) as an option for stiff postoperative knees; timing of MUA; use of Continuous Passive Motion (CPM) post-manipulation. RESULTS: We received 82 responses. 46% of respondents performed MUA routinely, 43% sometimes, and 11 never. Majority (71.23%) performed MUA within 3 months of the index procedure. 68% routinely used CPM post-manipulation while 7% of the respondents applied splints or serial cast post MUA. 41% of the surgeons routinely used Patient Controlled Analgaesia ± Regional blocks. Majority (55%) never performed open/arthroscopic debridement of fibrous tissue for adhesiolysis. CONCLUSIONS: Knee manipulation requires an additional anaesthetic and may result in complications such as: supracondylar femur fractures, wound dehiscence, patellar tendon avulsions, haemarthrosis, and heterotopic ossification. Moreover studies have shown that manipulation while being an important therapeutic adjunct does not increase the ultimate flexion achieved. Manipulation should be reserved for the patient with difficult and painful flexion in the early postoperative period.

Distal metatarsal coalition: A rare case report.

INTRODUCTION: Metatarsal coalition is an extremely rare condition. We report the second documented case of 4th and 5th distal metatarsal coalition in the literature. PRESENTATION OF CASE: An eight-year-old girl was referred to an orthopaedic clinic with a four-month history of forefoot pain and swelling on the plantar aspect of the right little toe. Radiograph and clinical examination confirmed distal metatarsal coalition between the 4th and 5th metatarsals. Following a period of conservative treatment, excision was eventually performed due to worsening symptoms. Patient re-attended two years later with a recurrence of the coalition confirmed by computed tomography (CT) scan. The case was discussed at a tertiary paediatric orthopaedic insititution. Decision was made to manage patient conservatively with insole and physiotherapy until skeletal maturity. A year later, patient's symptoms did not worsen, and her foot displayed no evidence of change in the arch and shape. DISCUSSION: The timing of ossification of coalition varies from one anatomical site to another. Surgery when performed before ossification is complete runs the risk of recurrence. CONCLUSION: Our case report illustrates the importance of restoring normal weight bearing dynamics and pain relief when managing metatarsal coalition, or synostosis in skeletally immature patients. We recommend persevering with conservative treatment, with operative treatment reserved only as a later option, and ideally, until skeletal maturity is achieved.

Acute nontraumatic clavicle fracture associated with long-term bisphosphonate therapy.

Cases of osteonecrosis of the jaw, insufficiency fractures and atypical low energy or atraumatic fractures of pelvis, femur (subtrochanteric/mid-shaft/distal-third), tibia, fibula, metatarsal, humerus, and ulna related to long-term bisphosphonate therapy have been reported in the literature. We present the case of an acute nontraumatic clavicle fracture, associated with long-term bisphosphonate therapy, which to our knowledge has not been reported previously. This case highlights the need of critical evaluation of patients with atypical fractures during long-term bisphosphonate therapy.

Conversion of hip arthrodesis to hip resurfacing: a case report.

Patients with hip arthrodeses are at risk of developing back pain or pain in other joints in the long term. Conversion to a total hip replacement or hip resurfacing leads to resolution of symptoms in most patients. We report a 40-year-old man who underwent conversion of a hip arthrodesis to hip resurfacing with good results.