Manipulation under anaesthetic following total knee arthroplasty: Predicting stiffness and outcome.

PURPOSE: A stiff total knee replacement can severely limit a patient's post-operative function, but there remain few prospective trials identifying those patients at risk, nor the efficacy of manipulation. We analysed our prospectively collected database to assess predictors of stiffness and outcomes following manipulation. METHODS: Using prospectively collected knee arthroplasty data, including preoperative and post-operative range of knee movement, SF-12 (physical and mental) and The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, patients requiring manipulation were compared to a matched group of patients not requiring manipulation, with a detailed statistical analysis undertaken to assess potential risk factors and the post-manipulation outcome. RESULTS: Of the 1313 arthroplasty patients, 69 required manipulation. Patients with less than 80° of flexion at discharge, diabetes or on warfarin were more likely to require manipulation, but flexion at discharge was the overwhelming predictive factor for stiffness. Forty per cent of the range of movement gained during manipulation was maintained at 1 year, with earlier manipulation deriving greater improvements. While the WOMAC scores improved post-manipulation, there was no significant difference in either of the SF12 scores. CONCLUSION: Flexion at discharge is the overwhelming predictive factor for the requirement for manipulation.

Medium-term (5-year) comparison of the functional outcomes of combined anterior cruciate ligament and posterolateral corner reconstruction compared with isolated anterior cruciate ligament reconstruction.

PURPOSE: To present a 5-year comparison of the functional outcomes of combined anterior cruciate ligament (ACL) and posterolateral corner (PLC) reconstruction with those of isolated ACL reconstruction. METHODS: All patients were reviewed clinically and completed knee function questionnaires prospectively, by use of the International Knee Documentation Committee (IKDC) 2000, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm scoring systems, preoperatively and at 1, 2, and 5 years postoperatively. Patients who underwent combined ACL-PLC reconstruction were identified and reviewed. These patients had intact lateral collateral ligaments. A comparison group was created from a group of patients who underwent isolated ACL reconstruction. The ACL group was selected to have the same profile with regard to age, sex, and meniscal procedure. RESULTS: There were 25 patients in the ACL-PLC group and 100 in the ACL group. All patients underwent restoration of their PLC function as shown on dial testing. The preoperative values for all KOOS measures and the Lysholm score were significantly lower in the ACL-PLC group than in the ACL group (P < .001). The IKDC score was not significantly different. All knee scores showed a significant improvement in both groups postoperatively at 1, 2, and 5 years (P < .001). At 5 years, the KOOS symptoms subscore (P < .001), KOOS pain subscore (P < .001), KOOS sports subscore (P < .001), KOOS quality-of-life subscore (P < .05), KOOS activities-of-daily living subscore (P < .001), aggregate score for all KOOS parameters (P < .001), and Lysholm score (P < .001) were significantly lower in the ACL-PLC group than in the ACL group. At 5 years, the IKDC scores were not significantly different. All patients in the ACL-PLC group resumed preinjury employment, and 23 of 25 had resumed sports. CONCLUSIONS: Combined ACL-PLC injuries have greater morbidity than isolated ACL injuries. However, return to work and sporting activity is possible in most cases after combined ACL-PLC reconstruction. The KOOS for sport outcomes suggests that sports were resumed at lower functional levels. LEVEL OF EVIDENCE: Level III, case-control study.

Causes of successful medico-legal claims following amputation.

INTRODUCTION: The causes of successful medico-legal claims following amputation were reviewed. METHODS: A retrospective analysis of claims handled by the National Health Service Litigation Authority, from 2005 to August 2010, was performed. Under the Freedom of Information Act, the National Health Service Litigation Authority provided limited details on closed claims, settled with damages, following a search of their database with the term "amputation." No demographic data were provided. RESULTS: During this period, 174 claims were settled by the National Health Service Litigation Authority, who paid out more than £36.3 million. The causes of the claims were the need for a lower limb amputation due to a delay in the diagnosis and or treatment of arterial ischaemia (56), an iatrogenic injury (15), the development of preventable pressure sores (15), the delay and or failure to diagnose a limb malignancy (6) and the delay in the management of an infected pseudo-aneurysm (1). Complications following orthopaedic surgery resulted in 25 successful claims as did the delayed diagnosis or mismanagement of 10 lower limb fractures. Additional claims followed the amputation of the wrong toe (1), a retained foreign body (2), an unnecessary amputation (4), inadequate consent (4), failure to provide thrombo-prophylaxis following amputation resulting in death (2) and a diathermy burn injury during an amputation (1). Delay in the diagnosis of and/or failure to manage an injury or infection resulted in 21 upper limb amputations. There was insufficient information provided in the remaining 11 claims to determine how the claim related to an amputation procedure. The largest single payout for damages (£1.9 million) resulted from the failure to diagnose and treat a femoral artery injury following a road traffic accident leading to an eventual below knee amputation. CONCLUSION: Delays in the diagnosis and or treatment of arterial ischaemia were the commonest reasons for a settled claim. Lessons can be learnt from potentially preventable cases that can be incorporated in medical education and training programs with the aim of reducing both amputation rates and litigation costs.

Non-operative management of a talar body fracture in a skeletally immature patient.

We present the case of an 11-year-old girl who presented to our Emergency Department having fallen from a height of 8.5 meters. Amongst the sustained injuries was a comminuted fracture of the body of the talus. This was managed conservatively with an excellent outcome. We discuss the case with reference to the literature in this field, particularly highlighting comparisons between cases from patients with mature bone and those with immature bone.

The severity and prediction of anterior knee pain post tibial nail insertion.

OBJECTIVES: To compare the prevalence of anterior knee pain and functional impairment post-tibial nailing to the contralateral knee and a background population. DESIGN: Patients were assessed by postal questionnaire, case note, and radiographic review. An age demographically matched control group answered the same questions. SETTING: The Orthopaedic Department at our institution. PATIENTS/PARTICIPANTS: Patients who had a tibial nail inserted between September 1999 and November 2004 in our hospital (85 patients). Twelve were excluded, and 52 replies from 73 cases (71%) were received. The mean age was 39.4 years (range 22-69), and 38 of the patients were men. INTERVENTION: Patients treated with AO tibial nail. MAIN OUTCOME MEASUREMENTS: Both knees were assessed using an analogue pain score (0-10) and a functional anterior knee pain score (0-50). RESULTS: Of the patients, 83% had anterior knee pain following tibial nailing. The mean analogue pain score was 4.3, and the functional score was 33.3. The prevalence of anterior knee pain in the uninjured knee was 40%; in the control group it was 42%. Mean visual analogue scores were 1.3 and 1.2, respectively (both P<0.001 compared to the nailed side). Functional knee pain scores were 43.3 and 46.8 (both P<0.001 compared to the nailed side). Pain scores between both the knee on the injured and the contralateral sides correlated significantly (P<0.01). Last, the pain scores of the patients' knees of the uninjured side in the operative group and the scores from the control group appeared similar but not with statistical significance (P<0.57 analogue pain score and P<0.77 functional knee pain score). CONCLUSIONS: There is a significant preinjury prevalence of anterior knee pain. Postnailing knee pain severity correlates with that in the uninjured limb. Relative risk of anterior knee pain postnailing is twice that of a comparative population.

CT-guided embolization of an isolated internal iliac artery aneurysm 8 years after AAA repair.

PURPOSE: To report the use of computed tomographic (CT) guidance for percutaneous treatment of an isolated internal iliac artery (IIA) aneurysm after open aortic aneurysm repair. CASE REPORT: A 74-year-old man presented with an isolated IIA aneurysm 8 years after an open repair of his abdominal aortic aneurysm. In view of his diabetes, hypertension, and chronic renal impairment, an endovascular technique was selected. However, because of previous ligation of the internal iliac origin, a transarterial approach could not be used. The proximity of the aneurysm to the anterior abdominal wall allowed us to gain access to it percutaneously using CT guidance to perform embolization. CONCLUSION: CT-guided direct puncture of isolated IIA aneurysms adds to the current armamentarium of minimally invasive modalities. It is a technique that can be applied to isolated IIA aneurysms that develop subsequent to AAA repair or appear in cases where intra-arterial access is not possible.