Description of a Revision Technique for Failed Polyvinyl Alcohol Hydrogel Implant in Patient with Freiberg's Disease.

Polyvinyl alcohol hydrogel synthetic cartilage implants are increasingly used to treat advanced Freiberg disease. We report a case with recurrence of symptoms within 6 weeks and required revision for fracture of the implant. We describe a revision technique with modified osteochondral bone graft to deal with the variables of revision surgery namely: the bone loss, collateral ligament insufficiency, and changes to the proximal phalanx articular surface. We describe a postoperative plan, recovery and a good outcome achieved in 12 month follow-up.

A cadaveric study investigating the role of the anterior inferior tibio-fibular ligament and the posterior inferior tibio-fibular ligament in ankle fracture syndesmosis stability.

BACKGROUND: This cadaveric study aimed to investigate the role AITFL and PITFL have on preventing talar shift in ankle fractures, as well as investigating the role of AITFL reconstruction in preventing talar shift. METHODS: Twelve lower limb cadavers were used. Talar shift was measured following: Step 1- no ligaments cut; Step 2- entire deltoid ligament division; Step 3- group A (5 specimens) PITFL cut whilst group B (7 specimens) AITFL cut; Step 4- group A had AITFL divided whilst group B had PITFL cut. Reconstruction of the AITFL was performed using part of the superior extensor retinaculum as a local flap. Measurement of talar shift was then repeated. RESULTS: With no ligaments divided, mean talar shift was 0.8mm for group A and 0.7mm for group B. When the deltoid ligament was divided, mean talar shift for group A was 4.8mm compared to 4.7mm in group B (P=1.00). The mean shift in group A after PITFL division was 6.0mm, increasing the talar shift by an average of 1.2mm. In group B after AITFL division mean talar shift was 8.3mm (P=0.06), increasing talar shift by an average of 3.6mm. After division of the second tibiofibular ligament, mean talar shift in group A measured 10.0mm and in group B was 10.9mm (P=0.29). Three times more talar shift occurred after the AIFTL was divided compared to the PITFL (P=0.06). CONCLUSION: Consequently, repairing the PITFL in isolation (for example by fixation of a posterior malleolus avulsion fracture) may not adequately prevent talar shift; we feel consideration should also be given to reconstruction of the AITFL to augment the syndesmosis fixation, which may provide a stronger restoration of ankle stability. LEVEL OF CLINICAL EVIDENCE: 5.

A comparison of surgical exposures for posterolateral osteochondral lesions of the talar dome.

BACKGROUND: Perpendicular access to the posterolateral talar dome for the management of osteochondral defects is difficult. We examined exposure available from each of four surgical approaches. MATERIALS AND METHODS: Four surgical approaches were performed on 9 Thiel-embalmed cadavers: anterolateral approach with arthrotomy; anterolateral approach with anterior talo-fibular ligament (ATFL) release; anterolateral approach with antero-lateral tibial osteotomy; and anterolateral approach with lateral malleolus osteotomy. The furthest distance posteriorly allowing perpendicular access with a 2mm k-wire was measured. RESULTS: An anterolateral approach with arthrotomy provided a mean exposure of the anterior third of the lateral talar dome. A lateral malleolus osteotomy provided superior exposure (81.5% vs 58.8%) compared to an anterolateral tibial osteotomy. CONCLUSIONS: Only the anterior half of the lateral border of the talar dome could be accessed with an anterolateral approach without osteotomy. A fibular osteotomy provided best exposure to the posterolateral aspect of the talar dome.

Stability of Lisfranc injury fixation in Thiel Cadavers: Is routine fixation of the 1st and 3rd tarsometatarsal joint necessary?

BACKGROUND: There is debate as to whether a home run screw (medial cuneiform to 2nd metatarsal base) combined with k-wire fixation of the 4th & 5th tarsometatarsal joints is sufficient to stabilise Lisfranc injuries or if fixation of the 1st and 3rd tarsometatarsal joints is also required. Unlike the 2nd, 4th and 5th tarsometatarsal joints, stabilisation of the 1st and 3rd requires either intra-articular screw or an extra-articular plate which risk causing chondrolysis and/or osteoarthritis. The aims of this cadaveric study were to determine if routine fixation of the 1st and 3rd tarsometatarsal joints is necessary and to determine if a distal to proximal home run screw is adequate. METHODS: Using 8 Theil-embalmed specimens, measurements of tarsometatarsal joint dorsal displacement at each ray (1st-5th) and 1st-2nd metatarsal gaping were made during simulated weight bearing with sequential ligamentous injury and stabilisation to determine the contribution of anatomical structures and fixation to stability. RESULTS: At baseline, mean dorsal tarsometatarsal joint displacement of the intact specimens during simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st-2nd intermetatarsal gap was 0mm. After transection of the Lisfranc ligament only, there was 1st-2nd intermetatarsal gaping (mean 4.5mm), but no increased dorsal displacement. After additional transection of all the tarsometatarsal joint ligaments, dorsal displacement increased at all joints (1st: 4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires virtually eliminated all displacement. Further transection of the inter-metatarsal ligaments increased mean dorsal displacement of the 3rd ray to 2.5mm. K-wire fixation of the 3rd ray completely eliminated dorsal displacement. CONCLUSIONS: The results of this cadaveric study suggest that stabilising the medial cuneiform to the 2nd metatarsal base combined with stabilisation of the 4th and 5th tarsometatarsal joints with K-wires will stabilise the 1st and 3rd tarsometatarsal joints if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments (3rd-4th) are intact, the 3rd ray does not need to be routinely stabilised.

Hip fractures sustained in hospital: comorbidities and outcome.

BACKGROUND: Guidelines on the management of hip fracture in the elderly focus on fractures suffered in the community. Between 4% and 7% of hip fractures occur in hospital. Mortality is higher in those who sustain hip fracture in hospital than those who sustain a fracture in the community. However, it is not known if sustaining a nosocomial fracture is an independent risk factor for a poor outcome. OBJECTIVE: To compare outcomes of hip fracture sustained in the community and sustained while in hospital for another reason. After adjusting for confounders, we sought to determine if sustaining a fracture in hospital was an independent risk factor for a poor outcome. METHODS: Using the National Hip Fracture Database, we identified all patients admitted to Leicester Royal Infirmary with hip fracture between July 2009 and February 2013. We extracted demographic data, details of comorbidity, and 30-day and long-term mortality. Age, gender, American Society of Anaesthesiologists (ASA) grade, time to surgery, and survival were compared between patients with hospital-acquired and those with community-acquired hip fracture. RESULTS: During the study period, 2987 patients were treated for hip fracture; 2984 were included in the study. Of these, 261 (8.7%) sustained the fracture while in hospital. Those who sustained the fracture in hospital were more commonly men (106/261 (41%)) than those with a community-acquired fracture (738/2723 (27%)) and had a worse ASA grade (III or IV, 215/230 (93%) vs 1647/2573 (64%)). Thirty-day mortality was higher in those with a hospital-acquired fracture (48/261 (18%)) than in those with a community-acquired fracture (212/2723 (7.8%)) (p<0.001). However, after adjustment for confounding variables, the association between hip fracture, in-hospital and 30-day mortality was not significant: OR 1.2 (95% CI 0.8 to 2.0), p=0.40. Longer-term mortality was associated with hip fracture in hospital after adjustment for confounding variables in multivariate proportional hazards regression: HR 1.5 (95% CI 1.2 to 1.8), p<0.001. CONCLUSIONS: Patients who sustain hip fractures in hospital are unsurprisingly sicker than those who sustain hip fractures in the community. Although being in hospital is not an independent risk factor, this easily identifiable group of patients are at particular risk of a poor outcome. We suggest that it might be appropriate to consider modifying the guidelines for treatment of hip fracture for this group in an attempt to improve outcome.

Hypothermia and low body temperature are common and associated with high mortality in hip fracture patients.

Hip fractures remain one of the commonest injuries treated by orthopaedic surgeons. Despite recent initiatives, the fracture engenders a very high mortality. The UK National Hip Fracture Database reports a 30-day mortality of 8%. The pathophysiology that results in such high mortality remains imperfectly understood. The significance of thermal dysregulation in polytrauma is becoming increasingly recognised. Hypothermia is a common feature of polytrauma and is associated with adverse outcomes. No previous studies have explored the prevalence and outcomes of hip fracture patients with hypothermia and/or low body temperature. We sought to evaluate this. We prospectively collected the demographic details and admission tympanic temperature of all patients presenting to our institution with hip fracture. Patient mortality was also recorded. Seven hundred and eighty-one patients were included. The mean age was 80 years. 38% (300) had a temperature below 36.5°C. 4% (30) presented with a tympanic temperature greater than 37.5°C. The 30-day mortality for patients with a normal admission temperature (between 36.5° and 37.5°C) was 5.1%. This value was 15.3% for those whose admission temperature was less than 36.5°C (p<0.0001). Correcting for potential confounders of age and gender, those with an admission temperature of less than 36.5°C had a 2.8 fold increase in the odds of mortality at 30-days compared with those with an admission temperature of between 36.5° and 37.5°C (p<0.0005). Low body temperature is strongly linked to 30-day mortality in hip fracture patients.

Haptic feedback can provide an objective assessment of arthroscopic skills.

UNLABELLED: The outcome of arthroscopic procedures is related to the surgeon's skills in arthroscopy. Currently, evaluation of such skills relies on direct observation by a surgeon trainer. This type of assessment, by its nature, is subjective and time-consuming. The aim of our study was to identify whether haptic information generated from arthroscopic tools could distinguish between skilled and less skilled surgeons. A standard arthroscopic probe was fitted with a force/torque sensor. The probe was used by five surgeons with different levels of experience in knee arthroscopy performing 11 different tasks in 10 standard knee arthroscopies. The force/torque data from the hand and tool interface were recorded and synchronized with a video recording of the procedure. The torque magnitude and patterns generated were analyzed and compared. A computerized system was used to analyze the force/torque signature based on general principles for quality of performance using such measures as economy in movement, time efficiency, and consistency in performance. The results showed a considerable correlation between three haptic parameters and the surgeon's experience, which could be used in an automated objective assessment system for arthroscopic surgery. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The diagnosis and management of infection following instrumented spinal fusion.

A 10-year retrospective audit. (1) The incidence of infection; (2) causative organisms; (3) whether eradication of infection is achievable with spinal implant retention; (4) patient outcome. The reported incidence of infection following posterior spinal instrumentation is between 2.6 and 3.8%. Management of infection is controversial, with some advocating serial wound debridement while others report that infection cannot be eradicated with retention of implants. There are no published data demonstrating that propionibacteria are associated with early postoperative infection. The management of infected cases at our institution includes eventual removal of their implants. Our population was identified by studying the case notes of all patients who had undergone removal of spinal implants and cross-referencing this population with positive microbiology or histology reports. The incidence of infection was 3.7%. Propionibacteria were isolated in 45% of cases. The diagnosis of infection was unexpected in 25% of patients, following removal of implants for prominence of implants or back pain. Sixty per cent of patients with acute postoperative deep wound infection had continuing active infection on subsequent removal of implants, despite long-term antibiotics and wound debridement. Fourty-six per cent of patients had a stable, pain-free spine at the end of their treatment. This is the largest reported series of infections following posterior spinal instrumented fusions of which we are aware. Propionibacteria are a common cause of infection and successful eradication of infection cannot be reliably achieved with antibiotics and wound debridement alone.

Usefulness and impact on management of positive and negative capsule endoscopy.

OBJECTIVE: To determine the usefulness of positive and negative capsule endoscopies (CEs), and the impact of each on short- and long-term patient management. METHODS: Medical records were reviewed for 70 consecutive CE patients. Based on outcomes from referring physicians, it was determined whether CE was useful, partially useful or not useful at all in the overall patient management, and whether CE assisted in providing a diagnosis, and impacted on short-term long-term management. RESULTS: CE indications included overt bleeding (37%), occult bleeding (20%), iron deficiency (17%), abdominal pain and weight loss (13%), assessing the extent of or confirming a diagnosis of Crohn's disease (9%) and screening for familial adenomatous polyposis (4%). Positive studies were seen in 58% of overt bleeds, 50% of occult bleeds, 33% of iron deficiencies and 33% of Crohn's diseases. Overall, 28 studies (40%) were positive studies and 42 (60%) were negative studies. CE aided in diagnosis in 11 of 28 (39%) positive and 12 of 42 (29%) negative studies (P=0.35). Positive and negative CEs had an impact on short-term management in 12 of 28 (43%) versus 18 of 42 (43%) cases, respectively (P=1.0), and on long-term management in 14 of 28 (50%) versus 15 of 42 (36%) cases, respectively (P=0.23). For positive and negative studies, respectively, CE was considered useful in 12 of 28 (43%) versus 15 of 42 (36%) cases (39% overall), partially useful in 10 of 28 (36%) versus 10 of 42 (24%) cases (28% overall), and not useful at all in six of 28 (21%) versus 17 of 42 (40%) cases (33% overall). CONCLUSIONS: Although a negative CE may aid in making a definitive diagnosis in only 29% of patients, its effect on management and overall usefulness is similar to that of a positive CE. A physician's decision on whether to order CE should not be based solely on the pretest probability of a positive examination but also on the clinical utility of a negative study.

Are osteoporotic fractures being adequately investigated? A questionnaire of GP & orthopaedic surgeons.

BACKGROUND: To investigate the current practice of Orthopaedic Surgeons & General Practitioners (GP) when presented with patients who have a fracture, with possible underlying Osteoporosis. METHODS: Questionnaires were sent to 140 GPs and 140 Orthopaedic Surgeons. The participants were asked their routine clinical practice with regard to investigation of underlying osteoporosis in 3 clinical scenarios. 55 year old lady with a low trauma Colles fracture. 60 year old lady with a vertebral wedge fracture. 70 year old lady with a low trauma neck of femur fracture. RESULTS: Most doctors agreed that patients over 50 years old with low trauma fractures required investigation for osteoporosis, however, most surgeons (56%, n = 66) would discharge patients with low trauma Colles fracture without requesting or initiating investigation for osteoporosis. Most GPs (67%, n = 76) would not investigate a similar patient for osteoporosis, unless prompted by the Orthopaedic Surgeon or patient. More surgeons (71%, n= 83) and GPs (64%, n = 72) would initiate investigations for osteoporosis in a vertebral wedge fracture, but few surgeons (35%, n = 23) would investigate a neck of femur fracture patient after orthopaedic treatment. CONCLUSION: Most doctors know that fragility fractures in patients over 50 years old require investigation for Osteoporosis; however, a large population of patients with osteoporotic fractures are not being given the advantages of secondary prevention.

Simple technique for evacuation of traumatic subcutaneous haematomas under tension.

BACKGROUND: Traumatic subcutaneous haematomas are common cases in the accident and emergency department. Occasionally, urgent evacuation is required to prevent skin necrosis. METHODS: We present a simple and safe technique, based on a principle similar to liposuction to evacuate traumatic subcutaneous haematomas under tension. Instruments readily available in the accident and emergency department are used without the need of general anaesthesia. RESULTS: The technique was performed in six cases without complication such as infection or re-collection of the haematoma under tension. We present two typical scenarios where urgent evacuation was indicated and the technique performed. CONCLUSION: The technique is useful as an urgent and safe procedure in the accident and emergency department setting.