Sliding rotational osteotomy for cases of dorsally angulated distal radius malunion: A technical note.

The aim of this study was to present a novel pre-planned distal radius sliding rotational osteotomy that can address all deformities in dorsally angulated distal radius malunion through a volar approach using a locking plate. Four consecutive adult women with symptomatic dorsally angulated distal radius malunion were surgically treated with sliding rotational osteotomy. All the patients underwent preoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores, a series of radiography, and a course of physiotherapy. The osteotomy was planned on 2 orthogonal radiographs, and the surgery was performed through a volar approach. A back slab was applied post-operatively for two weeks and changed to a removable splint for further four weeks. Gentle active movements out of splint were permitted at two weeks, and formal physiotherapy at six weeks post-operatively. Radiographs were taken immediately post-operatively, at three months, and with DASH scores at a mean final follow-up of 18 months. On radiographic evaluation, all the deformities were corrected within an acceptable range. The mean increase in radial inclination was 6.5 degrees. The mean gain in radial height was 2.95 mm. The mean improvement in ulnar variance was 4.25 mm. The mean change from dorsal to volar angulation was 23 degrees, and the mean improvement in the DASH score was 45.25 at a mean final follow-up of 16 months. All osteotomies achieved bony union within 3 months postoperatively. None of the patients required metalwork removal, and no complications were observed. Sliding rotational osteotomy appears to be a safe technique to correct deformity and improve function in patients with dorsally angulated, shortened, and radially deviated distal radius malunion.

Should Kirschner wires for fixation of lateral humeral condyle fractures in children be buried or left exposed? A systematic review.

BACKGROUND: Displaced lateral humeral condyle fractures in children are usually treated with open reduction and internal fixation. When treated operatively with Kirschner wires, the bent cut near side wire ends are either buried in the subcutaneous tissue or are left exposed. It is believed that burying the wires allows them to remain in longer and hence facilitate better union. Leaving them exposed seems to necessitate earlier removal, especially to reduce the risk of wire tract infection. There is not a clear consensus in published literature whether subcutaneous wire burial is better or not. PATIENTS AND METHODS: A systematic review of literature was performed using online database EMBASE, Pubmed, Medline, CINAHL and Cochrane database. The inclusion criteria comprised only those studies that compared lateral humeral condyle fracture fixation in children with wires buried subcutaneously versus those left exposed to skin. RESULTS: Of the four studies identified, three reported that it was safe to leave the wires exposed and that there was no statistically significant advantage of burying the wires with regards to risk of infection. However, our meta-analysis of the four studies demonstrated on forest plot charts that there is an increased risk of infection when the wires are left exposed (odds ratio 0.538 CI 0.437-0.639), but the overall complication rate was less in the group treated with exposed wires. Treatment with exposed wires was also cost effective when compared to treatment with buried wires. DISCUSSION: Our review concluded that despite a higher risk of superficial infections, exposed wires are safe and an economical option when fixing lateral humeral condyle fractures in children. LEVEL OF EVIDENCE: II, systematic review.

Effectiveness Of Plain Shoulder Radiograph In Detecting Degenerate Rotator Cuff Tears.

BACKGROUND: Studies have demonstrated radiographic findings of sclerosis and cortical irregularity at the greater tuberosity can suggest a rotator cuff tear. Plain radiographs are the most easily attainable first-line investigations in evaluating shoulder injuries. This study determines the effectiveness in predicting degenerate rotator cuff tears by detecting radiographic changes on shoulder x-rays. METHODS: Retrospective cross-sectional study with a consecutive series of patients conducted in Hinchingbrooke Hospital, Huntingdon, United Kingdom from January 2015 to June 2017. Anteroposterior shoulder radiographs of 150 symptomatic patients who underwent shoulder arthroscopy were independently analysed by surgeons who were blinded from the arthroscopic results. Patients aged fewer than 30 and over 70 years were excluded. Patients with advanced osteoarthritis and cuff tear arthropathy evident on x-rays were also excluded. Sixty-five patients included in the study had rotator cuff tears on arthroscopy. Radiographic changes were correlated with arthroscopic findings to determine this test's ability to predict degenerate rotator cuff tears. RESULTS: When both cortical irregularity and sclerosis were present on the plain radiograph, these signs had a sensitivity of 78.8% [95% CI 65.7, 87.8%] and specificity 77.4% [95% CI 67.2, 85.0%] with a positive predictive value of 68.3%, using contingency table analysis. The presence of cortical irregularity was found to be a better predictor of a tear as compared to sclerosis. CONCLUSIONS: This study concludes that plain radiograph are good modality for initial evaluation of rotator cuff tears and detecting when both cortical irregularity and sclerosis. Consideration of these radiographic findings serves as a useful adjunct in diagnostic workup and can guide subsequent investigations and treatment when evaluating rotator cuff tears of the shoulder.

Midterm results of Oxford shoulder hemiarthroplasty.

BACKGROUND: Hemiarthroplasty of the shoulder is known to provide satisfactory long term results provided concentric reduction can be obtained in a high percentage of patients. Careful soft tissue balancing with appropriate adaptation of version of the component appears to allow good results permitting centering of the arthroplasty without replacement of a glenoid component. MATERIALS AND METHODS: 29 consecutive patients (30 shoulders) who underwent Oxford cementless shoulder hemiarthroplasty between 2004 and 2006 were analyzed. Mean age was 71 years (range 34-91 years, 95% of the confidence interval [CI] of standard deviation [SD] was 10.32-17.58). Mean duration of preoperative symptoms was 42.8 months (range 9-84 months, 95% CI of SD was 17.83-30.11). Patients' self reported Oxford shoulder score (OSS) was collected prospectively and was used as an assessment tool to measure final outcome. RESULTS: The mean initial OSS was 17.9 (range 7-43, 95% CI of the SD was 7.19-12.13). The score improved by an average of 16.9 points at a mean followup of 5.9 years (range 4.3-7.6 years) to reach mean final OSS of 34.8 (range 13-48, 95% CI of the SD was 9.31-15.73). The improvement of OSS was highly significant with a two tailed P < 0.0001 and 95% CI of this difference was 11.47-22.20. CONCLUSION: This study demonstrates shoulder hemiarthroplasty as reliable procedure for improvement of shoulder function as shown by the patients' self reported outcome score (OSS) in end stage glenohumeral arthritis with intact or reparable rotator cuff at midterm followup. Our results suggest successful outcome of the Oxford shoulder hemiarthroplasty (Corin, UK) away from its originating center and in hospitals where fewer shoulder replacements are performed.

Enhanced recovery programme for total knee replacement to reduce the length of hospital stay.

PURPOSE: To compare the length of hospital stay in patients undergoing primary total knee replacement (TKR) with or without enhanced recovery (ER) programme. METHODS: Medical records of 57 and 55 consecutive patients who underwent primary TKR with or without ER programme, respectively, were reviewed. 17 men and 40 women aged 43 to 87 (mean, 70) years with ER programme were compared with 22 men and 33 women aged 53 to 90 (mean, 73) years without ER programme in terms of the preoperative haemoglobin level, American Association of Anesthesiologists (ASA) physical status grading, body mass index (BMI), and length of hospital stay. RESULTS: The length of hospital stay was significantly shorter in the ER than non-ER groups in overall patients (6 vs. 7.8 days, p=0.0003), in patients with preoperative haemoglobin level of ≥ 14 g/dl (5.4 vs. 7.7 days, p=0.02), in patients with preoperative haemoglobin level of <14 g/dl (6.2 vs. 7.7 days, p=0.02), in patients with ASA grades 1 and 2 (5.6 vs. 7.6 days, p=0.01), in patients with ASA grade 3 (6.4 vs. 8.2 days, p=0.01), in patients with BMI of <30 kg/m(2) (6 vs. 8.1 days, p=0.0061), and in patients with BMI of ≥ 30 kg/m(2) (5.9 vs. 7.5 days, p=0.0006). Complications were noted in 4 ER patients and 5 non-ER patients. CONCLUSION: ER programmes are readily transferable to patients undergoing TKR and significantly reduced the length of hospital stay.

Aequalis humeral head resurfacing in glenohumeral arthritis at a minimum followup of 2 years.

Aim. To evaluate results of Aequalis humeral head resurfacing in patients with end-stage glenohumeral arthritis at a minimum followup of two years. Patients and Methods. Twenty-one consecutive patients underwent humeral head resurfacing hemiarthroplasty between 2007 and 2009. Three patients did not fulfill the inclusion criteria. 18 patients with mean age of 75.1 years (range 58-91 years) and a mean duration of preoperative symptoms of 33.6 months (range 6-120 months) were analyzed. Patients' self-reported Oxford shoulder score (OSS) was collected prospectively and was used as an assessment tool to measure final outcome. Results. The mean initial OSS was 15 (range 3-29). The score improved by an average of 19.5 points at a mean followup of 36.3 months (range 24-54 months) to reach a mean final OSS of 34.5 (range 6-47). The improvement of OSS was highly significant with a two-tailed P value less than 0.0001. The overall patient satisfaction was 94%. Conclusion. This study demonstrates Aequalis shoulder resurfacing hemiarthroplasty as a reliable procedure, away from its originating center, for improvement of shoulder function as shown by the patients' self-reported outcome score (OSS) in end-stage glenohumeral arthritis at a minimum followup of 2 years.

Mid-term results of arthroscopic subacromial decompression in patients with or without partial thickness rotator cuff tears.

AIM: To evaluate mid-term outcome in patients who underwent arthroscopic subacromial decompression (ASD) for shoulder impingement syndrome with intact and partially torn rotator cuffs. MATERIALS AND METHODS: A total of 80 consecutive patients (83 shoulders) who underwent ASD for impingement syndrome between 2003 and 2006 were analyzed. Mean age was 57.1 years. Patients' self-reported Oxford Shoulder Score (OSS) for pain was collected prospectively and was used as an instrument to measure surgical outcome. RESULTS: The mean initial and final OSS for patients with an intact rotator cuff was 26.1 and 40.3, respectively, at a mean follow up of 71.9 months (nearly 7 years). The mean initial and final OSS for patients with a partially torn articular sided tear was 22.6 and 41.9, respectively, at mean follow up of 70.7 months. Both groups showed significant sustained improvement (P < 0.0001). The mean improvement of OSS following ASD was statistically greater (P < 0.03) for partially torn rotator cuff group (19.3 points) as compared to those with normal rotator cuff (14.2 points). CONCLUSION: Patients with dual pathology (partial rotator cuff tear and impingement) appreciated a significantly greater improvement following ASD compared to those with impingement alone. Both groups of patients had a similar final outcome at a mid-term follow up. LEVEL OF EVIDENCE: IV, retrospective study on consecutive series of patients.

Enhanced recovery program in total hip arthroplasty.

BACKGROUND: Enhanced recovery program (ERP) was implemented to optimize the hospital stay in total hip arthroplasty. This study assessed the effects of optimizing preoperative and perioperative care using enhanced recovery (ER) on patients undergoing Total hip arthroplasty. MATERIALS AND METHODS: We compared a prospective group of 64 patients on the ER program with a historic cohort of 63 patients that received conventional care (non ER). RESULTS: ER patients were discharged earliest from hospital [mean length of stay (LOS) 5.3 days, median 4; P < 0.001] as compared to a mean of 8.3 days among non ER patients. Comparison based on American Association of Anesthesiologists (ASA) grades, preoperative hemoglobin, and body mass index (BMI) revealed that patients with ASA grade 3, preoperative hemoglobin of <14 g/dl, and BMI >30 on ER program spent shorter time in hospital as compared to the non ER's conventionally treated patients with more favorable physiological parameters of ASA grade 1 and 2, preoperative hemoglobin of >14 g/dl, and BMI <30. CONCLUSION: The ER protocol is universally beneficial and confers an advantage regardless of the patients' preoperative condition.

No difference in the long term final functional outcome after nailing or cast bracing of high energy displaced tibial shaft fractures.

BACKGROUND: Cast bracing (CB) has been a well established method of treating tibial shaft fractures. Majority of the recent literature on treatment of tibial shaft fractures have upheld intramedullary nailing (IMN) as the treatment of choice. Most of these studies are from the west, in public funded health set ups and in hospitals with very low rates of infection. This has lead to bewilderment in the minds of surgeons wishing to opt for conservative treatment in countries with scarcity of health resources. We therefore undertook this study to compare the two modalities in the scenario of the developing world. MATERIAL AND METHODS: Sixty-eight consecutive patients were treated alternately with CB and IMN for high energy, displaced, closed and Gustilo Grade 1 open fractures of the tibial shaft, between 1995 and 2001. RESULTS: An average follow up at 4.3 years revealed no statistical difference in the final functional outcome as per Johner and Wruhs' criteria with modification to Indian lifestyle. IMN group had a) slightly shorter time to fracture union (mean 21.3 weeks versus 23.1 weeks for CB, p > 0.05), (b) lesser time off work (mean 17.6 weeks versus 25.6 weeks for CB, p <0.01), (c) fewer outpatient visits (mean 6.2 versus 9.7 for CB, p < 0.05), (d) less limb length discrepancy (mean 4.3 mm versus 6.6 mm for CB, p < 0.05). The difference in residual antero-posterior angulation (mean 3.2 degrees for IMN versus 4.9 degrees for CB, p = 0.14) and varus-valgus angulation (mean 3.7 degrees for IMN versus 5.1 degrees for CB, p = 0.7) were not statistically significant. However CB group had no deep infections as compared to two in the IMN group. The average cost of hospital treatment of CB group was less than half incurred by the IMN group (average USD 831 versus USD 2071 for nailed group, p < 0.05). CONCLUSION: Treating tibial shaft fracture either with IMN or CB provided equally gratifying results with no statistical difference in final functional outcome. The economic cost to the patient in Indian conditions is significantly less with CB and therefore stands as an equally reliable treatment option, especially in countries with fewer resources.

Evaluation of rehabilitated bilateral lower limb amputees - an Indian study.

OBJECTIVE: This study assessed activities of daily living (ADL) and ambulation of rehabilitated bilateral lower limb amputees with relation to their level of amputation in an Indian setting. SUBJECTS AND METHODS: This retrospective study of 25 subjects comprised 12 bilateral Trans-femoral (TF) amputees, 8 bilateral Trans-tibial (TT) amputees and 5 a combination of ipsilateral Trans-femoral and contralateral Trans-tibial amputation. All subjects were contacted by post/telephone, were physically examined and assessed at the Orthopaedic clinic at a mean follow-up of 6.6 years. Physical rehabilitation was evaluated using ADL score and by grading the level of ambulation. RESULTS: ADL scores showed no significant difference according to level of amputation (p > 0.05), but the scores of prosthetic users were significantly higher than non-prosthetic users (p = 0.002). Only 11/25 amputees became prosthetic ambulators and most (50%, 6/12) were TF amputees. All prosthetically rehabilitated subjects were mobilising with their prostheses at follow-up and graded as unlimited or limited community ambulators. CONCLUSION: Though it is well documented that the potential for successful rehabilitation is best for bilateral TT amputees, given the subjects' economic constraints, higher prosthesis rehabilitation among bilateral TF amputees indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

Are "knife and fork" good enough for day case surgery of resistant tennis elbow?

This observational retrospective study was performed on 22 consecutive patients treated surgically in a day surgery unit for resistant tennis elbow to ascertain the effectiveness of the "knife and fork" procedure. All patients had an unfavourable response to nonsurgical treatment lasting at least six months. A simple and inexpensive "knife and fork" technique yielded excellent results in 90.5% of patients and a high percentage (95.2%) of satisfied patients at an average follow-up of two years. There were no fair or poor results and no complications. We conclude that the "knife and fork" technique is a simple and dependable day case procedure. In the present National Health Service (NHS) era of tariff and "payment by results", this approach is more cost effective than an arthroscopic alternative.

The impact of posterior approach for total hip arthroplasty on early complications.

The optimal approach for total hip arthroplasty is hotly debated. We analysed 121 consecutive patients who underwent primary total hip arthroplasty during the first three years of practice of a newly appointed consultant. Patients were analysed for pain scores (1-6), function scores (1-6) and satisfaction levels (1-5). All complications, during and after surgery, were noted with special emphasis on incidence of dislocation and factors contributing to it. The results were gratifying and were comparable with major series of total hip replacement via the posterior approach. No patient had a dislocation. One hundred and five patients (89%) had no or minimal pain after the surgery. Eighty-six patients (73%) were mobilising without a stick. There were no major intra-operative complications and most (84%) patients rated the operation 'very good' at one year follow-up. We conclude that the posterior approach, already known to cause less blood loss and optimum component positioning, is compatible with a low overall rate of early complications especially dislocation.