The value of delayed MRI scans in the assessment of acute wrist injuries.

The aim of this study was to better quantify the role of delayed MRI scans in acute wrist injuries, and to assess the prevalence and distribution of multiple occult injuries of the wrist. A retrospective study was made of all patients who had been referred to the orthopaedic trauma clinic for a possible scaphoid fracture and with normal radiographs over a two year period. There were 110 patients. Patients were initially treated conservatively with a scaphoid cast or a futura splint for two weeks. This was then removed and the wrist examined and further radiographs taken. The patients with normal radiographs who had positive clinical findings for a scaphoid fracture at two weeks or persisting pain at six weeks had an MRI scan. MRI was performed with and without fat saturation sequences. A total of 110 wrists were analysed. Twenty-eight (25.4%) were reported as normal; 24 patients (21.8%) had occult bone fractures. Three (2.7%) had scaphoid fractures diagnosed by MRI scans. There were nine (8.1%) distal radius, two trapezium and five hook of hamate fractures. Bone bruising was seen in 12 (10.9%). Carpal degeneration was seen in ten and a TFC tear was noted in five (4.5%). Other findings were a ganglion in 14 (12.7%) and three (2.7%) had Kienbock's disease. The MRI scan is a useful tool in obtaining a definite diagnosis in acute wrist injuries. Among other findings, an occult scaphoid fracture was diagnosed on MRI in 2.7% of cases in this study. To conclude, in the majority of patients with persisting symptoms after two weeks following a wrist trauma, the cause of symptoms was pathology in other tissues in the wrist including soft tissues, other carpal bones and distal forearm.

The use of the three-point index in the management of extra-articular distal radius fractures.

Conservative management has been the mainstay of treatment for simple extra-articular distal radius fractures. Several factors, such as quality of definitive casting, have been implicated in the risk of fracture re-displacement during follow-up. Objective assessments of the quality of casting using various indices have been documented in literature, although overall evidence remains scant, and only one study in the literature discusses the use of the three-point index (3-PI) in adults. Currently, no independent study assessing the 3-PI in adults has been documented. This retrospective study aimed to assess the 3-PI in terms of (1) predicting fracture re-displacement and (2) evaluating its practicality in everyday clinical use. We had 54 patients (47 female, 7 female), out of which 35 patients had a 3-PI greater than the suggested cutoff value of 0.8; of these, 22 went on to re-displace. The remaining 19 patients had a 3-PI below the cutoff and 14 went on to re-displace. No statistical significance was found for the 3-PI as a predictor for fracture re-displacement, although inter-observer reliability was high; its impact on clinic times (in calculating the 3-PI) remained low.

Posterolateral Corner Reconstruction of the Knee Using Gracilis Autograft and Biceps Femoris.

We introduce our technique for posterolateral corner reconstruction, which is based on the principle described in Arciero's technique for anatomic reconstruction of lateral collateral ligament (LCL) and popliteofibular ligament (PFL) to gain static stability in varus strain and external rotation. This technique uses a doubled gracilis autograft to reconstruct the PFL and a split biceps tendon transfer to reconstruct the LCL. Using this technique an anatomical LCL and PFL reconstruction can be performed in combination with anterior cruciate ligament or posterior cruciate ligament reconstruction without contralateral graft harvest or allograft. The technique also enables an isolated reconstruction of LCL or PFL when required and can be performed to augment an acute repair.

Excellent outcomes with combined single stage Physica ZUK medial unicompartment knee replacement and anterior cruciate ligament reconstruction results in young, active patients with instability and osteoarthritis with a mean follow up of 5 years.

BACKGROUND (INCLUDING THE AIM OF THE STUDY): Young and more active patients with medial compartment osteoarthritis (OA) in conjunction with anterior cruciate ligament (ACL) deficiency are difficult to treat. The aim of this study was to explore the outcomes of combined fixed bearing Physica ZUK medial unicompartmental knee replacement (UKR) (Lima Corporate, Udine Italy) with ACL reconstruction for patients presenting with isolated medial compartment OA and symptomatic ACL deficiency. METHODS: Patients who underwent simultaneous single stage ACL reconstruction and medial UKR between 2012 and 2020 by a single surgeon (GG) were included. Preoperative outcome measures including Lysholm, Tegner, Oxford Knee Score and VAS pain score were evaluated and were repeated postoperatively at the most recent follow up appointment. RESULTS: Twenty four patients underwent simultaneous combined ACL and ZUK Medial UKR with a mean follow up of 5.1 years. Significant improvements in Lysholm (p < 0.001), Tegner (p < 0.001), Oxford Knee Score (p < 0.001) and VAS pain scores (p < 0.001) were seen with this combined approach with all patients returning to sport. Two patients had a minor peri-operative complication, which was treated conservatively. There were no revision procedures, and no evidence of implant loosening, however one patient had deceased due to an unrelated illness. CONCLUSION: UKR combined with ACL reconstruction can be an effective treatment option for selected patients suffering from medial unicompartmental knee osteoarthritis and symptomatic ACL deficiency. This allowed active patients to return to sports, addressing both instability and OA pain in a specific patient population.

Functional outcomes after fibula locking nail for fragility fractures of the ankle.

The aim of the present study was to assess the functional outcome of fragility fractures of the ankle treated with a fibular locking nail. A retrospective review of 24 patients with fragility fractures treated with a fibular locking nail from January 2005 to December 2007 was performed. The fibular nail used in our study was Biomet SST (stainless steel taper) small bone locking nail for the fibula. The Olerud and Molander scale was used to assess the functional outcome at the end of 1 year. The domains of the Olerud and Molander scale are pain, stiffness, swelling, stair climbing, running, jumping, squatting, support, and the activities of daily living. The patients were interviewed by telephone or the questionnaire was send by mail. Of the 24 patients, 2 were men and 22 were women. The left side was affected in 15 patients. The age group ranged from 71 to 91 years (average, 79). Of the fractures, 10 were lateral alveolus, 8 were bimalleolar, and 6 were trimalleolar fractures. All the patients were followed up at 6 weeks, 12 weeks, and after 6 months. The average period to fracture union was 8.7 weeks. No wound breakdown or any deep infections developed. The average Olerud and Molander scale score was 57 (range 30 to 65). The use of fibular locking nails to treat these difficult fracture are quite crucial to achieve early mobilization and also to maintain a good fracture position. In our study, the use of fibular nails was a very useful and successful method of treating fragility fractures with a very low risk of complications. It also helps to restore function and results in patient satisfaction.

Conventional versus 'all-inside' anterior cruciate ligament reconstruction: a randomized controlled trial comparing hamstring strength and functional outcome.

Cite this article: Bone Joint Open 2020;1-11:706-708.

Bilateral simultaneous rupture of the quadriceps tendon in a patient with psoriasis: a case report and review of the literature.

INTRODUCTION: Bilateral quadriceps tendon rupture is not common in the absence of systemic disease. Patients with chronic systemic diseases such as uremia and systemic lupus erythematosus and patients who are being treated with systemic steroids or local steroid injections are more prone to tendon rupture. The tendon can rupture spontaneously or as a result of trauma. We report an unusual case of simultaneous bilateral traumatic quadriceps tendon rupture in a patient with psoriasis who was being treated with topical steroid preparations. CASE PRESENTATION: A 57-year-old Caucasian man with a known history of psoriasis, for which he was being treated with topical steroid preparations, presented to our hospital with clinical signs of bilateral quadriceps tendon rupture after he fell while walking down stairs. The diagnosis was confirmed by bilateral ultrasound scans of the thighs. The patient underwent surgery to repair both quadriceps tendons. Post-operatively, the patient was immobilized first in bilateral cylinder casts for six weeks, then in knee braces for the next four weeks. His knees were actively mobilized during physiotherapy. CONCLUSION: Bilateral quadriceps tendon rupture is a rare occurrence in patients with psoriasis who are being treated with topical steroids.

Subacute dislocation of the elbow following Galeazzi fracture-dislocation of the radius: A case report.

INTRODUCTION: The Galeazzi fracture-dislocation was originally described by Sir Astley Cooper in 1822 but was named after Italian surgeon Ricardo Galeazzi in 1934. It is an injury classified as a radial shaft fracture with associated dislocation of the distal radioulnar joint and disruption of the forearm axis joint. The associated distal radioulnar joint injury may be purely ligamentous in nature, tearing the triangular fibrocartilaginous complex, or involve bony tissue (that is, ulnar styloid avulsions) or both. We report this case because of the rare association of posterior dislocation of the elbow along with Galeazzi fracture-dislocation. To the best of our knowledge, this has not been previously reported in the English literature. CASE PRESENTATION: A 26-year-old Caucasian man presented to our department after a fall from a motorbike. He sustained a closed, isolated Galeazzi fracture-dislocation of the right forearm and no associated elbow injuries, and this necessitated open reduction and internal fixation of the radius. Post-operative radiographs films were satisfactory. However, clinical and radiological evidence of ipsilateral elbow dislocation was noted at a five-week follow-up, subsequently requiring open reduction of the joint and collateral ligament repair. Our patient was noted to have full elbow and forearm function at three months. CONCLUSIONS: Although the Galeazzi fracture-dislocation has been classically described as involving only the distal radioulnar joint, traumatic forces can be transmitted to the elbow via the interosseous membrane of the forearm. This can lead to instability of the elbow joint. Therefore, we recommend that, in every case of forearm fracture, both elbow and wrist joints be assessed clinically as well as radiologically for subluxation or dislocation.