Low-Intensity Pulsed Ultrasound Treatment for Non-unions of Long Bone Fractures in a Scottish District General Hospital.

OBJECTIVE: Despite advances in treatment, the management of fracture non-union remains a challenging and complex problem in orthopaedics. Low-intensity pulsed ultrasound (LIPUS) treatment has been shown to be an effective, non-invasive, affordable treatment option. This treatment was evaluated in a Scottish district hospital over a nine-year period, which included the COVID-19 pandemic. MATERIALS AND METHODS: This submission describes a case series at Dr Gray's Hospital in Scotland, 18 patients in whom fracture non-union was treated using LIPUS. RESULTS: An overall healing rate of 94% was achieved. Exogen™ (Bioventus LLC, NC, USA) proved to be most successful in oligotrophic non-union. No observed patient demographic appeared predictive of outcome. LIPUS treatment failed in one case. No significant adverse effects of LIPUS were detected. CONCLUSION: LIPUS represents a useful, cost-effective potential alternative to revision surgery. LIPUS may therefore be the preferred treatment when surgical intervention and face-to-face interactions are to be minimised, as during the COVID-19 pandemic.

Ipsilateral Intracapsular Hip Fracture 2 Years after Fixation of Extracapsular Fracture by Dynamic Hip Screw.

INTRODUCTION: Sustaining an intracapsular fracture in a hip which was previously fixed with dynamic hip screw for extracapsular fracture, is a very rarely reported occurrence. We present one such case in order to discuss the presentation and management of this fracture. We have also reviewed the literature and pooled the previously reported cases to look at potential cause & risk factors. CASE REPORT: A 92 year old female, presented with new onset hip pain following a trivial injury. Couple of years back, she had sustained an extracapsular fracture on same side which was treated by DHS fixation. Further investigations confirmed a de-novo fracture which was treated by removal of DHS and cemented bipolar hemiarthroplasty. CONCLUSION: This complication might not be as rare as earlier thought to be. All patients, especially elderly females who present with new onset hip pain following DHS fixation of their hip fracture previously must be evaluated for a de-novo intracapsular fracture. On confirmation of diagnosis, they can be treated by removal of dynamic hip screw and hemiarthroplasty as most of these are low demand elderly patients.

A rare case of an osteochondral lesion of the tarsal navicular with a subacute stress fracture in a high level athlete.

In this report, an osteochondral lesion of the tarsal navicular associated with a subacute stress fracture in a professional basketball player surgical treatment is presented. The surgical technique involved extra-articular curettage, bone grafting and plate stabilisation. Postoperative CT scan confirmed that both the osteochondral lesion and the stress fracture healed. The talonavicular joint showed no signs of arthritis on imaging. Clinical foot scores showed marked improvement after surgery. At 6 months patient managed to return to competitive play without pain in the foot and ankle. The outcome of this case indicates that the combination of curettage, bone grating and plate stabilisation works well for this rare and potentially career ending dual lesions.

Surgical tip: Titanium foam blocks can simplify fusion of failed total ankle replacements.

Ankle arthrodesis following failed ankle replacements is a technically challenging task because of the large defect left behind after the prosthesis is removed. The usual practice is to use bulk grafts which are either autografts or allografts to fill the defect. We report our experience with the use of a titanium foam block specifically designed for fusion of failed ankle replacements. This particular method was chosen to avoid the technical difficulties and morbidities associated with the use of bulk autografts and allografts. We describe the surgical technique and early results in the first two cases performed in our unit. The satisfactory clinical and radiologic results in the two cases demonstrate the ability of the titanium foam block to simplify an otherwise complex procedure without compromising the outcome.

Management of recurrent multiple osteochondral lesions of the talus (OCLT) in a young active patient.

Management of recurrent osteochondral lesion of talus in a young active male is a challenging problem. We present one such case of recurrent talar osteochondral lesions treated by Autologous Matrix Induced Chondrogenesis (AMIC). Patient had a good functional outcome at short-term follow up. We also describe the technique and review the literature regarding this novel technique.

Two-year radiologic assessment of the Trident Peripheral Self-Locking cup using EBRA.

UNLABELLED: We performed a radiologic assessment of the Trident Peripheral Self-Locking cup 2 years after implantation to assess early migration behaviour and to establish if incomplete postoperative seating correlated with early instability. A retrospective analysis of 30 cases was performed using EBRA. No cups had acetabular screws. Average total migration was 1.5 mm (range 0.1 to 5.9 mm). Seventeen showed total migration >1 mm and 7 of these showed further migration >2 mm (range 2.3 to 5.9 mm). Twenty cups demonstrated incomplete seating on initial post-operative radiographs (mean 1.4 mm, range 0.3 to 3.0). No relationship between incomplete seating and migration was identified (p = 0.86). The majority of gaps consolidated at differing times within the 2 year period. Oxford Hip scores showed significant improvement after surgery (p = 0.001) and this was independent of migration (p = 0.76). At 5 years there were no revisions for aseptic loosening. CONCLUSION: The majority of the cups demonstrated early radiographic instability, and this was not related to incomplete seating. Five year functional outcome appears good and independent of migration and initial seating.

Natural distribution of the femoral mechanical-anatomical angle in an osteoarthritic population and its relevance to total knee arthroplasty.

A common surgical goal in TKA is to restore neutral alignment of the lower limb by making bone cuts perpendicular to the mechanical axes of the femur and tibia. Standard practice for many surgeons is to use the same distal femoral valgus resection angle for all patients, assuming little or no variation in the femoral mechanical-anatomical (FMA) angle between different patients' knees. This study analysed 174 pre-operative hip-knee-ankle radiographs of osteoarthritic knees (157 patients, 87 female and 70 male, mean age 70years and mean BMI 31.8). Measurements of mechanical femorotibial (MFT) and FMA angles were made. The mean FMA angle was 5.7° (SD 1.2°, range 2° to 9°). There was a statistically significant difference between the FMA angle for males and females with males tending to have larger FMA angles (p<0.001). There was a statistically significant correlation between MFT and FMA angle (r=-0.499) with varus knees tending to have larger FMA angles (p<0.001). These results indicate a wide distribution of FMA angle in an osteoarthritic population. In terms of achieving appropriate coronal alignment in TKA the use of a fixed valgus resection angle is not suitable for all patients and it may be preferable to adjust the distal femoral cut according to individual FMA angles. However if this angle is not available the cut may be adjusted according to pre-operative coronal alignment, using 6° for neutral/mild varus, >6° for more severe varus and <6° for valgus knees.

Outcome after short intramedullary nail fixation of unstable proximal femoral fractures.

In this study we assess the clinical and radiological outcomes after surgical fixation of unstable, extracapsular fractures of the proximal femur using two designs of short intramedullary nail. We reviewed 158 patients of which 131 had fixation using the Intra Medullary Hip Screw (IMHS original Richards Compression Hip Screw design) and 27 with the original design Proximal Femoral Nail (PFN Synthes). Outcome measures including non-union, peri-implant fracture, post-operative function and mortality were similar between groups. Proximal screw cut-out and consequently re-operation rate were significantly higher for the PFN. A number of variables may predispose a patient to develop screw cut-out including gender, experience of surgeon, fracture pattern, implant design and tip-apex distance. As such a multivariable logistic regression model was used to investigate the independent effects of these variables on proximal screw cut-out. Only tip-apex distance was found to have a significant association with proximal screw cut-out and differences between implant designs could be accounted for by surgical technique rather than implant design. The results of this study suggest that both implants have similar post-operative outcome measures and complication rates when implanted correctly.

Treatment of full thickness chondral lesions of the knee with microfracture in a group of athletes.

This prospective outcomes study was designed to prospectively investigate the outcome of the microfracture technique when applied to full thickness chondral lesions of the knee in a group of athletes. From 1991 to 1999, 109 patients were treated using the microfracture technique. We prospectively followed up 53 athletes who satisfied our inclusion criteria. Average age was 38 years (range 19-55) and mean follow-up was 72 months (range 36-120). Etiology, clinical signs, symptoms and activity level were noted preoperatively and at final follow-up. Lysholm, Tegner, IKDC and functional tests were utilized. Intraoperatively, location, size of the lesions and associated pathologies were recorded. Roentgenograms, MRI or CT scan were done before treatment and at final follow-up. Etiologic factors were mostly related to sports microtrauma (37.5%) and macrotrauma (21%), while 37.5% of our patients did not report any traumatic etiology and 4% showed patellar malalignment. The most common location was medial femoral condyle (61%). Knee pain and swelling improved in 70%, tibiofemoral crepitus in 60%. Hop test was normal in 70% at final follow-up. Subjective evaluation was 40/100 preoperatively and 70/100 at final follow-up. Lysholm was 56.8 preoperatively and 87.2 final. IKDC revealed: 0 A, 3 B, 40 C and 10 D preoperatively while at final follow-up 70% scored A or B. Tegner improved at 2 years from 3.2 to 6; however, at final follow-up 80% showed a decline in sport activity level (Tegner 5). Microfracture technique can offer clinical, functional and subjective improvement in athletically active patients. However because of the decline in sports participation over time, microfracture may not be the definitive procedure for the athlete's knee and other procedures may be indicated in the future.