Proposal of a modified tip apex distance for prediction of lag screw cut-out in trochanteric hip fractures.

INTRODUCTION: Lag screw cut-out is a serious complication of dynamic hip screw fixation of trochanteric hip fractures. The lag screw position has been acknowledged as one of the important factors affecting the lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesise that it could improve the reliability of predicting lag screws cut-out in these injuries. MATERIALS AND METHODS: A retrospective study was conducted for hip fracture entries in the period from Jan 2018 to July 2022. A hundred and nine patients were suitable for the final analysis. The modified TAD was measured in millimetres based on the sum of the traditional TAD in the lateral view and the net value of two distances in the AP view, the first distance is from the tip of the lag screw to the opposite point on the femoral head along the axis of the lag screw while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if inferior. A receiver operating characteristic curve was used to evaluate the reliability of the different parameters assessing the lag screw position within the femoral head. RESULTS: Reduction quality, fracture pattern as per the AO/OTA classification, TAD, Calcar Referenced TAD, Axis Blade Angle, Parker's ration in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the modified TAD had 90.1% sensitivity and 90.9% specificity for lag screw cut-out at a cut-off value of 25 mm with a P-value < 0.001. CONCLUSION: The modified TAD had the highest reliability in the prediction of lag screw cut-out. A value ≤ 25 mm could potentially protect against lag screw cut-out in trochanteric hip fractures.

The incidence of medial end clavicle fractures is higher than had previously been considered.

BACKGROUND: Previous X-ray epidemiological studies have estimated the incidence of medial end clavicle fractures to account for 2-3% of all clavicle fractures. MATERIALS AND METHODS: At our institution X-rays of every patient attending the Emergency Department are reviewed at a Virtual Fracture Clinic by a Consultant Orthopaedic Surgeon. Patients with a fracture are referred to the Shoulder and Elbow Fracture Clinic. Patients without a fracture are contacted and, if there are on-going concerns, are referred to the Shoulder and Elbow Fracture Clinic. Over an 18-month period we identified every patient that attended our Emergency Department that had sustained a clavicle fracture. RESULTS: In total 558 clavicle fractures were identified (139 (24.9%) - lateral, 360 (64.5%) - middle, 59 (10.6%) - medial). Of the 59 medial end fractures, 31 (52.5%) were identified on presentation at the Emergency Department, 13 (22%) at the Virtual Fracture Clinic, 6 (10.2%) on computed tomography scan at the Shoulder and Elbow Fracture Clinic and 9 (15.3%) were admitted directly to the trauma unit. CONCLUSION: The results of this study suggest that the incidence of medial end clavicle fractures in the general population is higher than had previously been considered. LEVEL OF EVIDENCE: IV.

Prognosis After Arthroscopic Superior Medial Scapuloplasty for Snapping Scapula Syndrome Improves After a Transient Beneficial Response With an Ultrasound-Guided Subscapular Cortisone Injection.

PURPOSE: To evaluate the prognostic value of an ultrasound-guided subscapular local anesthetic and cortisone injection in a consecutive series of patients who underwent an arthroscopic superior medial scapuloplasty for snapping scapula syndrome (SSS) and had been refractory to conservative treatment. METHODS: We undertook an arthroscopic superior medial scapuloplasty on patients with a clinical diagnosis of SSS who had failed a structured physiotherapy program and had either gained a good response or no to minimal response to preoperative ultrasound-guided subscapular local anesthetic and cortisone injection. The patients were assessed preoperatively and at final follow-up with the QuickDASH and Constant scores, and their pain was assessed with a visual analog scale (VAS). RESULTS: Between January 2009 and December 2016, 47 patients were included in the study, with a minimal follow-up of 2 years. There were 29 female and 18 male patients, and the mean age at the time of surgery was 27.4 years (range 15 to 61). Forty-two patients were available at final follow-up. There were 31 patients in the good response group and 11 patients in the no to minimal response group. For all patients, the mean time to follow-up was 41.8 months (range 24 to 108). There was a significant improvement after surgery in the mean QuickDASH score (from 39 to 20, P < .001) (minimal clinically important difference [MCID] 15.91) , Constant score (from 57 to 87, P < .001) (MCID 10.4), and VAS (from 6 to 2, P < .001) (MCID 3). For the good response group, there was a significant improvement after surgery in the mean QuickDASH score (from 38 to 18, P < .001) (MCID 15.91), the Constant score (from 57 to 89) (MCID 10.4), and the VAS (from 6 to 2, P < .001) (MCID 3). For the no to minimal response group, there was a significant improvement after surgery in the mean QuickDASH score (from 42 to 24, P < .01) (MCID 15.91), the Constant score (from 58 to 80, P < .002) (MCID 10.4), and the VAS (from 6 to 2, P < .01) (MCID 3). The difference in postoperative improvement of the QuickDASH and Constant scores between the good response and the no to minimal response groups was statistically significant (P < .05). CONCLUSION: The results of this study suggest that arthroscopic scapuloplasty can lead to a significant improvement in pain and function in all patients with a clinical diagnosis of snapping scapula syndrome refractory to conservative treatment. Patients who gained a good transient response to a preoperative ultrasound-guided subscapular cortisone injection obtained a significantly better recovery than those who did not. A preoperative ultrasound-guided subscapular cortisone injection appeared to be of prognostic value.

Proximal radioulnar translocations in adults: a tertiary centre study.

We present three cases of proximal radioulnar translocation in adults. Although rare, it is most commonly seen in paediatric cases. There have been three previously documented cases in adults, all requiring surgery and associated with ulnohumeral dislocations. Two of our cases required operative intervention, whilst one was reduced closed and did not require stabilisation. Furthermore, we have for the first time shown that proximal radioulnar translocations can occur in isolation in adults without an ulnohumeral dislocation. LEVEL OF EVIDENCE: Level IV.

A comparative study of 5 different antibiotic prophylaxis regimes in 4500 total knee replacements.

AIM: To compare the incidence of surgical site infection with different antibiotic regimes in elective total knee arthroplasty. We hypothesise that a single high dose of Teicoplanin and Gentamicin is as effective as other regimes. METHODS: A retrospective study of prospectively collected data on a total of 4500 elective knee replacements over a 9-year period was conducted in a district general hospital. Data were collected on antibiotic regime, patient characteristics, infection (treatment, infective agents, sensitivities) and complications. RESULTS: Five different antibiotic regimes that have been used in elective knee arthroplasty were identified in our institution. 40 patients in total were identified who had a deep infection. Rates of deep surgical site infection were not significantly different between the five groups (p = 0.83). CONCLUSION: A single pre-operative dose of Teicoplanin and Gentamicin has similar efficacy of prophylaxis to other regimes for patients undergoing primary elective total knee replacements. We recommend the choice of prophylaxis regimen is made locally based on pathogen virulence, drug resistance and cost.

Arthroscopic Excision Arthroplasty of the Sternoclavicular Joint for Osteoarthritis: A Case Series of 50 Patients.

PURPOSE: to report the results of a consecutive series of 50 patients who underwent an arthroscopic excision of the sternoclavicular joint (SCJ) for primary osteoarthritis refractory to conservative treatment. METHODS: We undertook an arthroscopic excision of the SCJ in 50 patients with primary osteoarthritis refractory to conservative treatment. This included an adequate course of physiotherapy and at least 1 ultrasound-guided cortisone injection. There were 26 female and 24 male patients and the mean age at the time of surgery was 54.5 years (range 39-72 years). Patients were assessed preoperatively and at final follow-up with the Constant, Rockwood SCJ, and Quick-DASH scores. The mean follow-up was 41.8 months (range 24-73 months). Surgery was undertaken as a day-case with no shoulder immobilization. RESULTS: Forty-five patients were available at final-follow up. The median Constant score had increased from 55 (range 37-79) to 72 (range 38-92), Rockwood score from 6 (range 4-9) to 13 (range 4-15), and Quick-DASH 36 (range 18-69) to 12 (range 0-51). All of these changes were statistically significant (P < .0001). There were no complications and, specifically, no problems with joint instability. Forty-four of the 45 patients were pleased with the results of their surgery and indicated that they would be happy to have the procedure again. CONCLUSIONS: The results of this study show that arthroscopic excision arthroplasty of the SCJ is a satisfactory treatment for primary SCJ osteoarthritis refractory to conservative treatment. LEVEL OF EVIDENCE: Level IV case series.

Smartphones in orthopaedics: a decade of innovation.

Smartphones have become a mainstream feature in medicine since the introduction of the Apple iPhone in 2007. Over the last decade they have taken on increasing prominence with multiple uses in daily practice. They have long been used for group messaging and accessing patient's electronic records while mobile. More recently, however, smartphones have allowed clinicians to improve patient assessment in clinic and manage follow-up appointments remotely. Furthermore they have been used to aid procedural tasks in surgery and provide a medium for simulation training for junior doctors. The role of smartphones in the future is predicted to increase exponentially and there will no doubt be countless further roles for them in the ever-expanding field of orthopaedics.

Digital tomography is an effective investigation for sternoclavicular joint pathology.

OBJECTIVE: Plain radiographs of the sternoclavicular joint (SCJ) are difficult to interpret, and a CT or MRI scan is the usual investigation of choice. At our hospital, we use digital SCJ tomograms as our first-line investigation for all SCJ pathologies. We wanted to ascertain whether this is a safe and appropriate first-line imaging investigation. MATERIALS AND METHODS: We retrospectively reviewed every patient who had undergone an SCJ digital tomogram (DT) over a 4-year period. We cross-referenced each patient with their records to assess the reason for referral, result, requirement for further investigation, diagnosis and management. RESULTS: We identified 132 SCJ tomograms over the study period. Twelve patients were referred from other hospitals with pre-existing imaging and were excluded. The reasons for radiological investigation in the remaining 120 patients were pain/lump without trauma (54.2%), pain/lump with trauma (30.8%) and post-operative review (15%). Of the 102 patients who had DT as their initial investigation, the most common diagnoses identified included osteoarthritis, normal SCJ, fracture and dislocation among others. Only 18 (17.6%) of these patients required further investigation with CT and/or MRI. CONCLUSION: Our study is the first to assess digital tomography in SCJ pathology. We have shown that digital tomograms are an accurate and economically beneficial investigation for SCJ pathology and propose that it should be used as a first-line imaging investigation.

Current concepts in the techniques, indications and outcomes of meniscal repairs.

Knee arthroscopy for meniscal tears is one of the most commonly performed orthopaedic procedures. In recent years, there has been an increasing incidence of meniscal repairs, as there are concerns that meniscectomy predisposes patients to early osteoarthritis. Indications for meniscal repair are increasing and can now be performed in older patients who are active, even if the tear is in the avascular zone. Options for meniscal tear management broadly fall into three categories: non-operative management, meniscal repair or meniscectomy. With limited evidence directly comparing each of these options optimal management strategies can be difficult. Decision making requires thorough assessment of patient factors (e.g. age and comorbidities) and tear characteristics (e.g. location and reducibility). The purpose of this paper is, therefore, to review the management options of meniscal tears and summarize the evidence for meniscal tear repair.

Computerized tomography based 3D modeling of the clavicle.

UNLABELLED: Previous studies have suggested clavicular morphology is highly variable, particularly in the lateral retrocurved section. Current clavicle fracture plating systems require three dimensional intra-operative contouring to achieve adequate fit and necessitate variable soft tissue dissection placing fracture perfusion and muscular attachments at risk. The aim of this study was to search for a surgically relevant superficial shape pattern. This is a retrospective CT-based analysis of 174 non-pathological clavicles in 95 adults (45 females, 50 males). Using the principle of cylindrical parameterisation generated 3-D computer models, we identified an implant preferred pathway (IPP), defined as a continuous linear region where the least possible soft tissue disruption would be necessary for plate fixation. The IPP mean form was within 3.04 mm (SD ± 1.34) on all clavicles. Clavicle length, and not shape, was found to be the biggest variable (correlation between size and form co-ordinates r = 0.99, p < 0.05), accounting for 79% of overall variability. This length variation was mainly located in the medial antecurved section. Superior convexity and recurvatum were the main shape variables, however they only contributed 8% and 5% to the overall variation, respectively. Three IPP lengths were shown to match all clavicles when aligned at the acromial end first. In contrast to previous studies, we have shown that the IPP is fairly consistent with respect to the general shape with the exception of length variation which mainly affected the medial antecurved section. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1216-1223, 2016. CLINICAL RELEVANCE: Future pre-contoured fracture fixation systems should provide variable length plates with a constant lateral section retrocurve and a variable medial antecurve.

Extensive gluteal haematoma after an intracapsular hip fracture in a patient on warfarin.

We describe a case of a patient on warfarin who developed an extensive haematoma after a hip hemiarthroplasty and was successfully treated with embolisation. This case highlights the importance of regular haematology input, careful consideration of a suitable surgical approach, close monitoring of postoperative wounds in patients on warfarin and the emerging role of embolisation.

Shoulder linked arthroplasty in patients with obstetric brachial plexus palsy can improve quality of life and function at short-term follow-up.

BACKGROUND: Patients with obstetric brachial plexus palsy (OBPP) are prone to develop degenerative shoulder disease at a younger age than the general population. To date, no reports have been published on the complexities or outcome of shoulder arthroplasty (SA) in this unique patient group. METHODS: We reviewed of 9 SAs in 9 patients (3 men and 6 women) with OBPP with mean follow-up 5.1 years (range, 2.6-7.6 years). Patients were a mean age of 29 years (range, 16-56 years). Patients had undergone a mean of 3 previous operations (range, 2-6). All patients underwent linked constrained SA. RESULTS: The mean Oxford Shoulder Score increased from 8 (range, 3-10) preoperatively to 21 (range, 12-32) at the final follow-up (P < .001) predominantly due to pain relief. Mean range of active forward elevation and abduction improved from 35° and 39° to 46° and 45°, respectively. Patients improved significantly in 2 of 8 Short-Form 36-Item health-related quality of life domains, bodily pain (P = .013) and mental health (P = .035), and the overall physical component summary score (P = .006). Range of motion had mild improvements. Three required reoperation (33%), comprising 1 excision of heterotopic ossification, 1 trimming of a prominent screw, and 1 deltoid rupture repair. CONCLUSIONS: SA is effective at relieving pain and health-related quality of life for young patients with OBPP; however, compared with the general population, the complication rate is high and functional gains are small.

Systematic review of outcomes following fixed angle intramedullary fixation of distal radius fractures.

PURPOSE: There remains little consensus regarding the optimal management of distal radius fractures. Fixed angle volar devices have gained recent popularity, but have also been associated with soft tissue complications. Intramedullary (IM) devices offer fixed angle stabilisation with minimally invasive surgical technique and low, IM profile. No formal review of outcomes could be identified. METHODS: We conducted a systematic review of clinical studies regarding the use of fixed angle IM devices in acute extra-articular or simple intra-articular distal radius fractures. Preferred Reporting Items for Systematic Reviews (PRISMA) guidance was followed. Numerical data regarding functional scores, ranges of movement, radiological outcomes and complications were pooled to produce aggregate means and standard deviation. RESULTS: A total of 310 titles and abstracts were identified. Fourteen papers remained for analysis. Total patient number was 357, mean age 63.72 years and mean follow-up 12.77 months. Mean functional scores were all rated as 'excellent'. Aggregate means: flexion 53.62°, extension 56.38°, pronation 69.10°, supination 70.29°, ulnar deviation 28.35°, radial deviation 18.12°, radial height 8.98 mm, radial inclination 16.51°, volar tilt 5.35°, ulnar variance 0.66 mm and grip strength 90.37 %. Overall complication rate was 19.6 %. Tendon rupture was unreported. Tendon irritation was 0.88 %. Radial nerve paraesthesia was 11.44 %. CONCLUSIONS: Fixed angle IM devices facilitate excellent functional outcomes, with radiological and clinical parameters at least equivalent to volar plate devices. Low rates of tendon irritation and absence of tendon rupture are advantageous. Significant limitations include a lack of application for complex articular injuries and the propensity to cause a transient neuritis of the superficial branch of the radial nerve.

Knee arthroplasty with a medial rotating total knee replacement. Midterm clinical findings: a district general experience of 38 cases.

BACKGROUND: The Medial Rotating Knee replacement (MRK) was first used in 1994, reporting high rates of satisfaction. It is designed to replicate natural knee kinematics and improve stability and function. There are limited studies on the mid-term clinical outcomes, in particular in a district general hospital (DGH) environment. This is the first study that we are aware of that evaluates the learning curve of the implementation of this knee system in this environment. PATIENTS/METHOD: Between 2007 and 2009 we performed 38 consecutive MRK replacements (MAT ORTHO, UK) in 36 patients. The mean follow-up was four years. Patients were evaluated clinically, using OKS and patient questionnaire and radiographically (good/acceptable/poor) to assess outcome. RESULTS: Mean age was 73.0 years. Mean pre-operative OKS was 17.7 (range 8-29), which rose to 38.1 (range 23-48) at latest follow up (p<0.005). Overall 71% of the patients were either satisfied (29%) or very satisfied (42%). 81% felt an improvement of the ability to go up or down stairs and 92% felt stable. All poor radiographic and the majority of acceptable outcomes were experienced in the first 50% of cases. CONCLUSION: The MRK can be successfully implanted in a DGH environment. It improves pain and function comparably to standard TKRs, however, subjective improvement may be higher. Radiographic evaluation shows an acceptable learning curve. LEVEL OF EVIDENCE: Level IV case series.

Genetic skeletal dysplasias: a guide to diagnosis and management.

The skeletal dysplasias are a large, heterogeneous group of genetic disorders characterised by abnormal growth, development and remodelling of the bones and cartilage that comprise the human skeleton. They typically present with disproportionate short stature in childhood, or premature osteoarthritis in adulthood. The latest classification lists 456 disorders under 40 group headings differentiated by specific clinical, radiographic and molecular criteria. Establishing an accurate diagnosis is important to predict final height, expected complications and treatment, and for specific genetic and psychological counselling. In addition to the skeletal disorder, individuals frequently demonstrate abnormalities of hearing, vision, neurological, pulmonary, renal or cardiac function that require multidisciplinary assessment. This review provides a guide to diagnosis and discusses management principles for the common limb and spinal abnormalities that affect quality of life for the majority.

Cementless surface replacement hemiarthroplasty for primary glenohumeral osteoarthritis: results of over 5-year follow-up in patients with or without rotator cuff deficiency.

BACKGROUND: Cementless surface replacement hemiarthroplasty (CSRHA) is an established treatment for glenohumeral osteoarthritis; however, studies evaluating its role in arthritis with rotator cuff deficiency are limited. This study reviews the outcomes of CSRHA for glenohumeral osteoarthritis with and without rotator cuff tears. METHODS: 41 CSRHA (Mark III Copeland prosthesis) were performed for glenohumeral osteoarthritis with intact rotator cuffs (n = 21) and cuff-deficient shoulders (n = 20). Patients were assessed using Oxford and Constant questionnaires, patient satisfaction, range of motion measurements and by radiography. RESULTS: Mean age and follow-up were 75 years and 5.1 years, respectively. Functional gains were significantly higher in patients with intact rotator cuffs compared to cuff-deficient shoulders, with Oxford Shoulder Score improving from 18 to 37.5 and 15 to 27 and forward flexion improved from 60° to 126° and 44° to 77° in each group, respectively. Two patients with deficient cuffs had deficient subscapularis tendons; one of which was dislocated anteriorly. CONCLUSIONS: CSRHA provides significant improvements in pain and function in patients with glenohumeral osteoarthritis. In patients with deficient cuffs, functional gains are limited, and should be considered in low-demand patients where pain is the primary problem. Caution should be taken in patients with a deficient subscapularis as a result of the risk of dislocation.

Treatment of meniscal tears: An evidence based approach.

Treatment options for meniscal tears fall into three broad categories; non-operative, meniscectomy or meniscal repair. Selecting the most appropriate treatment for a given patient involves both patient factors (e.g., age, co-morbidities and compliance) and tear characteristics (e.g., location of tear/age/reducibility of tear). There is evidence suggesting that degenerative tears in older patients without mechanical symptoms can be effectively treated non-operatively with a structured physical therapy programme as a first line. Even if these patients later require meniscectomy they will still achieve similar functional outcomes than if they had initially been treated surgically. Partial meniscectomy is suitable for symptomatic tears not amenable to repair, and can still preserve meniscal function especially when the peripheral meniscal rim is intact. Meniscal repair shows 80% success at 2 years and is more suitable in younger patients with reducible tears that are peripheral (e.g., nearer the capsular attachment) and horizontal or longitudinal in nature. However, careful patient selection and repair technique is required with good compliance to post-operative rehabilitation, which often consists of bracing and non-weight bearing for 4-6 wk.

Reverse shoulder arthroplasty in 41 patients with cuff tear arthropathy with a mean follow-up period of 5 years.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is an accepted treatment for patients with pseudoparalysis due to cuff tear arthropathy. There have been limited studies with midterm clinical and radiologic results. We present our results for a single surgeon from a district general hospital. METHODS: Forty-one consecutive Delta III RSAs were performed by an anterosuperior approach in 37 patients (29 women and 8 men) with pseudoparalysis due to cuff tear arthropathy. The patients' mean age was 79 years (range, 68-91 years). The mean follow-up period was 5 years. All patients were available for final review, and none were lost to follow-up. RESULTS: The mean age-adjusted Constant and Oxford scores improved from 34.2 points to 71.0 points and 15 points to 33 points, respectively. Mean abduction and forward flexion improved from 64° to 100° and 55° to 110°, respectively. Scapular notching was seen in 68% of patients, but there was no deterioration in function or satisfaction scores. Stress shielding of the proximal humerus was seen in 10% of patients. One patient underwent revision to a hemiarthroplasty because of glenoid component failure after a fall. There were no early postoperative dislocations in our series. CONCLUSION: RSA for pseudoparalysis due to cuff tear arthropathy provides good functional results at 5 years; however, there is a high rate of scapular notching, which does not seem to affect overall functional outcomes.

Complex shoulder arthroplasty in patients with skeletal dysplasia can decrease pain and improve function.

BACKGROUND: Patients with skeletal dysplasia are prone to the development of degenerative shoulder disease requiring shoulder arthroplasty at a younger age than in the general population. To date there have been no published reports on the complexities or outcome of shoulder arthroplasty in this unique patient group. METHODS: This is a review of 13 shoulder arthroplasties in 10 patients with skeletal dysplasia with mean follow-up of 7 years (2-17.6 years). There were 4 men and 6 women with a mean age of 53.1 years (23-76 years), mean height of 148 cm (122-177 cm), and mean weight of 60 kg (27-80 kg). RESULTS: The mean Oxford Shoulder Score increased from 13 (5-20) preoperatively to 28 (18-38) at final follow-up. Patients improved significantly in 2 of 8 Short Form 36 health-related quality of life domains: physical function (P = .04) and bodily pain (P = .04). Function was better in those who underwent nonconstrained total shoulder arthroplasty as opposed to hemiarthroplasty. Four (31%) required reoperation: 1 excision of heterotopic ossification, 1 relocation for anterior instability, and 2 revisions for periprosthetic fracture and glenoid erosion. CONCLUSION: Shoulder arthroplasty is effective at relieving pain, optimizing movement, and improving function for patients with skeletal dysplasia; however, compared with the general population, there is a higher complication rate and function is not as good. Furthermore, this procedure is less effective at restoring health-related quality of life than total hip arthroplasty or total shoulder arthroplasty performed for osteoarthritis in the general population. Custom implants may be required to compensate for short stature and rotator cuff and glenoid deficiency.