Strategies for the planning of complex shoulder arthroplasty: Use of a custom-made glenoid component in reverse shoulder arthroplasty for a neglected posterior fracture dislocation of the shoulder with malunited scapula fractures and severe eccentric glenoid bone loss.

Glenoid bone loss associated with abnormal glenoid morphology can be encountered in complex primary and revision reverse shoulder arthroplasty. Strategies to deal with this include allografts, augments and custom-made prostheses. We describe a unique case of a long-standing neglected posterior fracture dislocation of the shoulder with severe glenoid bone loss and retroversion. The patient also had malunited acromial and scapula fractures and an associated rotator cuff tear. The primary challenges were access to the shoulder joint due to the malunited fractures, reconstruction of the dysplastic glenoid and providing joint stability. A reverse shoulder replacement was planned using a custom-made glenoid component and patient-specific instrumentation (PSI). The custom base plate was manufactured based on the pre-operative computerised tomography (CT) scan and conformed to the native glenoid. A post-operative CT scan confirmed adequate positioning of the implants. 30 months following surgery, there was a significant improvement in pain and range of motion with an Oxford Shoulder Score (OSS) of 39/48, compared to a pre-operative score of 12/48. Plain radiographs did not show any evidence of loosening or osteolysis. This case report highlights the approach for planning a complex reverse shoulder arthroplasty and the use of custom-made prostheses and PSI in such scenarios.

Septic Arthritis of Neonates: Descriptive Study of a Neonatal Intensive Care Unit Nosocomial Outbreak.

Purpose  This is a retrospective descriptive study of a nosocomial outbreak of septic arthritis in a neonatal intensive care unit with a Pseudomonas species as the predominant organism. There have been no previous reports of the same. The risk factors for this disease were analysed. The different diagnostic modalities that we used are described and the short-term outcomes are reported after antibiotic therapy and surgery. Methods  Fourteen patients and 16 joints were included in the study over a three-month period. The risk factors were analysed from the records and included prematurity, birth weight, sex and joint predilection. The causative organisms were also analysed from microbiological profiling. The outcomes after surgery and adjunctive antibiotic therapy were analysed in terms of clinical and laboratory parameters. Results  Pseudomonas aeruginosa was found to be the predominant organism in this series. The hip joint was predominantly involved and the majority of the patients were found to be premature. All the neonates affected were found to have low birth weight. Conclusion  Prematurity and low birth weight were found to have an association with risk for septic arthritis. In our setting of a nosocomial outbreak, a Pseudomonas species was more common than other organisms. A treatment regimen of arthrotomy surgery and adjunctive antibiotic therapy was found to be effective in all our patients.

The Impact of Harm Review Service on Patients Awaiting Elective Orthopaedic Foot and Ankle Surgery for More Than 52 Weeks.

Background and objective There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery. Materials and methods The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients' mental health and their perception of the service was assessed as well. Results A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health. Conclusion This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions.

Intermediate to long term results of stemless metaphyseal reverse shoulder arthroplasty: A five to nine year follow-up.

BACKGROUND: Shoulder arthroplasty incidence is increasing as is the volume of revision surgeries. Revision surgery is easier if humeral bone stock is preserved with minimal bone defects and osteolysis. This has led to an increased focus on the development of various short stemmed and stemless implants which provides stable fixation whilst preserving humeral bone stock. PURPOSE: To review the medium to long term clinical and radiological outcomes, complications and survival rates of a stemless reverse shoulder prosthesis. PATIENTS AND METHOD: Patients with a minimum follow-up of 60 months following a reverse stemless shoulder arthroplasty were deemed eligible. Clinical and radiological data on twenty-one patients operated between 2009 and 2014 were recorded prospectively. Survivorship and patient recorded symptoms with the end point of revision surgery were recorded. RESULTS: Mean follow-up of 78 months (60-114 months). Mean range of active elevation was 136° (80-170°). Mean range of active abduction and active external rotation was 122° (70-170°) and 47° (10-75°) respectively. Mean Oxford score improved from 12 pre-operatively to 44 at final follow up (p < 0.0001). Mean Constant Murley Score improved from 18 to 72 (p < 0.0001). Mean ADLEIR score of 13 pre-operatively increased to 32 post-operatively (p < 0.0001). Notching was seen in 23.5% of cases and no radiolucent areas were observed around the glenoid component. There were two cases of post traumatic peri-prosthetic fractures that were managed conservatively and one case of deep-seated infection that required a washout. The survivorship at the most recent follow-up was 100%. CONCLUSION: The advantages of bone preservation with the stemless metaphyseal prosthesis combined with encouraging medium to long term clinical and radiological results are very promising, particularly with the improved post-operative patient satisfaction scores. This is the first study that reports the results with a minimum of 5 year follow-up and has the longest mean follow-up period. CLINICAL RELEVANCE: The reverse stemless shoulder prosthesis is an effective and reliable option for elective shoulder arthroplasty.

How Effective Are Telephone and Video Consultations in Shoulder and Elbow Clinics? Analysis Using an Objective Scoring Tool.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic resulted in disruptions of clinical services, which saw more clinics being conducted as telephone and videos. The study aimed to assess and compare the effectiveness of consultations, that is, telephone, video, and face-to-face (F2F) in a shoulder and elbow clinic. METHODS: A total of 84 clinic letters from a shoulder and elbow clinic at a district general hospital were analysed using the Ashford Clinic Letter Scoring System. Of these, 30 were F2F, 30 were telephone, and 24 were video consultations. The letters were analysed and scored based on four parameters, that is, whether a working diagnosis was formulated, relevant investigations were requested or available, a clear management plan was formulated, and whether the consultation was deemed valuable by both the clinician and patient. RESULTS: The mean score (out of a total possible of eight) for F2F was 7.967, 7.667 for video, and 7.333 for telephone consultations. Amongst new referrals, F2F performed the best, followed by video with telephone consultations scoring the lowest. With follow-up referrals, the performance of telephone and video consultations was similar but more inferior compared to F2F. Videos performed nearly as well as F2F when it came to formulating treatment plans for patients.  Conclusion: F2F consultations remain the gold standard in a shoulder and elbow clinic; however, careful stratification of patients into video, telephone, and F2F clinics can help in optimal delivery of care. These findings can be applied to other surgical specialties and medicine in general. Virtual clinics are viable and potentially cost-effective options to the traditional F2F.

Efficiency changes in orthopaedic trauma surgery and implications for resource allocation.

BACKGROUND/AIMS: The trauma and orthopaedic surgery department needed to modify practices as a result of the COVID-19 pandemic. This study quantitatively assessed the effects of changes in resource allocation on the efficiency of trauma, specifically the number of operations performed per defined trauma session. METHODS: Trauma lists were reviewed pre-COVID, at the peak and at the tail of the first wave of COVID-19 infections at a hospital in the UK. Efficiency was calculated before and after the reallocation of resources and this was defined as the number of cases per trauma session as well as turnaround times for each part of the surgical patient journey. RESULTS: The mean trauma list efficiency was 1.73 cases per session in February 2020 compared to 1.89 in February 2019. It reduced to 1.21 during the COVID peak in April 2020 compared to 1.90 in April 2019 and improved to 1.48 per session in June 2020 vs 1.82 in June 2019. CONCLUSIONS: Measures introduced at the start of the pandemic are likely to continue for the foreseeable future. Increased allocation of resources would be needed to allow urgent trauma surgery to provide a timely and efficient service.

Minimally invasive fixation with modified palm tree technique for proximal humerus fractures: Outcomes in a series of 132 patients.

INTRODUCTION: Various surgical techniques and implants are available for surgical treatment of significantly displaced proximal humerus fractures. We describe a minimally invasive technique using 3 curved wires, inserted in a retrograde fashion into the humeral head. These are aimed to diverge within the humeral head to provide three separate 3-point fixations to achieve good stability. We present the results of proximal humerus fractures managed with the modified palm tree technique. METHODS: A retrospective analysis of data collected prospectively including demographics, radiographs, clinical outcomes, complications and revision surgery for patients treated with the palm tree technique was performed. RESULTS: Between 1998 and 2017, 132 patients underwent fixation with this technique. Average age was 61.8 years. Fifty-Eight fractures were 2 part, 46 were three part and 28 were four part. Average follow up was 26 months. In three to four part fractures, a bone graft substitute block was used behind the humeral head fragment for structural support. There were 11 early revisions (8.3%). In 7 cases the fixation failed early and was revised to other implants like angular & locking plates (4), hemiarthroplasties (2) and reverse arthroplasty (1). In 4 cases the construct was revised to achieve better positioning of the wires. From the 125 remaining patients, 120 achieved union(96.8%). There were 3 painless fibrous non-unions and 2 painful non-unions requiring revision. The mean final Constant score was 75.5 and subjective shoulder value was 7.8/10. Nine patients (6.8%) developed avascular necrosis of the humeral head of which three patients were revised later to an arthroplasty. CONCLUSION: This technique is a simple, minimally invasive technique which can be used for two, three and four part fractures with good functional outcomes and high union rates. No metalwork remains in the proximal humerus should another procedure like arthroplasty be required in case of avascular necrosis of the humeral head or fracture sequela.

COVID-19 - Changes in the presentation and management of shoulder and elbow trauma in a UK district general hospital orthopaedic department.

INTRODUCTION: COVID-19 has had a significant impact on healthcare systems. We aim to quantify the impact of this outbreak on shoulder and elbow trauma in our institution. METHODS: We prospectively collected data on patients presenting to our hospital with shoulder and elbow injuries during COVID-19. This included the number of attendances to the emergency department, fracture clinic, inpatient admissions and operative treatments. This was compared to a pre-COVID-19 period. We also assessed the efficacy of telephone clinics. RESULTS: There has been a noticeable decrease in the number of emergency department and fracture clinic attendances with upper limb complaints. The number of in-person fracture clinic reviews also decreased, with a reciprocal exponential increase in telephone consultations. We recorded a decrease in the number of shoulder and elbow trauma procedures performed. There was a small increase in the proportion of injuries treated conservatively during COVID-19. Our telephone clinics yielded a diagnosis and management plan in many cases and patient perspective appeared favourable. CONCLUSION: We have noted significant change in the upper limb caseload. Certain injuries have reduced, likely due to COVID-19 lockdown. Moreover, we consider several changes to current practices could be taken forward after the pandemic.

Hospital transmission rates of the SARS-CoV 2 disease amongst orthopaedic in-patients in a secondary care centre: A quantitative review.

INTRODUCTION: Orthopaedic practice changed during COVID-19 with elective work ceasing, trauma reducing and work forces redistributed to medical areas. During the United Kingdom lockdown, hospitals were stretched thinly with admissions of SARS-CoV-2 positive patients. AIM: Evaluate orthopaedic admissions to a district general hospital during lockdown and the volume of those who subsequently were found to be COVID-19 positive. METHOD: Retrospective study of patients admitted under trauma and orthopaedics between March 23, 2020-June 18, 2020. Data includes; diagnosis, COVID-19 swab dates, results and mortality using orthopaedic admission sheets, patient and pathology electronic recording system. RESULTS: 3/4 of admitted patients tested negative for SARS-CoV-2 initially. Of these 240 patients, 12.5% subsequently tested positive during their stay, often within one week of their admission. 17.8% of patients were never tested. 7.8% mortality rate of which 48% were neck of femur fracture (NOF#) patients. 28 NOF# were confirmed COVID-19 positive; mortality rate of 21.4%. 87 NOF# were COVID-19 negative; mortality rate 6.9%. Mortality relative risk (RR) for NOF# and COVID-19 positive was 2.6. COVID-19 positive mortality 27% as compared to 4% in COVID-19 negative patients. Patients who acquired COVID-19 whilst in hospital had a mortality relative risk 6.4. CONCLUSION: 12.5% orthopaedic in-hospital viral transmission rate amongst orthopaedic patients despite the segregation measures taken, possibly due to asymptomatic health care workers or inpatients awaiting swab results. We emphasize the importance of testing all inpatients and regular testing of healthcare workers.

A Novel "Shark-Fin" Pyramidal Achilles Bone-Tendon Allograft Surgical Technique for Delayed Reconstruction of Triceps Tendon Rupture and Review of the Literature.

Purpose: Triceps tendon injuries are rare and often caused by direct trauma to the arm. There are no clear guidelines on the management of these and typically partial tears are treated conservatively whilst full thickness tears are treated with primary surgical repair. We aim to review the literature on the methods for triceps repair and propose a novel surgical technique. Methods: A "Medline" and "Embase" literature search of titles and abstracts combining "triceps brachii muscle," "reconstruct/ed" or "reconstruction" alongside "reconstructive surgical procedures," and further cross referenced with "repair/s/ed." Excluded those related to brachial plexus injuries or general elbow trauma and removing duplicate results. 32 English results within 10 years were relevant and reviewed. Results: A 50-year-old gentleman with a 4-month-old full thickness triceps tear was repaired with a novel surgical technique of using an Achilles bone-tendon allograft fashioned into a "shark-fin" pyramidal shape and secured to the proximal ulnar in a lock and key type construct. The tendon was secured to the triceps remnant using a Krackow stitch. Complete radiological and clinical recovery was made by 18 months postoperatively with return to full physical activity.The literature review concluded no consensus in the method of treatment for delayed triceps reconstruction. Conclusion: The use of the bone-tendon allograft specifically shaped to fit congruently into an olecranon osteotomy site allows for direct bone-to-bone healing has not previously been mentioned in the literature. Results have been encouraging and the technique described is easily reproducible.

Objective assessment of the efficacy of telephone medicine consultations in dispensing elective orthopaedic care using a novel scoring tool.

BACKGROUND: Telemedicine consultations have increased significantly as a result of the COVID-19 pandemic. As remote consultations have been employed across specialities, there has been limited analysis of their efficacy. The goal of this study is to objectively assess if telephone medicine is valuable for clinical consultations in elective orthopaedics using a novel scoring tool. METHODS: A literature review and survey were performed to determine the objectives of a specialist consultation. Based on the results, a four-component scoring system was developed with a set of guidelines. Eighty telephone consultation letters from a hip and knee clinic were scored by two independent observers. The results were compared and the guidelines were clarified. Clinic letters from previous face to face consultations from the same clinic were scored and compared to telephone medicine letters. The inter-observer reliability was calculated using Cronbach's Alpha. RESULTS: The mean score of the telephone consultations was 7.3 as compared to 7.9 (Maximum possible score-8) with face to face consultations. Second opinion referrals scored the least when consulted over the telephone, while follow-up patients both pre-operative and post-operative scored similar to face to face consultations. The inter observer reliability co-efficient was more than 0.8 for every component of the score suggestive of good reliability. CONCLUSIONS: This study identifies the areas where telephone medicine can make a valuable contribution to making diagnosis and treating orthopedic patients. We plan to use this to stratify future clinic appointments. The score is a simple, concise and reliable tool whose role may not be limited to orthopaedics but can be extended to other medical fields.

Use of reverse stemless shoulder arthroplasty in a patient with multiple hereditary exostosis.

INTRODUCTION: Multiple hereditary exostosis (MHE) is the formation of benign, cartilage-capped bony outgrowths predominantly extending from the metaphysis of long bones that presents with reduction in growth, deformity, restricted motion, short stature and premature osteoarthritis. AIM: To review the clinical and radiological results of a stemless reverse shoulder arthroplasty in a case of MHE. CASE: 81-year-old, right hand dominant short-statured retired male engineer with long standing shoulder pain and restricted movements on the background of an old proximal humeral fracture managed conservatively.The radiographs revealed osteoarthritis and a mal-united proximal humerus fracture on the background of MHE with 3 plane bone deformity and a lack of medullary canal. RESULTS: The patient underwent a stemless reverse shoulder arthroplasty. At 6 months post operatively the patient had recovered well with a range of movement including: forward flexion 110°, external rotation 20° and abduction of 80°. Internal rotation remained limited to buttocks. Improved ADLIER, Subjective shoulder value and Constant Murley score compared to pre-operative figures. CONCLUSION: The stemless humeral component relies on metaphyseal impaction for stability. When the humeral canal is malformed or in presence of malunited distal fractures, it circumvents the need of navigating a deformed diaphysis with encouraging postoperative results.

Redeployment of the trainee orthopaedic surgeon during COVID-19: a fish out of water?

Background and purpose - COVID-19 has had a significant impact on health services and the entire healthcare sector, including trauma and orthopaedics, has been compelled to adapt. At the heart of this was the redeployment of the orthopaedic trainees to support "frontline specialties". This paper sheds light on the experience of orthopaedic trainees in redeployment. Methods - In this retrospective study, we asked orthopaedic trainees in the KSS (Kent, Surrey, Sussex) and London Deaneries to complete a survey regarding their experience in redeployment during the COVID-19 outbreak. The study took place in the Kent, Surrey, Sussex, and London regions of the United Kingdom over a period of 8 weeks from 15th of March 2020 until 15th of May 2020. The study was based at East Kent Hospitals University NHS Foundation Trust and participants were recruited from a number of secondary and tertiary care centres across the region. 120 orthopaedic trainees were contacted, working in 21 teaching hospitals. Of these, 40 trainees (30%) from 13 hospitals responded and completed the survey. Results - 50% of the surveyed trainees were redeployed to other specialties. Trainees spent varying amounts of time in the redeployed speciality and gave differing views on how comfortable they felt and how useful they felt the experience was. One-third of trainees experienced symptoms and/or tested positive for COVID-19 and the majority of these were redeployed to other specialties. Interpretation - Orthopaedic training appears to have taken a temporary back seat at this time but trainees have made a significant contribution to reinforcing key front-line specialties in the fight against COVID-19.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral prosthesis without a stem: survivorship, early to mid-term clinical and radiological outcomes in a prospective study from an independent centre.

INTRODUCTION: The use of reverse total shoulder arthroplasty has increased for the management of cuff-deficient glenohumeral joint arthritis and fractures. With bone preservation being a major target in reverse shoulder arthroplasty, metaphyseal humeral components without a stem were developed. The aim of this study is to present the survivorship, functional and radiological outcomes of a novel short metaphyseal prosthesis without a diaphyseal stem from an independent centre. METHODS: Clinical function and radiological features of patients undergoing stemless reverse shoulder arthroplasty were prospectively recorded. Patients' demographics, indications for surgery, complications, functional and radiological assessment at the final follow-up as well as survivorship with the end point of revision for any reason were recorded. RESULTS: Between 2009 and 2016, 36 patients received 37 reverse shoulder arthroplasties with the stemless Verso prosthesis. Mean age of the patients was 76.9 years. The most common indication for surgery was cuff tear arthropathy. Mean follow-up was 3 years (range 1-7 years). Oxford shoulder score improved from an average of 11 pre-operatively (range 2-19) to 44 post-operatively (range 29-48) (p < 0.0001). There was one case of a deep post-operative infection that needed washout, liner exchange with retention of the prosthesis. Radiographic analysis showed no lucencies, or stress shielding around the humeral or glenoid components. Constant score at the final follow-up was on average 63 (range 35-86). Activities of daily living with requirement for internal and external rotation score (ADLEIR) was on average 12 pre-operatively (range 0-27) and 31 post-operatively (range 18-36) (p < 0.0001). There was 100% survivorship of the prosthesis in this early to mid-term study. CONCLUSION: This early to mid-term prospective study demonstrates excellent survivorship and radiological results of the Verso reverse shoulder replacement. It needs a simple reproducible technique, and the results have been replicated at an independent centre. This study underlines its survivorship in the early to mid-term and confirms lower incidence of complications such as instability, notching, loosening and the need for revision surgery. Most importantly, it conserves the humeral bone stock for revision arthroplasties in the future. Our results are similar to those of the currently published literature.

Cadaveric study for ideal dorsal pedicle screw entry point.

OBJECTIVE: To determine the entry for the dorsal pedicular screw in relation to the notch present at the junction of base of the lateral margin of superior articular process with superior border of transverse process in dorsal spine. The advantage of this technique is a constant and easily identifiable entry point which does not involve partial resection of the inferior facet, thus maintaining stability and maintaining the well defined transverse and sagittal screw angles and decreasing the incidence of medial and inferior pedicle violation. MATERIALS AND METHODS: The study was carried out using ten cadavers (four male and six female). Spinal column was dissected completely from cadavers. Before the experiment, normal anatomy was confirmed on all cadavers excluding cases of spinal deformity. Dissection was done by the spine surgeons taking care to preserve all the bony landmarks near the entry point. This study was carried out bilaterally on pedicles between the first and twelfth thoracic (T) vertebrae. RESULTS: The relation of the superior articular notch and transverse process to the thoracic spine pedicles was studied. It was found that superior third of the pedicle was related to the superior articular notch and the transverse process in the first five thoracic vertebrae. The relation of these structures to the pedicle of the sixth thoracic vertebra was somewhat equally distributed between the superior and middle third of the pedicle. From the 7th to 12th thoracic vertebrae the superior articular process and transverse process were related to the middle third of the pedicle in almost all the cases. It is important to note that the inferior 1/3rd of the pedicle was not related to these landmarks at any of the levels. CONCLUSION: We conclude that the ideal pedicle entry point described here should be considered by surgeons during thoracic pedicle screw instrumentation. The notch at the base of the superior articular process will always remain constant and therefore an important anatomical landmark in guiding the screw toward the entry of the pedicle.

Functional Results of Communited Intra-articular Distal Humerus Fractures Treated with Bicolumnar Plating.

INTRODUCTION: Communited intra-articular distal humerus fractures are commonly encountered in orthopaedic practice and they are present with unique difficulties for internal fixation. This problem is especially worse in the elderly due to osteoporotic bone. AIM: To evaluate the intermediate term results (minimum follow up of two years) of communited intra-articular distal humerus fractures treated with bicolumnar plating with or without olecranon osteotomy in elderly Indian population. MATERIALS AND METHODS: Sixty three consecutive patients operated with bicolumnar plating for communited intra-articular distal humerus fractures at the tertiary care centre were identified in the time period between 2009 and 2013. All patients had an age more than 60 years at the time of surgery. A minimum follow up of two years post surgery was a mandatory criteria. The Disabilities of Arm and Shoulder and Hand (DASH) score and the Mayo Elbow Performance (MEP) score calculated along with complete range of motion. RESULTS: The mean follow-up was 38 months. All patients achieved fracture union with mean MEP and DASH scores being 85 ± 15.5 and 21.4 ± 4.9 respectively. These scores although poor were comparable to the opposite side (90 and 12.2 respectively). Also the mean supination-pronation arc and flexion-extension arc was 156 degrees and 105 degrees respectively. This is well within the functional range of elbow. The mean block to extension was at 15 degrees with a mean maximal flexion of 120 degrees. CONCLUSION: Our study conclusively establishes that excellent functional outcome can be achieved with open reduction and internal fixation in Type C distal humerus fractures in elderly including the ones that are communited. Total elbow arthroplasty although a viable option, gives similar results to a well done internal fixation with added cost.

A unique case of bilateral trans-scaphoid perilunate dislocation with dislocation of lunate into the forearm.

INTRODUCTION: Perilunate dislocations are commonly seen after fall on an outstretched hand in extremes of dorsiflexion and ulnar deviation. A greater arc injury is one when there is an associated fracture of one or more bones around the lunate while a lesser arc injury is associated with pure ligamentous disruption around the lunate. CASE REPORT: We report a unique case of bilateral trans-scaphoid perilunate dislocation in a 35-year-old male labourer. This is the first reported case where the lunate dislocated into the forearm on the volar aspect. Urgent open reduction and stabilization of both wrists was done. Currently, the wrist is stable with functional range of motion with union of both scaphoid fractures at 1-year follow-up. DISCUSSION: A delay in management of perilunate dislocations is associated with unfavourable prognosis. Prompt reduction and fixation is of paramount importance. Radiocarpal arthritis is associated with delayed management. In our case, the patient has regained painless functional range of motion without any radiological evidence of arthritis. CONCLUSION: We thus conclude that all perilunate dislocations must undergo emergency reduction. Open reduction and ligamentous repair should be considered as the treatment of choice as it is associated with better functional outcomes in terms of pain and arthritis.

What have we learned from 100% success of press fit condylar rotating platform posterior stabilized knees?: A 5-10 years followup by a nondesigner.

BACKGROUND: Total joint arthroplasties of the hip and knee represent a remarkable feat of modern medicine in terms of reducing pain and restoring function to millions of patients afflicted with severe arthritis. Oftentimes, the performance and longevity of new implants and devices are based on limited data. This is the first study by a non-designer on the press fit condylar rotating platform posterior stabilized (PFC-RP-PS) design with 100' success. This has a relevance, vis-á -vis bias that one may have in terms of reproducibility of technique and funding from the manufacturer. We associate our excellent mid-term results to intra operative technical aspects and stringent intra operative exclusion criteria. MATERIALS AND METHODS: Our study includes a cohort of 121 selected knees operated between January 2003 and October 2010. We used cemented, posterior stabilized (PS), mobile bearing (MB), and RP prosthesis from the same manufacturer in all these 121 knees. The patients were evaluated bi-annually with the calculation of their Knee Society Scores (KSS) and a radiological assessment for loosening/osteolysis. RESULTS: 120 knees were available for followup. The average Knee Society clinical and functional scores, respectively, were 27 points and 40 points preoperatively and 93 points and 95 points postoperatively. This indicates a mean increase of about 71' in the clinical score and about 58' in the functional score, which is statistically significant. The mean postoperative flexion was 124°, a mean increase of 23° from the preoperative flexion of 101°. There were no revisions (Kaplan--Meier survivorship of 100'). CONCLUSIONS: We feel durable and reproducible results of PFC-RP-PS design knees are very technique sensitive. The way ahead with the PFC-RP-PS knees looks promising when the exclusion criteria for this design are strictly met. Coming from a non-designer, this study acquires a higher degree of relevance without any designer's or manufacturer's bias.

Impact of negative pressure wound therapy on open diaphyseal tibial fractures: A prospective randomized trial.

INTRODUCTION: Open tibial fractures are associated with a high incidence of mainly osteomyelitis. Negative pressure wound therapy (NPWT) is a novel form of treatment that uses subatmospheric pressure to effect early wound healing. OBJECTIVES AND STUDY DESIGN: To determine the effect of NPWT on incidence of deep infections/osteomyelitis after open tibial fractures using a prospective randomized study design. MATERIALS AND METHODS: Ninety-three open tibial fractures were randomized into two groups receiving NPWT and the second group undergoing periodic irrigation, cleaning and debridement respectively. The wounds were closed or covered on shrinkage in size and sufficient granulation. Evidence of infection was sought during the course of treatment and follow up. Also serial cultures were sent every time the wound was cleaned. RESULTS AND CONCLUSIONS: Patients in the control group developed a total of 11 infections (22%) as opposed to only 2 (4.6%) in the NPWT group (p < 0.05). The relative risk was 5.5 (95% confidence interval) suggesting patients who received NPWT were 5.5 times less likely to develop infection. Twenty patients developed positive growth when samples were sent for culture with 3 (6.9%) in the NPWT group and 17 (34%) in the control group (p < 0.05). Only 5 patients (25%) went on the develop osteomyelitis, all being a part of the control group. Thus negative pressure wound therapy is indeed beneficial for preventing the incidence of both acute infections and osteomyelitis in open fractures. However a significant difference was not seen in the time required for the wound to be ready for delayed primary closure or coverage.