STAGED VERSUS SIMULTANEOUS APPROACH IN COMPLEX BILATERAL TOTAL KNEE REPLACEMENT: EXPERIENCE FROM TERTIARY INSTITUTION IN NIGERIA.

Background: Bilateral end-stage knee osteoarthritis is a common presentation. The decision facing both patient and surgeon is whether to undertake the replacement of both knees in one sitting i.e. simultaneous bilateral total knee replacement (SMTKR) or to undertake this as a staged bilateral total knee replacement (STTKR). The decision is made harder by the presence of severe coronal and sagittal plane deformities and associated bone loss. We present our results of treating such patients with a focus on a trilogy of cost, complication and functional outcome following SMTKR. Methodology: A retrospective review of 31 patients who presented with bilateral knee arthritis. 19 underwent SMTKR and 12 underwent STTKR. Data on the trilogy of complication, cost and functional outcome were collected and analysed. Results: Our cohort of patients was overwhelmingly female in both groups at overall F/M = 30/1. Patients in the SMTKR group were slightly younger at a mean of 65 years compared to 69 years in the STTKR group. Mean Oxford Knee Score (OKS) improved significantly in all groups, mean of 54 in SMTKR and 56 in the STTKR groups. There was one fatality in the STTKR from upper GI bleeding and 1 revision for bone graft failure. The overall cost is less with SMTKR. Summary: SMTKR is a safe and effective undertaking in properly selected patients with bilateral end-stage knee arthritis with severe deformities. Significant experience is however needed to successfully tackle complex deformities and such procedures should be undertaken by experienced arthroplasty surgeons.

Predictors of excessive blood loss during operative treatment of hip fractures.

OBJECTIVES: To determine the total blood loss and transfusion needs during operative treatments of hip fracture, and identify predictors of excessive blood loss. METHOD: A prospective study of 242 consecutive patients operated for hip fractures over a 6 month period. The main outcome measure of blood loss was assessed by blood volume in the drainage system and swab weight. A loss of more than 480 mls was considered as excessive blood loss. RESULTS: The study consisted of 190 women and 52 men, mean age was 81.6 years (range 44-99). More than one-third of patients (34%) lost more than 480 mls of blood, and mean units transfused per patient was 2.3. Univariate predictors of increased blood loss were patients of American Society of Anaesthesiology (ASA) grade III and IV, patients at risk of cerebral or cardiac ischemia from volume depletion as defined by the American College of Physicians, patients with two or more pre-existing medical conditions and patients who had a hemiarthroplasty carried out. However, with subsequent multivariate analysis, patients who had undergone a hemiarthroplasty and those at risk predicted increased blood loss. CONCLUSION: Pre-operative characteristics can help determine which patients should have either blood requested on the day of surgery (group and cross-match) or the customary group and save policy.

Irreducible dorsal radiocarpal fracture dislocation with dissociation of the distal radioulnar joint: a case report.

We report a case of dorsal radiocarpal fracture dislocation with dissociation of the distal radioulnar joint. Closed reduction was unsuccessful due to interposition of the osteochondral fragments and open reduction and fixation was carried out with a satisfactory end result. The advantages of volar approach and use of external fixator in the management of this injury are discussed.

Prophylactic carpal tunnel decompression during buttress plating of the distal radius--is it justified?

Our objective was to evaluate the role of carpal tunnel decompression in preventing median nerve dysfunction after buttress plating of the distal radius. We studied 69 consecutive patients with distal radial fractures managed by volar plating over a 4-year period. (1995-1998). Patients' clinical notes were assessed for symptoms of median nerve dysfunction and all the patients were followed up for a minimum period of 6 months. Twenty-four patients had prophylactic carpal tunnel decompression and 45 patients did not. Forty-two patients (61%) were women and 27 patients (39%) men. The average age of the patients was 56 years, (range 24-81 years). Overall 17 patients (25%) developed median nerve dysfunction post-operatively of which nine patients had and eight patients did not have formal prophylactic tunnel decompression, respectively; this was not statistically significant (P=0.08). In addition prophylactic decompressed patients had more than twice the relative odds=2.7 (confidence interval: CI=0.94-4.76) of developing median nerve dysfunction. All cases resolved spontaneously except for three cases that required carpal tunnel decompression. We conclude that prophylactic median nerve decompression does not alter the course of median nerve dysfunction and may increase post-operative morbidity.

Synovial knee fistula: A cause of prolonged morbidity.

Postarthroscopy knee fistulae may lead to prolonged morbidity. A 62-year-old man presented with a synovial knee fistula 4 weeks after knee arthroscopy, which was confirmed by magnetic resonance imaging. He was treated with antibiotics and knee immobilization that resulted in closure of the fistula. He then developed recurrent septic knee effusion that required arthroscopic washout, further antibiotic treatment, and physiotherapy. The patient's clinical condition resolved after a further 6 weeks. This case shows that not all fistulae resolve spontaneously; they may lead to prolonged morbidity and necessitate further treatment. We also wish to note that magnetic resonance imaging is a useful diagnostic tool in place of the traditional sinogram.

Osteoid osteoma of the lunate--a case report.

We report a rare case of an osteoid osteoma of the lunate bone in a young lady who presented to us with chronic wrist pain. She was treated by excision and cancellous bone grafting of the lesion with complete resolution of symptoms.