Management of proximal humerus fractures in adults.

The majority of proximal humerus fractures are low-energy osteoporotic injuries in the elderly and their incidence is increasing in the light of an ageing population. The diversity of fracture patterns encountered renders objective classification of prognostic value challenging. Non-operative management has been associated with good functional outcomes in stable, minimally displaced and certain types of displaced fractures. Absolute indications for surgery are infrequent and comprise compound, pathological, multi-fragmentary head-splitting fractures and fracture dislocations, as well as those associated with neurovascular injury. A constantly expanding range of reconstructive and replacement options however has been extending the indications for surgical management of complex proximal humerus fractures. As a result, management decisions are becoming increasingly complicated, in an attempt to provide the best possible treatment for each individual patient, that will successfully address their specific fracture configuration, comorbidities and functional expectations. Our aim was to review the management options available for the full range of proximal humerus fractures in adults, along with their specific advantages, disadvantages and outcomes.

Reverse polarity shoulder replacement: Current concepts and review of literature.

Shoulder replacement in cuff tear arthropathy (CTA) is an unsolved challenge. CTA poses a soft tissue deficiency in an arthritic glenohumeral joint which the anatomical total shoulder replacement and hemiarthroplasty cannot reliably provide stability, range of movement, function or satisfactory long term outcome. In the past two decades since the introduction of the reverse shoulder replacement, the prosthesis has evolved and has shown promising results. It is a partially constraint joint by virtue of its design features. The reversal of the concavity and convexity of the joint to the proximal humerus and the glenoid, respectively, also shifts and improves its center of rotation onto the osseous surface of the glenoid with less exposure to shear stress. It is a successful pain relieving procedure, offering good outcome in patients with irreparable massive rotator cuff tear with or without osteoarthritis. Consequently, this has led to wider use and expansion of its indication to include more complex elective and trauma cases. Whereas originally used in the more elderly patients, there is increasingly more demand in the younger patients. It is important to have good quality long term data to support these increasing indications. Therefore, we review the literature on the concepts of reverse shoulder replacement and the contemporary evidence.

Outcome of pyrocarbon proximal interphalangeal joint replacement.

Pyrocarbon arthroplasty of the proximal interphalangeal joint (PIPJ) has been reported to provide excellent pain relief when treating osteoarthritis of the hand. We retrospectively reviewed 20 PIPJ arthroplasties performed on 14 patients by a single surgeon using Ascension prosthesis. The mean follow up period was 3.5 years (range 1-7 years). Excellent pain relief was noted at the final follows-up. The mean range of motion improved from 40° pre-operatively to 70° post-operatively which was statistically significant. Twelve patients had significant improvement in quality of life and would consider similar procedure for other fingers. Radiological assessment revealed an average of 1 mm subsidence and there was no correlation noted between subsidence, migration and ROM at the final follow-up. Stiffness was the main complication and was comparable with other studies. The results of this series are encouraging and demonstrate excellent to good outcome in 86% of patients at the mid-term follow-up.

Manipulation for stiffness following total knee arthroplasty: when and how often to do it?

Stiffness following total knee arthroplasty is a disabling complication. One of the management options of stiffness includes manipulation under anaesthesia, but no real consensus exist on appropriate timing of intervention, and the timing and results of the manipulation under anaesthesia (MUA) are under debate in the literature. Our aim was to determine the efficacy of single and multiple manipulations under anaesthesia following total knee arthroplasty and to determine the most appropriate timing for manipulation. We retrospectively reviewed 86 patients who underwent manipulation for stiffness following primary total knee replacement with at least 1-year follow-up. Range of motion before surgery, at the time of the MUA, immediately after MUA and at 6 weeks and 1 year post-MUA were recorded. At the end of 1 year post-manipulation, manipulations performed at less than 20 weeks, following primary total knee arthroplasty, showed 31° of flexion gain as compared to only 1.5° of flexion gain when manipulation was undertaken after 20 weeks. Of the 86 patients, 21 had multiple manipulations with no significant difference in flexion gain after the second manipulation. Patients on warfarin (26%) had an increased incidence of stiffness and poor flexion gain. This study showed that better results were achieved when manipulation was performed at less than 20 weeks (particularly between 12 and 14 weeks) from primary surgery with no added benefit from re-manipulations.

Leg length discrepancy after total hip arthroplasty: a review of literature.

Discrepancy of leg length is often considered to be a problem after total hip replacement and can adversely affect an otherwise excellent outcome. Furthermore, it has been associated with patient dissatisfaction and remains one of the most common reasons for litigation against the orthopedic community. As a consequence of the need to equalize leg length, several authors have sought to validate methods of minimizing limb length discrepancy based on preoperative planning with preoperative radiological templates or intraoperative methods of measurement. In this article, we present a review of the limb length discrepancy in total hip arthroplasty, its implications and several techniques to avoid it. We recommend that a combination of the above mentioned methods will give the best chance for the surgeon to minimise the risk of leg length discrepancy following total hip replacement.

Acetabular revision surgery with the uncemented oblong BOFOR Cup--early to midterm results.

INTRODUCTION: Failure of acetabular components frequently leads to bone loss with extensive elongated defects in the surrounding bone. In these cases the use of an oblong cup has been described as an option for acetabular reconstruction. We report the longest follow up results obtained with this implant to date. MATERIALS AND METHODS: A prospective study was conducted to evaluate the results of the BOFOR oblong revision cup. Between 2001 and 2006, 15 acetabular revisions were performed for aseptic loosening of the acetabular cup. The acetabular defects were classified as type 2A to 3A, according to Paprosky's criteria. No allografts were used in any of the cases. The mean follow-up was 90 months (range 60-120 months). RESULTS: Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 39 points preoperatively to 84 points postoperatively and a mean Oxford Hip Score from 55 points preoperatively to 22 points postoperatively. Only one case underwent re-revision due to aseptic loosening in a patient with severe ankylosing spondylitis. There were no cases of dislocation or infection. One patient had a sciatic nerve neurapraxia. After an average follow up of 7.5 years, 93% of the investigated implants remained in-situ without further revision. CONCLUSION: This study shows that the BOFOR cup provided good clinical results and showed satisfactory stability at early to midterm follow-up.

Lateral sesamoid position in hallux valgus: correlation with the conventional radiological assessment.

BACKGROUND: We aimed to quantify the severity of the hallux valgus based on the lateral sesamoid position and to establish a correlation of our simple assessment method with the conventional radiological assessments. METHODS: We reviewed one hundred and twenty two dorso-plantar weight bearing radiographs of feet. The intermetatarsal and hallux valgus angles were measured by the conventional methods; and the position of lateral sesamoid in relation to first metatarsal neck was assessed by our new and simple method. RESULTS: Significant correlation was noted between intermetatarsal angle and lateral sesamoid position (Rho 0.74, p < 0.0001); lateral sesamoid position and hallux valgus angle (Rho 0.56, p < 0.0001). Similar trends were noted in different grades of severity of hallux valgus in all the three methods of assessment. CONCLUSIONS: Our method of assessing hallux valgus deformity based on the lateral sesamoid position is simple, less time consuming and has statistically significant correlation with that of the established conventional radiological measurements.

Tissue necrosis after use of enoxaparin in total knee arthroplasty: a case report.

Tissue necrosis at the injection site of enoxaparin is a rare adverse effect. Most of the reported clinical course of this necrosis is uneventful. Here we review a case of tissue necrosis that developed after use of enoxaparin and required debridement followed by reconstructive surgery. Until now, such a case has not been reported in the English-language literature. As enoxaparin is being used more often for prevention of deep vein thrombosis in patients who undergo arthroplasty surgery, awareness and recognition of this adverse event and careful supervision of all patients who receive this medication are essential.

Critical review of the current practice for computer-assisted navigation in total knee replacement surgery: cost-effectiveness and clinical outcome.

In this article, we present a review of the current practice regarding computer-assisted navigation in total knee replacement together with the bearing on cost-effectiveness and clinical outcome.

Functional and radiological evaluation of a simple intra operative technique to avoid limb length discrepancy in total hip arthroplasty.

We aimed to assess the radiological and functional outcome of total hip arthroplasty performed using a simple technique for intra-operative leg length assessment. The comparative group was made up of patients receiving total hip arthroplasty prior to introduction of the technique. Fifty patients were studied in each group. The pre- and 3 month post-operative leg length difference (LLD) was measured radiologically along with pre- and 12 months post-operative Oxford hip scores (OHS) and University of California Los Angeles (UCLA) activity scores.There were no statistically significant differences in pre-operative parameters between the two groups. The mean LLD in the new technique group was 0.46 mm which was significantly less than in the control group (p< 0.001). Post operative OHS values were worse when shortening or lengthening was >5 mm in both groups. UCLA activity scores were significantly better in the new technique group than in the control group (p< 0.001). The overall radiological and functional outcome of the patients was better in the new technique group.Functional outcome is related to small differences in leg length and our simple new technique can be used to control leg length intraoperatively.

A simple technique to position patients with bilateral above-knee amputations for operative fixation of intertrochanteric fractures of the femur: a case report.

INTRODUCTION: Intertrochanteric fractures of the femur are common fractures in the elderly, and management includes operative fixation after patient positioning on the fracture table. Patients with bilateral above-knee amputations are challenging in terms of positioning on the table. We describe a simple technique to overcome this special problem. CASE PRESENTATION: A 75-year-old wheelchair-bound Caucasian man with bilateral above-knee amputations presented to our hospital after a fall. Plain radiographs showed an intertrochanteric fracture of the femur, and operative fixation with a dynamic hip screw was planned. His positioning on the table posed a particular problem, and therefore we developed a technique to overcome this problem. CONCLUSION: Positioning of patients for fixation of intertrochanteric fractures of the femur poses a particular problem that can be solved by using our simple technique.

Critical appraisal of subjective outcome measures used in the assessment of shoulder disability.

INTRODUCTION: Objective measures can be impractical in some settings, because they are time consuming and require face-to-face contact. More recently, there is an increasing trend towards the use of subjective outcome measures. Hence, in this article, five common subjective shoulder outcome measures are critically appraised in terms of their development, validity, reliability, responsiveness and clinical application. MATERIALS AND METHODS: Following an extensive literature search, five common shoulder patient-based scores were identified: Disability of Arm, Shoulder and Hand (DASH), Oxford Shoulder Score (OSS), Shoulder Disability Questionnaire (SDQ-UK), Shoulder Pain and Disability Index (SPADI), and the Shoulder Rating Questionnaire (SRQ). These questionnaires were then critically appraised in terms of their development process, validity, reliability, responsiveness, and clinical application. RESULTS: The SDQ-UK has shown good construct validity but there is no data available regarding internal consistency, reliability and responsiveness. The SPADI has good internal consistency, fair reliability with adequate criterion and construct validity. The DASH has shown to have good construct validity, excellent test-re-test reliability and responsiveness to change. The OSS has good sensitivity, validity and responsiveness. Though SRQ has good internal consistency, its reproducibility and responsiveness are poor. CONCLUSIONS: Based on this critical appraisal, the DASH received the best ratings for its clinimetric properties followed by the OSS.

Total hip arthroplasty in slipped capital femoral epiphysis: a novel technique to remove embedded knowles pins.

The Knowles pin has been well recognized in fixing slipped capital femoral epiphysis. When these pins are left in place for a long period, it is very difficult to remove them during total hip arthroplasty, because the pins have fluted threads, which are oversized in the end and allow bone growth in the previously threaded slots. We present a simple and novel technique to remove Knowles pins so that both unnecessary trauma to the lateral femoral cortex and operating time is reduced significantly.

Discharging pin sites following K-wire fixation of distal radial fractures: a case for pin removal?

The aim of this study was to find out whether discharging pin sites following Kirschner-wire fixation of distal radial fractures warrant early wire removal. In a prospective study of 50 patients with a closed distal radial fracture treated by manipulation and either percutaneous or mini-incision Kirschner-wiring, we identified 14 patients (28%) with discharging pin sites. All of the cases were observed within the first two weeks following surgery. Of the 14 cases, only 2 patients had a positive swab culture and were treated with systemic antibiotics. In all cases the Kirschner wires were left in situ until serial radiographs demonstrated satisfactory union. Three patients (8.6%) in the percutaneous group had superficial radial nerve irritation, which settled following wire removal. Deep soft tissue infection, pyoarthrosis, osteomyelitis, and extensor tendon rupture were not encountered. We conclude that pin site discharge, whether sterile or infected, is in general not an indication for early wire removal.

Cemented total hip arthroplasty in a patient with alpha-mannosidosis: a case report.

Mannosidosis is an extremely rare genetic disease occurring due to deficiency of the lysosomal enzyme, alpha-mannosidase. Patients with this disorder often suffer from musculoskeletal abnormalities and muscular weakness leading to joint destruction and severe morbidity along with other major systems involvement. We present here such a case of a 27-year-old male that highlights the challenges in management of hip joint destruction secondary to Mannosidosis.

Extracorporeal shock wave therapy in chronic calcific tendonitis of the shoulder--is it effective?

Extracorporeal shock wave therapy has been claimed to be an effective non-invasive treatment for chronic calcific tendonitis of the supraspinatus tendon. However many trials have been criticised for not achieving necessary scientific standards. We report a prospective, single blinded, randomised control trial of 20 patients, which looked into effectiveness of the therapy. Subjectively, 45% of the treated patients were satisfied with the outcome and also had objectively increased their Constant score by 11% at 6 months. The control group experienced no subjective or objective improvement with p value < 0.03. This study confirms that extracorporeal shock wave therapy is effective in treating chronic calcific tendonitis when compared with a placebo group. However in our experience it is not as successful as previously claimed, with half the patients failing to achieve a satisfactory out come and requiring surgical excision. Patients found the procedure painful, which has not been previously alluded to.

Does intraarticular steroid infiltration increase the rate of infection in subsequent total knee replacements?

Steroid injection into the arthritic joint is a well-known treatment. Its efficacy is well documented. An increase in the incidence of infection secondary to steroid injection has been reported in recent literature. Based on the current literature we carried out a retrospective study to evaluate the incidence of infection in primary total knee arthroplasty as a result of previous steroid infiltration into the knee joint. In our study, 440 patients underwent total knee replacement between 1997 and 2005. Only 90 patients had intraarticular steroid injection prior to surgery, of which 45 patients had injection within 1 year prior to surgery. A matched cohort of 180 patients who had total knee replacement without steroid injection was used as control group to compare the infection rate. All patients had at least 1 year follow up. Two cases of superficial infection were noted in the study group and five cases of superficial infection in the control group. No cases of deep infection were noted in either group. Statistical analysis showed no significant difference in incidence of infection in either group (P value 1.0). This study showed no increase in the incidence of infection in patients with total knee arthroplasty with prior steroid injection.

Periprosthetic osteolysis due to metastatic renal cell carcinoma: a case report.

Failure of total hip arthroplasty through septic or aseptic loosening, periprosthetic fracture, or recurrent dislocation is well recognized and understood. We present an unusual cause of failure of total hip replacement which occurred on a 79 year old gentleman: that of prosthetic loosening secondary to malignant infiltration around components. Our aim is to highlight the fact that malignant infiltration should be considered as part of the differential diagnosis in aseptic and septic loosening of prosthetic implants.