Treatment of neglected quadriceps tendon ruptures using LARS™ ligament augmentation: A case series.

BACKGROUND: Late presentation of Quadriceps tendon rupture (QTR) is rare. Treatment of neglected QTR's can be challenging due to scar tissue and muscle wasting and may require augmentation. Delayed tendon repairs tend to have less favourable outcome compared to acute repairs. There are very few case reports of delayed repair using various techniques. METHODS: a case series of 5 patients (6 tendon ruptures) presenting late with quadriceps tendon rupture. Repair was performed using a Codivilla V-Y plasty to extend the tendon, followed by LARS artificial ligament augmentation. All patients then received 6 weeks targeted physiotherapy after wound healing. RESULTS: Repair using our technique was possible in all patients. No patients needed to return to theatre due to re-rupture or infection. Only one patient required oral antibiotics for a superficial wound infection. No patient was left with a functional deficit following physiotherapy, with 4 of the 6 repairs achieving a full range of movement. CONCLUSIONS: V-Y plasty followed by LARS augmentation can be used safely and reproducibly for the repair of delayed presentation quadriceps tendon ruptures in our cohort comprising of both healthy and co-morbid patients to achieve good functional results.

Functional relevance of patellofemoral thickness before and after unicompartmental patellofemoral replacement.

The aim of this study was to assess the increase in the anterior height of the knee after unicompartmental patellofemoral replacement and the impact of this increase on the range of motion and function of the knee. Twenty-eight patients (34 knees) who underwent patellofemoral replacement with FPV(TM) prosthesis between 2005 and 2009 were identified and retrospectively analyzed using chart and radiological review. Trochlear height and patellar thickness were measured combined and compared pre and postoperatively. The range of movement and functional outcome scores after 6-12 months follow-up were noted. The effect of increased postoperative anterior-posterior height of the knee on the range of motion was studied. Postoperative mean range of flexion of the knee joint was 116°. The mean Oxford knee score was 21 points. The mean American Knee Society Knee Score was 80 points for pain and 61 points for function. The trochlear height and patellar thickness were increased by 3.5 and 2.5 mms respectively, resulting in average total increase of 6mm in the anterior-posterior height of the knee. We found no relationship between range of motion and function of the knee and the increase in the anterior-posterior height. We found a negative correlation between increase in the anterior-posterior height and preoperative anterior-posterior height. FPV patellofemoral replacement results in correct anatomical reconstruction of the trochlear height rather than 'overstuffing' of the patellofemoral joint. There is an increase in anterior-posterior height of the knee but this does not affect range of movement or clinical outcome.

Robotic systems in orthopaedic surgery.

Robots have been used in surgery since the late 1980s. Orthopaedic surgery began to incorporate robotic technology in 1992, with the introduction of ROBODOC, for the planning and performance of total hip replacement. The use of robotic systems has subsequently increased, with promising short-term radiological outcomes when compared with traditional orthopaedic procedures. Robotic systems can be classified into two categories: autonomous and haptic (or surgeon-guided). Passive surgery systems, which represent a third type of technology, have also been adopted recently by orthopaedic surgeons. While autonomous systems have fallen out of favour, tactile systems with technological improvements have become widely used. Specifically, the use of tactile and passive robotic systems in unicompartmental knee replacement (UKR) has addressed some of the historical mechanisms of failure of non-robotic UKR. These systems assist with increasing the accuracy of the alignment of the components and produce more consistent ligament balance. Short-term improvements in clinical and radiological outcomes have increased the popularity of robot-assisted UKR. Robot-assisted orthopaedic surgery has the potential for improving surgical outcomes. We discuss the different types of robotic systems available for use in orthopaedics and consider the indication, contraindications and limitations of these technologies.

The use of erythropoietin and its derivatives to treat spinal cord injury.

Spinal Cord Injury (SCI) is a complex process which leads to destruction of neuronal tissue and also vascular structure. After SCI many potentially toxic substances are activated and released into the injury site causing secondary degeneration. Erythropoietin (EPO) is a possible therapeutic strategy to treat SCI. Over the last decade attention has been focused on the molecular mechanisms underlying its neuroprotective effects. A major concern expressed by clinicians is that besides its protective effects, EPO also demonstrates hematopoietic activity and increases the risk for thrombosis after the administration of multiple doses of this glycoprotein. Recently, tissue protective functions of EPO have been separated from its hematopoietic actions leading to the development of EPO derivatives and mimetics. Neuroscientists are focusing on recombinant human EPO (rhEPO) and its non-erythropoietic derivatives, investigating their anti-apoptotic potential and anti-inflammatory function as well as their role in restoring vascular integrity. Carbamylated erythropoietin (CEPO) and asialo erythropoietin (AsialoEPO) are structural derivatives of EPO that have no effect on erythrocyte mass whereas they retained its neuroprotective effects. In this review article, we provide a short overview of the animal studies on rhEPO and its derivatives in experimental models of SCI. Both the efficacy and the safety profile of EPO-structural and functional variants are still to be demonstrated in patients. Further clinical studies should reveal whether derivatives and variants of erythropoietin provide any benefits over the use of rhEPO in the treatment of spinal cord injury observed in the experimental studies.

Validation of medium-pressure UV disinfection reactors by Lagrangian actinometry using dyed microspheres.

Lagrangian actinometry (LA) has been demonstrated to represent an alternative to conventional biodosimetry for validation of ultraviolet (UV) disinfection systems used in drinking water treatment. However, previous applications of LA for this purpose have all involved monochromatic (lambda = 254 nm) UV reactor systems. To address this issue, dyed microspheres (DMS) were applied for quantification of dose distribution delivery by field-scale UV reactor systems based on medium-pressure Hg lamp (MP) technology. These MP reactor systems are characterized by polychromatic output. Dose distribution estimates developed by LA for these reactors were reported as equivalent 254 nm distributions. When combined with the UV(254) dose-response behavior for challenge organisms used in simultaneous or parallel biodosimetry experiments, the dose distribution estimates developed from the microspheres yielded estimates of challenge organism inactivation that were in agreement with measured values. For one of the reactors tested, biodosimetry tests were conducted with two challenge organisms that had different UV dose-response behavior; UV dose distribution estimates from LA yielded predictions of microbial inactivation that were in agreement with measured inactivation responses for both challenge organisms for all test conditions. It is likely that the agreement between LA results and biodosimetry data was related, in part, to the agreement between the action spectra of the microspheres and the challenge organisms. Because LA yields a measure of the UV dose distribution delivered by a reactor, the information from LA assays will eliminate many sources of uncertainty in the design and operation of UV systems, thereby allowing for implementation of UV reactor systems that are less expensive than their predecessors, yet more reliable.

Usefulness of functional outcome questionnaires in primary screening of spinal disease.

Back pain screening clinics are established to clinically screen patients with back pain for organic lumbar pathology. The aim of this study is to assess the relationship between clinical signs of organic pathology and the level of disability as measured by functional outcome scores. Sixty-nine patients who were found to have clinical signs of organic pathology and 69 age- and sex-matched patients from 512 patients who were found to have no signs of organic pathology in the same time period in the back pain screening clinic were selected. The Oswestry Disability, Short Form-36, and visual analogue (pain) scores between the two groups were statistically analyzed. We found a significant increase in the level of disability in the group with organic pathology; however, the variation in the scores makes them unspecific for use in screening of acute spinal pathology. We also found a strong relationship between psychologic disability and length of symptoms.

Minimally displaced Colles' fractures: a prospective randomized trial of treatment with a wrist splint or a plaster cast.

Sixty-six adult patients with minimally displaced distal radial fractures were randomly assigned to treatment with either a plaster cast or a lightweight removable wrist splint. Outcome assessment was by clinical and radiological evaluation and an independent physiotherapy assessment. There were significant differences between the treatments for cast satisfaction, cast problems and the functional assessment score at 6 weeks, with the removable splint scoring better in all cases.

Screening of lower back pain, low back pain clinic. The clinical experience.

Acute low back pain is a common complaint with high prevalence in society. Orthopaedic and specialist spinal services may be overwhelmed by large numbers of patients with low back pain who do not require investigation or surgical intervention. This phenomenon has led to the establishment of back pain screening clinics as a system of triage for those with acute low back pain. In March 2001, a back pain screening clinic was established in the Adelaide and Meath Hospitals incorporating the National Children's hospital. Six hundred and sixty-five patients were seen in the first year of this clinic. Of these, only ninety-six required referral to the orthopaedic spinal clinic. Just twenty-nine of these patients required surgical intervention. The introduction of this service resulted in a reduction in the waiting periods for the specialised spine clinic. We conclude that back pain screening clinics result in a clinical and economical improvement in the care of those suffering from acute low back pain. This is achieved by the systematic and efficient assessment, treatment and referral of patients afflicted with acute low back pain.

Functional outcome study of patients after surgical decompression for lumbar spinal stenosis: effects of concomitant pathology.

The aim of this study is to identify factors associated with poor outcome in the medium (2-5 years) postoperative period following lumbar stenosis surgery. Fifty-six consecutive patients who underwent decompression for lumbar spinal stenosis were retrospectively analyzed using chart and radiologic review, questionnaire using American Association of Orthopaedic Surgeon's MODEM questionnaire containing disability, symptoms, and illness rating, as well as Short Form-36 questionnaires. Postoperatively, there was 98% partial or total relief in leg pain, 85% had partial or total relief in back pain, and 69% had partial or total recovery of neurologic deficit. Functional outcome according to the Short Form-36 was comparable with the age-adjusted population when other comorbidities were taken into account. We found a direct relationship between poor outcome and coexisting medical conditions (p <0.001). Accompanying comorbid conditions have a significant impact on outcome after surgical decompression for lumbar spinal stenosis.

Compartment syndrome of the shoulder girdle.

We report a case of subacute compartment syndrome involving the deltoid muscle of a young person. We discuss the presentation, predisposing factors, investigation and treatment of this otherwise rare condition.

Traumatic dislocation of hip joint following low-velocity trauma, similarities to glenohumeral instability.

Acute posterior hip dislocation following low velocity trauma in a young healthy adult is a rare injury. Almost 30 cases previously have been described in the literature. They are usually associated with prior trauma to the hip joint and will lead to recurrent instability after relocation. This injury is similar to shoulder instability: lesions and anomalies present in the hip joint with posterior instability are identical to the ones in the shoulder with instability. These are Bankart-like lesion of the posterior labrum, defect in ischiofemoral ligament similar to inferior glenohumeral ligament laxity of the shoulder, relative retroversion of femoral neck angle similar to loss of retroversion of the humeral neck and, finally, Pipkin type 1 fracture of the femoral head resembling a Hill-Sachs lesion of the humeral head. Successful treatment of this injury depends on addressing these pathologies. We present three cases of acute posterior hip dislocation in young adults after low-energy trauma, which presented to our unit over a 4-year period, and a review of another 21 cases of similar injury previously described in the literature. We will demonstrate these lesions and discuss the investigation and treatment modalities for posterior instability of the hip joint. We conclude that hip dislocation caused by low-energy trauma must be investigated and treated to avoid recurrence of dislocation and associated complications.

Wound complications following operative fixation of calcaneal fractures.

The aim of our study was to find the incidence of wound complications following operative fixation of fractured calcanea and identify the risk factors contributing to them. We retrospectively reviewed the results of operative treatment of 33 calcaneal fractures in 30 patients over a 4-year period. We report an overall wound complication rate of 18.1%. Wound infection, haematoma, dehiscence and heel necrosis were noted in our series with or without underlying osteomyelitis. We identified the following as risk factors to the causation of post-operative wound complications: (a) fall of more than 3.4 m (p<0.005); (b) surgery within 7 days (p<0.05); (c) operating time in excess of 2 h (p<0.05); (d) tourniquet time in excess of 1.5 h (p<0.001). We recommend careful attention to these factors in treating calcaneal fractures.

Feasibility of day case varicose vein surgery in a district general hospital.

BACKGROUND: Day case surgery may reduce inpatient bed requirements, and varicose surgery may be an ideal operation to test the functioning of a day surgery service. AIMS: To evaluate retrospectively the feasibility of day case varicose vein surgery in all-comers, and to identify the risk factors for admission. METHODS: Over a three-year period from July 1995 to July 1998, all patients requiring varicose vein surgery had their procedure performed as a day case. A standard technique of sapheno-femoral ligation with below-knee stripping of the long saphenous vein and multiple stab avulsions of varicosities was performed. All limbs were dressed with wool in crepe bandage and were reviewed post-operatively at six weeks. RESULTS: Five hundred and forty two patients underwent varicose vein surgery, of whom 26% had bilateral varicose veins, 88% had primary varicose veins and 22% had recurrent disease. The procedure was performed under general anaesthesia in 86% of cases and under spinal anaesthesia in the rest. There was no peri-operative mortality. Ten patients (1.9%) developed post-operative complications. Seventy two per cent of patients were discharged on the day of surgery, a further 25% required admission for one night due to minor anaesthetic complications and patient preference. Four per cent required admission for more than 24 hours. The need for overnight admission was associated with the age of the patients (p < 0.0001), bilateral varicose vein surgery (p < 0.005) and the use of spinal anaesthesia (p < 0.01). CONCLUSION: Although varicose vein surgery is safe, acceptable and cost-effective as a day case procedure, if attempted in all-comers, overnight admission will be required in a significant proportion. Pre-operative selection is advised.

Community mental health program efficiency.

Six urban community mental health centers participated in a capitated payment system designed for persons with severe mental illness who frequently used the state hospital. The centers and their funding agency agreed that a chief outcome measure would be the length of time clients were able to remain enrolled in the outpatient program. Clients of the six agencies were quite similar to one another. During the 18-month study length of enrollment in the outpatient program did not vary among the agencies whereas agency expenditures varied by more than three-fold. Although some of this expenditure variation was due to economies of scale at larger agencies, different practice styles also contributed to variable efficiency.

A capitated payment system for involuntary mental health clients.

This DataWatch examines an outpatient capitated payment system, in the state of Oregon, designed to enhance community services for persons with chronic mental illness who had repeatedly been hospitalized involuntarily. Special state funds and Medicaid dollars were used to pay providers prospectively on a risk-adjusted basis for the delivery of outpatient mental health services. During the three-year study period clients were able to be discharged from the state hospital. Although the data are not straightforward, capitated clients' use of the state mental hospital seems to have declined somewhat more than that of comparison subjects. Outpatient service use was modest and appeared to have little relationship to a client's level of illness severity. Indeed, it was not possible to predict prospectively these clients' outpatient mental health services expenditures.