The Segond fracture: a clue to intra-articular knee pathology.

This short report presents the case of a 32-year-old man with a knee injury sustained while playing football. A plain radiograph revealed a Segond fracture and a subsequent MRI confirmed a complete anterior cruciate ligament rupture. While the Segond fracture, and its associated intra-articular pathology, is well recognised among orthopaedic surgeons, it is less well recognised among staff in the emergency department. The report aims to emphasise the importance of plain radiographs in patients with a history of knee injury and to highlight that this seemingly innocuous avulsion fracture may reveal more severe underlying pathology.

A prospective randomised study comparing the jubilee dressing method to a standard adhesive dressing for total hip and knee replacements.

AIM OF THE STUDY: It is important to reduce potential wound complications in total hip and total knee arthroplasty procedures. The purpose of this study was to compare the jubilee dressing method to a standard adhesive dressing. METHOD: 124 patients (62 total hip replacements and 62 total knee replacements) were randomly selected to have either a standard adhesive dressing or jubilee method dressing. The number of dressing changes, incidence of blistering, leakage, appearance of inflammation, infection rate and the average stay in hospital was recorded for each patient. RESULTS: The jubilee dressing significantly reduced the rate of blistering, leakage and number of dressing changes when compare to a traditional adhesive dressing (p < 0.05). The rate of inflammation and average length of stay in hospital was not significantly different between the two groups. CONCLUSION: The authors recommend the use of this dressing for total hip and total knee arthroplasty procedures due to the associated lower complication rate.

Outcome of periacetabular osteotomy for the management of acetabular dysplasia: experience in an academic centre.

Periacetabular osteotomy (PAO) is a very effective reconstructive procedure for treatment of acetabular dysplasia. An orthopaedic paediatric surgeon and a reconstructive hip arthroplasty surgeon performed this procedure together in the early phase of their learning curve and then performed it individually. The early clinical and radiographic results of 85 consecutive PAOs performed in this academic orthopaedic unit were reviewed. The mean Merle-d'Aubigné score increased from 12.4 preoperatively to 16 at follow-up. Pre-operatively 73 hips were anteverted and 12 were neutral or retroverted. The mean angle of Wiberg improved from 5 degrees to 21 degrees (p < 0.0001) in anteverted hips, and from 9 degrees to 30 degrees in neutral or retroverted hips. The mean angle of Lequesne and de Sèze improved from 6 degrees to 35 degrees (p < 0.0001) in anteverted hips, and in neutral or retroverted hips from 9 degrees to 30 degrees (p < 0.0001). The acetabular index improved from 26 degrees to 8 degrees (p < 0.0001) in anteverted hips, and from 21 degrees to 7 degrees (p < 0.0001) in neutral or retroverted hips. Over the 7 year period the blood loss and operative time improved from 2000 ml to 900 ml and 4 hours to 2 hours respectively. Four hips (four patients) required conversion to total hip replacement. The radiographic correction and improved clinical scores are similar to those in previous studies. This study shows a survival rate of 94% at 58 months following periacetabular osteotomy. The learning curve and the early results of this procedure performed in our academic unit are encouraging.

Total hip replacement-the cause of failure in patients under 50 years old?

AIM: To establish the mode of failure of primary total hip replacement in patients under 50 years old. METHODS: A total of 1062 revision total hip arthroplasties were performed over a 5-year period, with 146 on patients under 50 years old. These were subdivided into early (< 5 years) and late (> 5 years) failures from the index procedure. RESULTS: The commonest mechanism of failure was aseptic loosening (42.3%) followed by metal-on-metal failure (15.8%), infection (14.4%) and instability (9.6%). The commonest cause of early revision surgery was due to metal-on-metal failure (27.8%) followed by aseptic loosening (19.7%) and infection (18.4%). In the late revision group, the main cause of failure was aseptic loosening (64%) and infection (10.7%). CONCLUSION: The changing trend of early revision due to metal-on-metal failure is important to recognise. Continuous review of the mechanism of primary total hip replacement failure is necessary to ensure the best patient outcome and maximise implant survivorship.

Locking plate fixation with and without inferomedial screws for proximal humeral fractures: a biomechanical study.

PURPOSE. To compare the efficacy of locking plate fixation with and without inferomedial screws in maintaining the reduction of a proximal humeral fracture. METHODS. 22 synthetic humerus models were used. A standardised 3-part proximal humeral fracture with a 4-mm wedge segment was created and fixed with a locking plate and screws with (n=11) and without (n=11) inferomedial screws. The intrafragmentary motion of the construct at 250, 500, 750, and 1000 cycles of 532 N loading, and the load to failure of the 2 groups were compared. RESULTS. Locking plate fixation with inferomedial screws reduced the mean intrafragmentary motion in all cycles (p<0.01) and increased the load to failure (1452 N vs. 1159 N, p<0.001), compared to fixation without inferomedial screws. CONCLUSION. Additional inferomedial screws provide medial column support for fracture healing. This may reduce intrafragmentary motion and thus implant complications resulting from varus malalignment such as screw perforation or loss of reduction.

Transstyloid, transscaphoid, transcapitate fracture: a variant of scaphocapitate fractures.

Transstyloid, transscaphoid, transcapitate fractures are uncommon. We report the case of a 28-year-old man who sustained this fracture following direct trauma. The patient was successfully treated by open reduction internal fixation of the scaphoid and proximal capitate fragment, with a good clinical outcome at 1-year follow-up. This pattern is a new variant of scaphocapitate fracture as involves a fracture of the radial styloid as well.

Bilateral distal tibial stress fractures in a healthy field-hockey goalkeeper.

Stress fractures occurring within the lower limbs are relatively common in athletes and military personnel. The specific bones affected are often predictable when the patient's activities are considered. We present an unusual case of bilateral distal tibial stress fractures sustained while playing as a goalkeeper in field hockey, in an otherwise healthy 46-year-old woman.

Effect of calcium triphosphate cement on proximal humeral fracture osteosynthesis: a cadaveric biomechanical study.

PURPOSE. To evaluate the effect of filling a central humeral bone void with calcium triphosphate cement on the strength and stability of an osteosynthesis in elderly cadavers. METHODS. 14 fresh cadaveric shoulder specimens obtained from 11 donors (mean age, 91.5 years; mean body weight, 61 kg) were divided into 2 age- and sex-matched groups. A standardised 3-part proximal humeral fracture with a central bone void was created in each specimen. Each specimen was reduced and fixed with a locking plate. In half the specimens the central bone void was packed with calcium triphosphate cement. The intra-fragmentary motion and the load and mode of failure were recorded. RESULTS. Respectively in the test group and controls, the intra-fragmentary motion was 1.0 and 6.4 mm, and the peak displacement at the 500 N load was 1.8 and 9.1 mm. The Cohen's d was 1.6 to 2.7 for all load steps, indicating a large effect of the calcium triphosphate cement on strength and stability. The mean difference in the failure load was 300 N (p<0.05). CONCLUSION. Construct stability and failure load improved significantly when the central humeral bone void was filled with calcium triphosphate cement.

Locking plate fixation for proximal humerus fractures.

Locking plates are increasingly used to surgically treat proximal humerus fractures. Knowledge of the bone quality of the proximal humerus is important. Studies have shown the medial and dorsal aspects of the proximal humeral head to have the highest bone strength, and this should be exploited by fixation techniques, particularly in elderly patients with osteoporosis. The goals of surgery for proximal humeral fractures should involve minimal soft tissue dissection and achieve anatomic reduction of the head complex with sufficient stability to allow for early shoulder mobilization. This article reviews various treatment options, in particular locking plate fixation. Locking plate fixation is associated with a high complication rate, such as avascular necrosis (7.9%), screw cutout (11.6%), and revision surgery (13.7%). These complications are frequently due to the varus deformation of the humeral head. Strategic screw placement in the humeral head would minimize the possibility of loss of fracture reduction and potential hardware complications. Locking plate fixation is a good surgical option for the management of proximal humerus fractures. Complications can be avoided by using better bone stock and by careful screw placement in the humeral head.

Musculoskeletal oncology training during residency.

PURPOSE: To evaluate the efficacy of a musculoskeletal oncology training module during residency. METHODS: 24 orthopaedic residents with differing years of experience were recruited. 12 of them received musculoskeletal oncology training for 6 months. The remaining 12 were controls who did not attend the training and had no clinical experience in a musculoskeletal oncology unit but had at least 3 years of postgraduate surgical training. Upon completion, residents in both groups were assessed by a knowledge test and then an objective structured clinical examination (OSCE). RESULTS: Residents who attended the training module had better mean knowledge test scores (48 vs 25 out of 58, p<0.0001) and OSCE scores (32 vs 22 out of 42, p<0.004), compared to those who did not attend. No residents who attended the training module marked an inappropriate biopsy site that would have compromised definitive surgery, compared to 5 (42%) of the untrained residents who marked an inappropriate biopsy site that may have resulted in an unnecessary amputation. All residents who attended the training module agreed that such a module should be included in the orthopaedic residency programme. CONCLUSION: Residents who attended the training module were more aware of the biopsy principles and risks. A training module for musculoskeletal oncology should be included in the orthopaedic residency programme.

Diagnostic gait pattern of a patient with longstanding left femoral nerve palsy: a case report.

The gait pattern of a 35-year-old man with longstanding, left femoral nerve palsy was assessed using 3-dimensional kinematic and kinetic analysis. Stability of his left knee in stance was achieved by manipulating the external moments of the limb so that the ground reaction force passes in front of the knee joint. This compensatory mechanism of locking the knee in extension is reliant on the posterior capsular structures. The patient was managed conservatively and continued to walk without aids.

An unusual cause of pain post ankle arthrodesis in patients with rheumatoid arthritis.

Rheumatoid arthritis is an autoimmune disease which frequently affects the ankle and foot. End stage ankle arthritis from rheumatic disease is commonly managed by the established practice of ankle arthrodesis. Among the adverse sequelae causing pain following this surgery is infection, pseudo-arthrosis and non-union. Stress fracture of the distal third is a recognised but unusual cause of pain of tibia following ankle arthrodesis. The authors' present three patients with rheumatoid arthritis who sustained a stress fracture of the distal tibia following arthrodesis, and discuss the contributing factors and highlight the need for orthopaedic surgeons to be suspicious of this complication post surgery.

Contamination of histology biopsy specimen - a potential source of error for surgeons: a case report.

Tissue contamination is a common occurrence in pathology, but surgeons are relatively unaware of this. We present the case of a 45-year-old man with Barrett's oesophagus, in which the histology of routine biopsies of an asymptomatic patient, were reported as 'carcinoma in situ'. Further biopsies were taken over a three month period but showed no evidence of malignancy. Tissue contamination or 'cross over' was identified as the likely cause of the abnormal result. This case report highlights the importance of the correlation of the clinical and histopathological findings and tissue contamination should be considered when both of these findings are not consistent.

An isolated proximal tibiofibular joint dislocation in a young male playing soccer: a case report.

Isolated dislocation of the proximal tibiofibular joint is a rare injury. We present a 23-year-old caucasian man who sustained a traumatic anterolateral dislocation of the proximal tibiofibular joint. There is no consenus on definitive management, and we review the different published treatment and rehabilitation regimens for this injury. Our patient was successfully treated by open reduction and temporary Kirschner-wire fixation. The authors recommend their structured rehabilitation process involved using cast brace immobilization as allows for excellent soft tissue healing.