Background

Total ankle replacement (TAR) design has evolved greatly in recent years and offers a reasonable alternative to ankle arthrodesis in a select patient population with end-stage arthritis. Originator series’ report good longevity and excellent patient reported outcomes (PROMs). We report our outcomes in an independent, non-inventor cohort.

Background

Nonsurgical treatment of Acromioclavicular joint dislocations is well established. Most patients treated conservatively do well, however, some of them develop persistent symptoms. We have used two different surgical reconstruction techniques for Chronic ACJ dislocation stabilization. The study evaluates the effectiveness of a braided polyester prosthetic ligament and modified Weaver-Dunn reconstruction methods.

Introduction

Total ankle replacement (TAR) surgery remains a reasonable alternative to arthrodesis in a select group of patients with end stage ankle joint arthritis. We describe the early results of a prospective study of the first 50 Zenith total ankle replacements performed by a single surgeon (SKG).

Aim

To study the efficacy of Zoledronic acid in the treatment of benign osteolytic tumours or tumour like conditions of bone as a therapeutic or as an adjuvant agent

Most common current surgical treatment options for cuff tear arthropathy (CTA) are hemiarthroplasty and reverse total shoulder replacement. At our unit we have been using Reverse Total shoulder replacement (TSR) for CTA patients since 2001. We present our results of Reverse TSR in 64 patients (single surgeon) with a mean follow up of 2 years (Range 1 to 8 years). There were 45 males and 19 females in the study with a mean age of 70 years. Preoperative and postoperative Constant scores were collected by a team of specialist shoulder physiotherapists. Preoperatively plain radiographs were used to evaluate the severity of arthritis and bone stock availability.

90% patients showed an improvement in the Constant score post operatively. The mean improvement in Constant score was 25 points. The mean Pain Score (max 15) improved from 6.3 to 11.8; the mean ADL Score (max 20) improved from 6.8 to 12.3; the mean Range of Motion score (max 40) improved from 10.8 to 20.2; but the mean Power Score (max 25) only improved from 0.9 to 4.9. The differences in improvement were statistically significant in each category. A total 6 patients (10%) required 10 revision surgeries for various reasons. Two patients dislocated anteriorly who were treated by open reduction. Two patients required revision of the glenoid component due to loosening after a mean of 2 years. One patient required revision of the humeral component with strut grafting secondary to severe osteolysis. Only one patient required revision of both humeral and glenoid components secondary to malpositioning. Three patients died for reasons unconnected with their shoulder problems and surgery. Radiographic analysis at the latest follow up (mean 24 months) showed inferior glenoid notching in 40% cases. Heterotrophic ossification was not seen in our series.

We conclude that reverse TSR is a viable option for treatment of cuff tear arthropathy however glenoid loosening and scapular notching remains an issue.

Introduction: Patients presenting with fracture of the femoral neck are usually elderly, and often have extensive co-morbidity. Patients who are considered too unwell for surgery are often keep being delayed until assumed optimised or treated non-operatively. These patients have a high morbidity and mortality and present significant nursing difficulties.

Materials and Methods: We describe a technique of fixation of fracture of the femoral neck under direct infiltration local anaesthesia; that can be performed on the sick elderly patient without the risks associated with general or regional anaesthesia. In a series of twenty eight patients all diagnosed with serious co-morbidity (ASA4) on pre-operative assessment. Twenty three patients suffered from extracapsular fracture neck of femur and five intracapsular fracture neck of femur. All patients were informed about the risks of anesthesia by the senior anesthetist prior to surgery. A mixture of 20 mls n.saline + 20mls of 1% lignocaine with 1:200,000 adrenaline + 20mls 0f.25% plain marcaine (total 60 mls used). This can be increased up to 140 mls in the same ratios.

Results: All patients were operated by various grade registrars. Twenty four (24) DHS and four Hemiarthro-plasty were performed. The patients were all able to complete the surgery using this technique; none required conversion to another form of anaesthesia.

The average duration of surgery was 44 min. All patients survived the procedure and until discharge form hospital.

Discussion: Finlayson and Underhill (1988) suggested that extracapsular fractures are supplied predominantly by the femoral nerve and are therefore more amenable to this type of treatment.

We recommend the consideration of this technique for management of patients with severe co-morbidity and fracture of the femoral neck in order to optimise their chance of survival and avoid the morbidity associated with bed rest.

The locked plates are commonly used to obtain fixation in periarticular and comminuted fractures. Their use has also gained popularity in fixing fractures in osteoporotic skeleton. These plates provide stable fixation and promote biological healing. We have used over 150 locked plates with varying success in last 3 years to fix periarticular fractures involving mainly Knee and Ankle. These plates need to be removed if indicated which may be implant failure, infection, non-union or a palpable symptomatic implant. There are no reports in the literature regarding complications associated with removal of these locked plates. We report our clinical experience of removing locked plates in 28 adult patients. The procedure of implant removal was associated with a complication rate of 25%. The main problems encountered were difficulty in removing the locked screws and the implant itself. The locking plate could not be removed in two patients and had to be left in situ. We recommend that surgeon should be aware of these potential complications whilst removing these plates and that fluoroscopic control and all available extra equipment mainly metal cutting burrs and screw removal set should be available in theatre.

Advances in implant design and instrumentation have led to total ankle replacement (TAR) becoming an attractive alternative to ankle fusion in selected cases. We present the short-term results for Mobility TAR with clinical and radiological findings.

Methods: Prospective study from Dec 2004 to Dec 2007. Single surgeon, anterior approach to the ankle. Patients assessed clinically, radiologically and with pre and postoperative visual analogue (VAS) and American orthopaedic foot and ankle society (AOFAS) hindfoot score.

Results: 34 patients, 36 TAR, 2 bilateral. Male 25, female nine. Mean age 66.9 years, range 43 to 89 years. 26 osteoarthritis, four rheumatoid arthritis, four post-traumatic osteoarthritis. Follow up 6 months to 3.5 yrs, mean 22 months. VAS pre-operative mean 8, postoperative mean 1.5. AOFAS score mean pre-operative 30, post-operative mean 85. No deep infections, 3 superficial infections, which settled with antibiotics. No nerve damage. Two medial malleolar fractures. Two lateral malleolar fractures. One talar malposition – one of first six cases, no surgery required outcome not affected. Three unexplained painful TAR. No revisions. 90% patients satisfied and would have operation again

Conclusion: Short-term results for TAR are encouraging. Implants and instrumentation are improving and patients are satisfied with the results. There is a steep learning curve of at least six cases. Surgical skill, technique and careful patient selection are paramount in achieving satisfactory results. With patient demands increasing TAR is a realistic alternative to ankle fusion.

Complex proximal humerus fractures have been described as the unsolved fracture. Review of literature shows a variety of treatment methods and results. We present the results of a prospective study of 47 complex proximal humerus fractures treated by PHILOS (Proximal Humeral Internal Locking System) plate. The aim of this study was to assess the effectiveness of the PHILOS plate in the surgical treatment of Neer’s type 3 & 4 fractures.

We operated upon 47 patients (mean age 56yrs) between March 2002 and January 2006 for fixation of 3 part (28 patients) and 4 part (19 patients) fractures at a level 1 trauma centre. An independent observer reviewed patients at 6 monthly intervals for clinical and radiological assessment. Outcome measures included DASH and Constant scores.

42 patients were available for follow up, which ranged from 12–66 (average 24.4) months. Recovery of movements, and relief in pain was satisfactory in most of the patients, but the strength of shoulder did not recover fully in any patient. There were two failures in our series, one due to breakage of plate and another due to non-union; both treated successfully by revision. 4 patients (8%) had radiological signs of avascular necrosis of humeral head but only 2 of them were symptomatic requiring further treatment. Pain due to impingement was noted in several patients leading to removal of plate (6 patients) and subacromial decompression (3 patients). We encountered the problem of cold welding and distortion of screw heads, while removing the plate. The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure.

We concluded that in spite of the above-mentioned complications, the PHILOS plate is a reliable implant to fix 3 and 4 part proximal humeral fractures. We were particularly impressed with the satisfactory results of fixation in 4 part fractures. However, we are not convinced about its strength. The plate may cause impingement in some patients necessitating its removal later on, which itself may not be easy.

Level of Evidence: Therapeutic study, level IV (case series).

50 consecutive cases of Scaphoid non-union were treated by open reduction and internal fixation. Average age of non-union was 2.8 yrs ranging fron 6 months to 6 years. Most common approach used was volar. Herbert screw was used to fix 48 non-unions while K wires were used in 2 cases. Bone graft was harvested from patient’s iliac crest and was used in nearly all cases. Wrist was immobilised in a plaster for an average duration of 12 weeks post operatively. All the cases were done by a single surgeon and the cases were recorded by an independent observer.

The average follow up was 2 years ranging from 1 year to 6 years. Radiographic union was achieved in 45(80%) cases. Failure of union was seen in 10 cases out of which 5 were proximal pole fractures of which 2 went into avascular necrosis. Denervation of wrist, proximal row carpectomy and four corner fusion was used in 5 cases to salvage the wrist.

This modest study carried out at a district general hospital of South East England suggests that scaphoid bone continues to be a challenge for general orthopaedic surgeon as some of these fractures are missed initially. Open reduction and internal fixation of Scaphoid non-union continues to give a predictable outcome.

Four part (Neer’s) proximal humeral fractures if treated by fixation are prone to develop avascular necrosis of humeral head; requiring further treatment and possible reoperation. This has led to the popularity of hemiarthroplasty as the primary treatment in these fractures. Since the availability of contoured locking compression plate (PHILOS) in our unit, we have treated most of the 4 part proximal humeral fractures by internal fixation. The aim of this study was to assess the usefulness of the PHILOS plate in the treatment of these fractures.

We prospectively reviewed 21 patients (mean age 57 yrs) operated between March 2002 and January 2006 at a level 1 trauma centre, using 3/5 hole PHILOS plate for fixation. An independent observer reviewed them postoperatively at 6 monthly intervals for clinical and radiological assessment. Outcome measures included DASH and Constant score. A SPECT/bone scan was done in appropriate cases.

18 patients were available for follow up, which ranged from 12–66 (average 24.4) months. Recovery of movements and relief in pain was satisfactory in most of the patients with mean Constant score of 63 points (range 37 to 95) and DASH score of 20 points (range 15–78) at last follow up.. We encountered a few complications including non-union (1); implant breakage (1) and impingement (4). Only one patient in our series required hemiarthroplasty; out of two who developed symptomatic avascular necrosis. Patient satisfaction was high in spite of moderate Constant score. Removal of PHILOS plate was difficult in some cases due to problem of cold welding and distortion of screw heads. The broken plate was subjected to biomechanical and metallurgical analysis, which revealed that the plate is inherently weak at the site of failure.

Our series is comparatively small to draw any firm conclusions but we feel that with the availability of better implants, there is a case to consider the fixation rather than arthroplasty as the primary treatment of 4 part proximal humeral fractures.

Level of evidence: Therapeutic study – Level IV (prospective case series)

Percutaneous repair of the ruptured tendo Achillis has a low rate of failure and negligible complications with the wound, but the sural nerve may be damaged.

We reviewed 96 patients who had an acute percutaneous repair done by a single surgeon at district general hospital between January 1998 to April 2004. The mean follow up was 27 months. The repair is carried out using six stab incisions over the posterolateral aspect of the tendon. The procedure can be carried out under local anaesthesia. All patients were put in a below knee cast after the operation. Cast was changed at 4 weeks keeping the foot in plantigrade position. The mean period of immobilization was 8 weeks.

They returned to work at 12 weeks and to sport at 16. One developed a minor wound infection and another complex regional pain syndrome type II. There were 2 injuries to the sural nerve. There were no late reruptures. This technique is simple to undertake and has a low rate of complications. We present one of the largest series reported in literature.