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Orthopaedic Proceedings
Vol. 91-B, Issue SUPP_I | Pages 74 - 74
1 Mar 2009
Rafee A Rajasekhar C Saeed Z Jalgaoankar A Shah S Paul A
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Background: The standard diagnostic approach in patients suspected of having pulmonary embolism starts with D-dimer and perfusion-ventilation lung scanning. If the resulting scan is not diagnostic, pulmonary angiography will perform.

Aims: This study evaluates the effectiveness of D-dimer as a screening tool for Pulmonary Embolism (PE) and to determine the accuracy and potential clinical utility of VQ scan in the diagnosis of pulmonary embolism in orthopaedic trauma patient.

Methods: We retrospectively reviewed 757 consecutive trauma admissions involving lower extremity and spinal injuries over 12 months and identified 20 patients with symptoms mimicking PE, without typical clinical symptoms, which underwent rotten investigations for PE (ABG, Blood test, D dimer, Chest X-ray and VQ scan).

Plasma D-dimer levels were measured as a prerequisite test in all patients before undergoing VQ scan to confirm the absence of PE. All patients had either mechanical, such as foot pumps, or chemical DVT prophylaxis.

Results: The mean age was 65 (ranging from 45–88) years, there were 11 female and 9 male. D-dimer levels in the postoperative or post traumatic period were elevated. Mean value was 3.63 (sd=2.72, range 0.60–14.34), Comparing D-dimer levels between those treated operatively (14 patients) and those treated conservatively (6 patients) we found that both groups displayed the same trend; however levels were higher following surgery.

The classical triad of dyspnoea, pleuritic chest pain and haemoptysis occurred in only 2 patients. Signs of DVT were present in 3 patients. The electrocardiographs were normal in only 4 patients, though changes particularly suggestive of PE (S1Q3T3, Right bundle branch block or right heart strains) were absent in all of the patients. Chest X-ray changes were of limited value. None showed any of the supposedly characteristic changes.

All of the patients had a VQ scan were started on chemical treatment for PE and non of them had definite PE, 12 the patients had probable PE Those patient with probable scan were not subsequently given anticoagulants owing to their medical conditions

Conclusion: The D-dimer level is never normal (< 0.5mg/l), following total trauma, and so cannot exclude a DVT or PE. The level it raises to is indistinguishable form that seen in the population with a PE and so cannot identify those patients in whom further investigation is warranted. VQ scan is not a definitive diagnosis we should rely more and more on a CT Angiography scan for the diagnosis of PE in this group of patients. This should be organised by medical team, especially with shortening of training time, to avoid wasting of resources and time which are of paramount. Requesting a D-dimer test in this population wastes time and resources and is of no benefit


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_I | Pages 17 - 17
1 Mar 2008
Rajasekhar C Das S Smith A
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We report the outcome of 135 knees with medial compartment osteoarthritis treated by Oxford meniscal-bearing unicompartmental arthroplasty. They have been performed in a Distict General hospital by a single surgeon. All the knees had an intact anterior cruciate ligament, a correctable varus deformity and the lateral compartment was uninvolved or had minor osteoarthritic changes. At review 29 knees were in patients who had died and 106 were in those who were still living. The mean elapsed time since operation was 5.82 years (range 2–12 yrs).

Using revision as the end point the outcome for every knee was established. Five knees have been revised, giving a cumulative prosthetic survival rate at ten years of 94.04% (95% confidence interval 84.0 to 97.8). The causes for revision were aseptic loosening in three, progressive valgus deformity in one and dislocation of the bearing in one. Knee rating and patient function were assessed using the modified Knee Society Scoring system. The mean Knee score was 92.2 (51–100), and mean Functional score was 76.2 (51–100). 90% of the patients did not require blood transfusion. Two patients had deep vein thrombosis and three knees had superficial wound infection that responded to antibiotics. Intraoperatively, one patient had fracture of the proximal tibia which was fixed with two partially threaded cancellous screws.

92% of patients were fully satisfied with the procedure and 91% of them said that they would undergo a similar procedure in the opposite knee.

The implant survival is comparable to that reported by the designers of the prosthesis and not significantly different from those for total knee replacement. Uni-compartmental knee replacement with all its advantages offers a viable alternative in patients with medial gonarthrosis. Appropriate patient selection and good surgical technique are the key factors.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_II | Pages 154 - 154
1 Apr 2005
Higgins G Rajasekhar C Hirst P
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To evaluate the functional outcome after anterior cruciate ligament reconstruction using bioabsorbable femoral cross-pin fixation

30 patients with chronic anterior cruciate ligament deficiency, treated by arthroscopic reconstruction using hamstring tendon autograft have been reviewed. 3.3mm bioabsorbable (polylactic acid) cross-pins (Rigidfix, Ethicon) were used for graft fixation in the femoral tunnel. Outcome assessment was performed using Lysholm score,Tegner activity level, KT-1000 Arthrometer laxity measurements, single legged hop test and SF-36 evaluation. There were 20 male and 10 female patients with an age between 17 and 45 years(mean 25.1 yrs).The mean follow up was 20.3 months (range12–29 months). The mean Tegner score was 5.5 with a range of 3 to 7. Lysholm scores averaged 88.27 with a range of 74 to 100. The range of movement in the operated knee was comparable to that in normal knee. The single legged hop was 93.4% of the unoperated side. The average KT-1000 side to side difference was 3.2 mm using a 30 lb force and 3.5mm on manual maximal load.

Biabsorbable femoral cross-pin fixation offers a viable and safe method of graft fixation in anterior cruciate ligament reconstruction and yeilds a satisfactory functional outcome.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_I | Pages 6 - 6
1 Mar 2005
Rajasekhar C Paul A Bale R Stringfellow H
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Liposarcoma is the most common soft tissue sarcoma accounting for 20% of all mesenchymal malignancies.We report a rare histological variant arising from the dorsum of the foot. A 55 year old lady presented with a slow growing, well defined swelling on the dorsum of the foot. Histological examination following complete excision showed a tumor with zones of dense collagenous tissue containing pleomorphic spindle cells and scattered atypical adipocytes. A diagnosis of spindle cell sarcoma was made and referred to the local Sarcoma unit. Repeat excision and histology confirmed margins free of tumor. Four years after primary excision, patient is well with no evidence of recurrence or metastasis.

Spindle cell liposarcoma is a rare variant of well differentiated liposarcoma characterized by prominent spindle cell component. Previously reported cases originated in the subcutaneous tissues of shoulder girdle and upper limb. Main differential diagnoses include benign lesions such as spindle cell lipoma, and diffuse neurofibroma as well as dermatofibrosarcoma pro-tuberans and other malignancies such as sclerosing liposarcoma, myxofibrosarcoma, malignant peripheral nerve sheath tumor and fibromyxoid sarcoma. Spindle cell Liposarcomas tend to recur locally and may dedifferentiate with a potential for metastasis. Wide excision and long term follow up looking for recurrence and metastasis is necesssary in these rare variants of liposarcoma especially those arising at atypical sites as in our case.


The Journal of Bone & Joint Surgery British Volume
Vol. 86-B, Issue 7 | Pages 983 - 985
1 Sep 2004
Rajasekhar C Das S Smith A

We report the outcome of 135 knees with anteromedial osteoarthritis in which the Oxford meniscal-bearing unicompartmental arthroplasty was inserted in a district general hospital by a single surgeon. All the knees had an intact anterior cruciate ligament, a correctable varus deformity and the lateral compartment was uninvolved or had only minor osteoarthritis. The mean follow-up was 5.82 years (2 to 12).

Using revision as the end-point, the outcome for every knee was established. Five knees have been revised giving a cumulative rate of survival of the prosthesis at ten years of 94.04% (95% confidence interval 84.0 to 97.8). Knee rating and patient function were assessed using the modified Knee Society scoring system. The mean knee score was 92.2 (51 to 100) and the mean functional score 76.2 (51 to 100).

The survival of the implant is comparable to that reported by the designers of the prosthesis and not significantly different from that for total knee replacement. Unicompartmental knee replacement offers a viable alternative in patients with medial osteoarthritis. Appropriate selection of patients and good surgical technique are the key factors.


Orthopaedic Proceedings
Vol. 86-B, Issue SUPP_III | Pages 291 - 292
1 Mar 2004
Rajasekhar C Das S Smith A
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Aims: To evaluate the outcome of 135 Oxford Unicompartmental Knee replacements with regards to knee function and implant survival. Methods: 135 Oxford unicompartmental knee replacements were performed by a single surgeon between 1989–2000. Indication was anteromedial knee osteoarthritis with a correctable varus deformity and intact anterior cruciate ligament. The patients were evaluated in clinic both clinically & radiologically. Modiþed Knee Society Score was used to evaluate knee function. X-rays were performed to look for implant loosening and progression of arthritis. Results: 29 patients died and 5 were too ill to attend clinic. A total of 5 revisions were carried out. There were 53 male and 43 females. 74% patients were betweem 60 Ð 80 yrs. Follow up ranged from 1–11 yrs with a mean follow up of 5.2 yrs. 88% patients had range of movement of more than 105 degrees. The mean Total Knee Score was 92 and the mean functional knee score was 76. Blood transfusion was not necessary in 90% of patients. Superþcial wound infection was noted in 2 cases and hematoma formation in 4 cases. Tibial component loosening was the cause for revision. Conclusions: 1. With appropriate patient selection Oxford unicompartmental knee is a reliable treatment option for anteromedial osteoarthritis of the knee. 2. It offers long term relief of symptoms and good knee function in a high percentage of cases. 3. Implant survival is comparable to total knee replacement and to the series reported by the designers.