Charalambos Panayiotou Charalambous

Complications associated with open coracoid transfer procedures for shoulder instability

BACKGROUNDnInterest has been maintained in the use of coracoid transfer procedures for recurrent shoulder instability despite the significant potential for serious complications. A comprehensive systematic review of the literature was performed to quantify and characterize the complication rate associated with these procedures to better inform practicing surgeons and their patients.nnnMATERIALS AND METHODSnMedline, Excerpta Medica Database (EMBASE), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for therapeutic studies published between 1985 and 2011. Data regarding complications was extracted from selected articles in a standardized manner. Complication rates were determined and expressed as percentages with 95% confidence intervals.nnnRESULTSnIncluded were 30 studies describing the results of 1658 coracoid transfer procedures. Repeat surgery was documented in 4.9% ± 1.0% of cases. Recurrent instability occurred in 6.0% ± 1.2%. Hardware complications occurred in 6.5% ± 1.3%. Collectively, the rate of graft nonunion, fibrous union, or postoperative graft migration was 10.1% ± 1.6%; graft osteolysis occurred in 1.6% ± 0.7%. There was a 1.2% ± 0.8% rate of nerve palsy. Surgical site infection occurred in 1.5% ± 0.7%. Intraoperative fractures occurred in 1.1 ± 0.6%.nnnCONCLUSIONnCoracoid transfers for shoulder instability can improve shoulder stability with acceptable recurrence rates. They are challenging procedures associated with a broad range and significant incidence of complications. A detailed appreciation of anatomy and meticulous attention to technical detail, particularly graft placement, is key to reducing complications. These procedures may be best indicated in the setting of glenoid or humeral bony deficiency, although efficacy over open capsular procedures remains equivocal.

Posttraumatic Elbow Stiffness

Early posttraumatic elbow contractures may be treated with a combination of manipulation with the patient under anesthesia followed by bracing.Extrinsic contractures of the elbow may be treated with open or arthroscopic release, whereas intrinsic and combined contractures may require tissue release as well as partial or total arthroplasty.

Comminuted radial head fractures: aspects of current management

The radial head articulates with the humerus at the radiocapitellar articulation and with the ulnar sigmoid notch at the proximal radioulnar articulation. The radiocapitellar articulation may transmit up to 60% of loads applied across the elbow, with the greatest force transmission occurring between 0 and 30 . The peripheral part of the radial head that articulates with the sigmoid notch is covered with thick hyaline cartilage, whereas a nonarticulating arc (106 -120 ) is covered by thinner yellowish cartilage. The blood supply of the radial head is tenuous, in most cases via a single extra osseous intracapsular vessel that enters the radial head laterally via its nonarticulating bare area, giving rise to a transversely orientated subarticular plexus. An extra osseous extraarticular ring and intraosseous vessels supply the radial neck but only reach the radial head margin. The fact that the main blood supply is via the peripheral bare area would explain why avascular necrosis is rare after displaced radial neck fractures. It is increasingly understood that the radial head is an important elbow stabilizer, being a major constraint to valgus,posterolateral, axial, andvarus loading.

Metal allergy screening prior to joint arthroplasty and its influence on implant choice: a delphi consensus study amongst orthopaedic arthroplasty surgeons.

Purpose This study was undertaken to obtain a consensus amongst joint arthroplasty experts with regards to metal allergy screening prior to joint arthroplasty and the choice of implant in patients with potential metal allergy. Materials and Methods A web based Delphi consensus study was used including orthopaedic surgeons that had previously published on the topic of knee, hip or shoulder arthroplasty. Two rounds of questionnaires were sent via electronic mail. Consensus was considered reached if agreement was 60% or higher. Results Eighteen surgeons responded to the first and 17 to the second round of questionnaires. There was consensus that patients having metal arthroplasty surgery should not be routinely questioned about metal allergy prior to surgery. There was consensus that patch testing is not necessary even if metal allergy is suspected. Most respondents agreed in proceeding with cobalt chromium or stainless steel implant in patients suspected of metal allergy regardless of the results of cutaneous patch testing. Conclusions This consensus study suggests that routine metal allergy screening prior to joint arthroplasty is not essential. The use of traditional cobalt chromium/stainless steel implants is recommended regardless of the patients metal allergy status based on expert opinion through this study.

Managing and Leading

Managing and leading often form an integral part of a doctor’s daily work life. Apart from managing yourself, your own time and affairs, you may get involved in managing others, your team, your clinic, your department, your hospital or institution. You may manage a process, a project, the rota, the teaching program, the theatre list allocation. You may manage a conflict, a meeting, or manage change.

Graft salvage following infected anterior cruciate ligament reconstruction

AIMSnTo examine the rates of hamstring graft salvage with arthroscopic debridement of infected anterior cruciate ligament (ACL) reconstruction as reported in the literature and discuss functional outcomes.nnnMATERIALS AND METHODSnA search was performed without language restriction on PubMed, EMBASE, Ovid, CINAHL and Cochrane Register of Controlled Trials (CENTRAL) databases from their inception to April 2015. We identified 147 infected hamstring grafts across 16 included studies. Meta-analysis was performed using a random-effects model to estimate the overall graft salvage rate, incorporating two different definitions of graft salvage.nnnRESULTSnThe graft salvage rate was 86% (95% confidence intervals (CI) 73% to 93%; heterogeneity: tau(2) = 1.047, I(2) = 40.51%, Q = 25.2, df = 15, p < 0.001), excluding ACL re-ruptures. Including re-ruptures as failures, the graft salvage rate was 85% (95% CI 76% to 91%; heterogeneity: tau(2)xa0= 0.099, I(2) = 8.15%, Q = 14.15, df = 13, p = 0.36).nnnCONCLUSIONSnArthroscopic debridement combined with antibiotic treatment can lead to successful eradication of infection and graft salvage, with satisfactory functional outcomes in many cases of septic arthritis following ACL reconstruction. Persistent infection despite repeat arthroscopic debridements requires graft removal with the intention of revision ACL surgery at a later stage.nnnTAKE HOME MESSAGEnArthroscopic debridement combined with antibiotic therapy is an appropriate initial approach in most cases of septic arthritis following ACL reconstruction, achieving graft salvage rates of about 85%. Cite this article: Bone Joint J 2016;98-B:608-15.

Metal Hypersensitivity in Patients with Conventional Orthopaedic Implants

Metal implants are widely used in orthopaedic surgery for elective joint arthroplasty or fracture fixation. Metal alloys also are widely used in other medical specialties for devices such as dental implants, cardiovascular stents, and gastrointestinal wire mesh stents. Metal hypersensitivity, as detected with skin patch testing, is common, with a prevalence of between 10% to 17% in the general population1-5. This raises the concern that hypersensitivity reactions may occur in patients with metallic orthopaedic implants and the possibility that metal hypersensitivity reactions may account for ongoing pain or aseptic loosening following joint arthroplasty6,7.nnThe purpose of the present review is to examine the current understanding of metal hypersensitivity and its potential clinical importance in orthopaedic surgery. The methods of testing for metal hypersensitivity and the limitations of such tests are also discussed. In this article, we consider conventional arthroplasty implants (metal-polyethylene and metal-ceramic articulations) and fracture-fixation devices. Coverage of the localized reactions reported in association with metal-on-metal arthroplasty is beyond …

Research and Audit

Research is defined by the Oxford dictionary as “the systematic investigation into and study of materials and sources in order to establish facts and reach new conclusions”. Clinical audit is defined as “a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change”.

Perioperative Care of a Patient with Refractory Idiopathic Thrombocytopenic Purpura Undergoing Total Knee Arthroplasty

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder leading to low platelet count and an increased risk of bleeding. Major joint replacement surgery in a patient with ITP can be associated with severe postoperative bleeding. We present our experience of perioperative management in a patient with severe refractory chronic idiopathic thrombocytopenic purpura who successfully underwent a cemented total knee replacement.

Safety in Surgery

The Institute of Medicine defines patient safety as “the prevention of harm to patients”, that is “avoiding injuries to patients from the care that is intended to help them” [1].