Haroon Rehman

Imaging of occult hip fractures: CT or MRI?

OBJECTIVES Patients presenting with hip pain but normal plain radiographs may ultimately be shown on further investigation to have suffered an occult hip fracture (OHF). This diagnosis can be made with CT or MRI. Traditionally MRI has been considered a superior modality. We performed a retrospective review of all patients presenting to our service with a suspected OHF over a four-year period, investigated with either CT or MRI. DESIGN Retrospective review. SETTING Urban trauma centre. PATIENTS Patients with suspected hip fractures and negative radiographs. INTERVENTION CT or MRI. MAIN OUTCOME MEASURES Detection rate; delay in request for further imaging; delay to theatre; re-presentations with missed fractures. RESULTS A total of 179 patients were investigated, with a mean age of 82±13 years. The ultimate diagnosis was of an OHF in 71 cases and pelvic or acetabular fracture in 34. The average time from presentation plain radiograph to further imaging was 2.0±2.7 days, but was significantly shorter for CT. No patient re-presented with unidentified fractures or other localised hip pathology within a 12-month period. CONCLUSIONS Modern imaging technology does not appear to miss clinically significant fractures. As CT is usually more accessible than MRI, the results of our study should encourage surgeons to consider CT as a first line investigation for occult hip fractures. We advocate a high index of suspicion and early imaging referral for elderly patients presenting with non-specific hip pain following a fall. Level 3 Evidence.

A Review of Minimally Invasive Single-Port/Incision Laparoscopic Appendectomy

INTRODUCTION Single-port/incision laparoscopic appendectomy (SPILA) is a modern advancement toward stealth surgery, using a single point of entry. Despite the paucity of clinical data, it is increasingly being used to minimize scarring and, potentially, pain associated with the multiple entry points. We aimed to summarize and present available data on this new approach. METHODOLOGY All available databases until December 2010 including the Cochrane Controlled Trials Register, MEDLINE, and EMBASE were searched and cross-referenced for studies describing single-incision laparoscopic appendectomy. Case and experimental reports, series with fewer than 5 patients, and non-English articles were excluded. Outcome measures were operative time, postoperative hospital stay, pain scores, complications, conversion, and mortality, stratified according to type of SPILA approach. SPSS version 18.0.0 software was used for data collection. RESULTS Database query yielded 79 articles; 45 were included (1 randomized controlled trial, 44 case series). Total cases were 2806, with mean patient age for studies ranging from 7.0 to 37.5 years. No mortality was reported. The overall complication rate was 4.13%. The overall weighted mean operating time was 41.3 minutes (range, 15.0-95.9 minutes). The weighted mean hospital stay was 2.79 days (range, 1.0-6.6 days). CONCLUSIONS Although the incidence of complications with SPILA remains low and operating times between new and traditional approaches are comparable in case-based literature, adequately powered randomized trials are required to assess its effectiveness. Occurrence of long-term complication types remains unexplored.

Quadriceps tendon repair using hamstring, prolene mesh and autologous conditioned plasma augmentation. A novel technique for repair of chronic quadriceps tendon rupture

BACKGROUND Several techniques have been described for the primary repair of quadriceps tendon ruptures but there is a paucity of literature on operative management of chronic/recurrent quadriceps tendon ruptures. We describe a novel technique for the revision of quadriceps tendon ruptures which uses hamstring, prolene mesh and autologous conditioned plasma augmentation. METHODS Our patient was an independently mobile, active 61 year-old man who sustained staggered, bilateral quadriceps tendon ruptures. He had two failed direct repairs on the left side. The patient was unable to actively extend his knee. On the third attempt, despite maximising quadriceps tendon length using the Codivilla technique the gap remained significant. The left and right semitendinosus and left gracilis tendons were thus harvested and used to augment our repair. A prolene mesh, sized to fit the whole length quadriceps tendon and patella, was then secured to the repair to reinforce it. The repair site was finally injected with autologous conditioned plasma. RESULTS Satisfactory post-operative outcomes were achieved. The patient was pain-free and able to maintain straight leg raise with a 10 degrees extensor lag at his four months review in clinic. CONCLUSIONS We were able to achieve a stable construct with combination of both well-established and novel tendon lengthening techniques, in addition to mesh and biological augmentation. In our experience this surgical procedure is suitable for the treatment of a large tendon gap defect and will withstand high force transmission.

Assessment Following Distal Radius Fractures: A Comparison of 4 Scoring Systems, Visual Numerical Scales, and Objective Measurements.

PURPOSE To compare 4 recognized upper-limb scoring systems that are regularly used to assess wrist function after injury. METHODS We reviewed 116 patients 6 months after volar locking plate fixation for distal radius fractures. Two purely subjective and 2 composite scoring systems composed of both subjective and objective components were compared along with visual numerical scores for pain and function and objective measures of function. Each score was standardized into a scale from 0 to 100. RESULTS The distribution of the standardized total scores was statistically significantly different and indicated marked variability between scoring systems and therefore the information provided. Overall, the subjective scoring systems correlated well with each other and with both visual numerical scores for pain and function. However, the composite scores and objective measures of function correlated poorly with the subjective scores including the visual numerical scores. CONCLUSIONS Results from wrist scoring systems should be interpreted with caution. It is important to ensure that the component parts of each score are taken into consideration separately because total scores may be misleading. CLINICAL RELEVANCE Composite scores may be outdated and should be avoided.

Lesser Trochanter Avulsion Fracture in an Adolescent after Seizure

BACKGROUND Injury secondary to epileptic seizure is widely documented in the literature. In particular, uncontrolled muscular contractions generated during a seizure can lead to a variety of musculoskeletal injuries. CASE REPORT We present the case of a 16-year-old male who presented on two separate occasions after a tonic-clonic seizure with hip pain, an antalgic gait, and marked discomfort on hip flexion. Radiologic investigation revealed an acute isolated fracture of the lesser trochanters. Such fractures in adolescents are normally secondary to athletic injury and in adults are mainly associated with the presence of metastatic bone disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case with its previously undocumented mechanism to highlight the injury to frontline emergency medical teams, create awareness of its presentation, and to discuss its potential mechanism and treatment.

3D-Printed Patient-Specific ACL Femoral Tunnel Guide from MRI

Background: Traditional ACL reconstruction with non-anatomic techniques can demonstrate unsatisfactory long-term outcomes with regards instability and the degenerative knee changes observed with these results. Anatomic ACL reconstruction attempts to closely reproduce the patients individual anatomic characteristics with the aim of restoring knee kinematics, in order to improve patient short and long-term outcomes. We designed an arthroscopic, patient-specific, ACL femoral tunnel guide to aid anatomical placement of the ACL graft within the femoral tunnel. Methods: The guide design was based on MRI scan of the subjects uninjured contralateral knee, identifying the femoral footprint and its anatomical position relative to the borders of the femoral articular cartilage. Image processing software was used to create a 3D computer aided design which was subsequently exported to a 3D-printing service. Results: Transparent acrylic based photopolymer, PA220 plastic and 316L stainless steel patient-specific ACL femoral tunnel guides were created; the models produced were accurate with no statistical difference in size and positioning of the center of the ACL femoral footprint guide to MRI (p=0.344, p=0.189, p=0.233 respectively). The guides aim to provide accurate marking of the starting point of the femoral tunnel in arthroscopic ACL reconstruction. Conclusion: This study serves as a proof of concept for the accurate creation of 3D-printed patient-specific guides for the anatomical placement of the femoral tunnel during ACL reconstruction.

Water-based lubricant as an adjunct to wound toilet: Validation of a technique by experiment

INTRODUCTION Metal debris can produce a foreign body inflammatory reaction or as third body wear in the situation of joint arthroplasty. We evaluate a simple method for reducing this debris using a sterile water-based lubricating gel. MATERIALS AND METHODS Eight experimental surgical models consisting of porcine muscle overlying a polyethylene tube with a titanium locking plate and screws secured were constructed. Four models had water based lubricating gel applied to the wound edges, four were left without as controls. Image were then captured before and after irrigation from which the amount of debris could be quantified. RESULTS The reduction of surface area covered by debris for models with water-based gel was greater (p=0.001). The average reduction in surface area was 27.2% for the control group and 94.1% for the models covered with lubricating gel. CONCLUSION We show that using a safe, inexpensive and easily available water-based lubricating gel reduces the amount of embedded debris when burring metal implants using a high-speed burr.

A novel and effortless technique for application of lower limb backslabs

Backslabs are used widely throughout trauma and orthopaedic practice and its some of its sister specialties. Amongst their functions, backslabs are used to great effect for soft tissue trauma and fracture care as they accommodate for swelling [1,2]. Applying lower limb backslabs with wet plaster, in an acute setting with untrained personnel can be challenging. Traditional teaching of backslab application involves the assembly of two or three large pieces of plaster (the medial and lateral walls ‘‘u’’ and posterior slab ‘‘j’’) around the posterior, medial and lateral aspects of the leg [3]. The traditional technique requires dexterity from both clinician and the assistant(s). An ill-timed procedure can result in the plaster setting early and compromise of the limb or fracture position prepared for immobilisation. This may be especially frustrating in cases where fracture manipulation has been performed under anaesthetic. Possible solutions include split casts or application of plaster on a prone limb. We describe a novel, user-friendly technique for applying an effective lower limb backslab.

The athlete biological passport: ticket to a fair commonwealth games

In summer 2014, the world watched as Glasgow hosted the 2014 Commonwealth Games and athletes pushed the boundaries of human performance. Sport has developed into a multi-billion pound industry leading to the development of a ‘win at any cost’ mentality in some individuals. The abuse of performance-enhancing drugs has developed into a sophisticated arms race between those unfairly enhancing performance and those wishing to preserve the dignity of sport and the health of the competitors. The challenge for the Commonwealth games organising committee was to ensure that competition remained fair and that athletes were kept safe. The athlete biological passport is a system implemented by the World Anti-Doping Agency directed towards enhancing the identification of those athletes accountable for the misuse of performance-enhancing substances. This article exemplifies which drugs are currently being exploited and how the athlete biological passport has evolved to improve their detection.

Fabella Syndrome Following De-Rotation Surgery to Correct a Femoral Malunion

Background: The fabella is a sesamoid bone situated within the lateral head of the gastrocnemius tendon, close to the lateral femoral condyle, and adjoined to the fabellofibular ligament. It is a normal variant, found in up to 87% of patients. Fabella Syndrome describes traditionally posterolateral knee pain, occurring due to biomechanical pressure of the fabella against the lateral femoral condyle. Given its rarity, its diagnosis is often overlooked. We present a case of Fabella Syndrome with a modified surgical excision technique and review of the literature. Methods and Results: A thirty-four-year-old man presented with posterolateral knee pain following de-rotation surgery to correct a femoral malunion, from a previous femoral shaft fracture. Due to the patient’s complex orthopaedic history, Fabella Syndrome was not initially diagnosed. Fabellectomy eliminated all symptoms of knee pain, with no limitations in knee function. Conclusion: Review of the literature identified ten publications (evidence level IV) describing Fabella Syndrome. This is the first reported case of Fabella Syndrome secondary to femoral de-rotation surgery. The authors recommend fabellectomy as a definitive treatment for Fabella Syndrome, in keeping with published literature.