Hk Sharma

Efficacy of Hylan G-F 20 and Sodium Hyaluronate in the treatment of osteoarthritis of the knee -- a prospective randomized clinical trial.

In this independent prospective randomized trial, we compared the clinical effectiveness, functional outcome and patient satisfaction following intra articular injection with two viscosupplementation agents - Hylan G-F-20 (n=199) and Sodium Hyaluronate (n=193) in patients with osteoarthritis (OA) of the knee. All patients were prospectively reviewed by blinded independent assessors at pre injection, 6 weeks, 3, 6, 12 months. Knee pain and patient satisfaction were measured on a visual analogue scale. Functional outcome was assessed using WOMAC, Oxford knee score and EuroQol EQ-5D scores. Knee pain on VAS improved from 6.7 to 3.2 by 6 weeks (p=0.02) and was sustained until 12 months (3.7, p=0.04) with Hylan G-F 20. In the Sodium Hyaluronate group, pain improved from 6.6 to 5.7 at 6 weeks (p>0.05) and to 4.1 at 3 months (p=0.04) but was sustained only until 6 months (5.9, p>0.05). Improvement in the WOMAC pain subscale was significantly superior in the Hylan G-F 20 group at 3 months (p=0.02), 6 months (p=0.01) and 12 months (p=0.007). There was no significant difference in the EQ-5D scores at 6 weeks and 3 months between the two groups. The numbers of treatment related adverse events were higher (39 vs. 30) in the Hylan G-F 20 group. One patient in the Hylan G-F 20 group who had a serious adverse event was also included in the final analysis. Although both treatments offered significant pain reduction, it was achieved earlier and sustained for a longer period with Hylan G-F 20. From this study, it appeared that the clinical effectiveness and general patient satisfaction are better amongst patients who received Hylan G-F 20.

The Birmingham Hip Resurfacing Prosthesis : An Independent Single Surgeon's Experience at 7-Year Follow-Up

An independent single surgeons 7-year experience with Birmingham hip resurfacing is presented. The study also involved investigation of the significance of pedestal sign in patients requiring revision. A consecutive 117 hips in 101 patients (59 male and 42 female patients) operated on by the senior author (VGJ) were assessed at a mean follow-up of 7 years (range, 5-9.4 years). Mean age at surgery was 54 years (range, 20-74 years). Seventy-three hips had a preoperative diagnosis of primary osteoarthritis, and secondary osteoarthritis was seen in 44 hips. Failure was defined as revision for any reason. Revision of the femoral component alone was undertaken in 8 hips (6.8%): 5 within first year for periprosthetic fracture neck of femur and in 3 hips after 5 years of follow-up. In 2 patients who were known to have osteonecrosis of the femoral head preoperatively, the femoral component progressively collapsed into varus after 5 years of follow-up. Pedestal sign was the earliest radiologic sign noted in these 2 patients and progressed rapidly within 1 year on serial radiographs well before the onset of clinical symptoms. Kaplan-Meier survival with revision as end point at 7 years was 91.5% (95% confidence interval, 97.6%-85.4%).

Do We Need Radiological Guidance for Intra-Articular Hip Injections?

There is still a debate as to whether radiological guidance is needed for intra-articular hip injections. The aim of this study was to evaluate correct needle positioning for the hip joint performed with a non-radiological method and confirmed on arthrogram under image intensifier. Patients listed for diagnostic and therapeutic hip joint injections were included in our study. Eighty seven patients (100 hips) underwent injections with the non-radiological method using anatomical landmarks. Fluoroscopy and arthrogram were then used to confirm the needle position. The primary outcome measure was the success rate of correct positioning of the needle in hip joint by the non-radiological method, as confirmed on arthrogram under image intensifier. The secondary outcome measures were relationship between the grade of the surgeon and patient BMI to success rate of hip injections by the non-radiological method. Overall success rate with the non-radiological method was 67%. Consultants were 77.1% successful and registrars 57.7% (P = 0.039). The average body mass index (BMI) in the successful group was 28.45 (SD = 5.21) and 32.03 (SD = 4.84) in the unsuccessful group (p=0.001). Success was further improved to 88% when performed by a consultant in low BMI (< 30) patients. This prospective study shows that hip injections can be performed with reasonable success without radiological guidance. Experienced surgeons may be able to perform this procedure in outpatient clinics in normal BMI patients; thereby reducing costs and the need for bed space.

Functional outcomes after tibial shaft fractures treated using the Taylor spatial frame.

Objectives: To analyze functional and radiologic outcomes of tibial shaft fractures treated with the Taylor spatial frame (TSF). Design: Prospective follow-up study of radiologic and functional outcomes. Setting: University teaching hospital. Patients: From January 2006 to December 2012, prospective data were collected for 56 consecutive patients completing treatment of a tibial shaft fracture with the TSF. Intervention: Treatment of tibial shaft fractures, including those with simple extension into the knee or ankle joints, using the TSF. Main Outcome Measurements: Residual deformity on x-ray and functional outcomes using the EQ-5D health status questionnaire, Iowa Knee and Ankle Evaluation Rating System scores, and Olerud and Molander Ankle score were recorded 1 year after frame removal. Results: Average residual deformity was 1.8 degrees in the coronal and 1.6 degrees in the sagittal planes. EQ-5D outcomes showed patients returning to a health status no different from scores for the UK population as a whole. Iowa Knee scores demonstrated “good” or “excellent” outcomes in 87.3% of our cohort (mean, 90). Ankle Evaluation Rating System scores and Olerud and Molander Ankle scores showed “good” or “excellent” outcomes in 76.8% and 89.3% of our cohort, respectively (mean, 84.1 and 84). Conclusions: Use of the TSF for treatment of tibial fractures, with support from a dedicated limb reconstruction rehabilitation team, has a number of technical advantages while producing good functional and surgical outcomes, with patients recovering to a pre-injury health status. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature.

We report on the surgical and functional outcome of 22 patients with Grade 3 open tibial fractures treated with circular frame. All cases united and there were no re-fractures or amputations. All patients were assessed at a minimum of 1-year post frame removal. Assessment included clinical examination, IOWA ankle and knee scores, Olerud and Molander ankle score and EuroQol EQ-5D. Clinical scores were either good or excellent in over half of the patients in all knee and ankle scores. There was a significant positive correlation between functional outcomes and the EQ-5D score. The EQ-5D mean health state visual analogue score was comparable to the general UK population despite patients scoring less than the average UK population in three of the five domains. 36% reported some difficulties in walking and 41% had problems with pain. 14% had difficulties with self-care and 46% had difficulties with their usual activities. 14% had problems with anxiety or depression. Systematic review of the literature suggests, in the management of open tibial fractures, circular frames provide equivalent or superior surgical outcomes in comparison with other techniques. Our study finds the application of a circular frame also results in a good functional outcome in the majority of cases.

Cadaveric analysis of capsular attachments of the distal femur related to pin and wire placement

OBJECTIVES Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices inserted in the lower extremity [1,2]. The authors were unable to find reference to or exact measurements of the capsular attachments relating to the distal femur documented in the current literature. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires or traction devices. METHODS The attachments of the capsule to the distal femur were measured in 10 unembalmed cadaveric knees. Capsular attachments were measured anteriorly at the maximal extension of the supra-patella pouch. Medially and laterally measurements were expressed as percentages related to the maximal AP diameter of the distal femur. RESULTS Mean distance from the centre of the anterior part of the notch to the superior fold was 79.5mm (Range 48.1-120.7 mm). The medial capsular reflections measured in a plane from the adductor tubercle to the anterior edge of the medial femoral condyle demonstrated the capsular reflection was attached an average of 57% back from the anterior edge (Range 41-74%). Laterally the capsular reflections on a line drawn from the maximal diameter in the sagittal plane were attached an average of 48% from the anterior reference point (Range 33-57%). Measuring the reflections at 45 degrees to the long axis of the femur in the sagittal plane the attachment was an average of 51% from the anterior reference point. CONCLUSIONS Capsular reflections varied among specimens. Medially the capsule attachment was up to 74% of diameter of distal femur at the level of the adductor tubercle. Therefore, the insertion of distal femoral traction pins or similar should be placed proximal to the adductor tubercle and no further than 25% of the distance to the anterior cortex. Care is also needed to ensure pins do not travel to exit too anteriorly on the lateral side as capsular attachments were found to be up to a distance 48% of the diameter of the femur from anterior reference point. Distal condylar extra-articular fixation with Schanz screws is feasible if orientated in the oblique plane.

Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame

The closure of small-to-moderate-sized soft tissue defects in open tibial fractures can be successfully achieved with acute bony shortening. In some instances, it may be possible to close soft tissue envelope defects by preserving length and intentionally creating a deformity of the limb. As the soft tissue is now able to close, this manoeuvre converts an open IIIb to IIIa fracture. This obviates the need for soft tissue reconstructive procedures such as flaps and grafts, which have the potential to cause donor-site morbidity and may fail. In this article, the authors demonstrate the technique for treating anterior medial soft tissue defects by deforming the bone at the fracture site, permitting temporary malalignment and closure of the wound. After healing of the envelope, the malalignment is gradually corrected with the use of the Taylor Spatial Frame. We present two such cases and discuss the technical indications and challenges of managing such cases.

Cost implications of the physiotherapy management of complex tibial fractures treated with circular frames

Seventy-three consecutive patients with complex tibial fractures treated with an Ilizarov frame or Taylor Spatial Frame received physiotherapy between April 2008 and April 2010. Data were collected prospectively, and physiotherapy input was recorded (in minutes) for the patients identified. This included treatment received as an inpatient as well as an outpatient. The data were categorized for proximal, middle and distal third tibial fractures for analysis. The average cost of physiotherapy for an inpatient with an Ilizarov frame is £121.82 per case, whereas that for an outpatient receiving treatment for trauma was calculated as £404.60. The combined average cost of physiotherapy to support treatment of a complex tibial fracture with a fine wire fixator is £546.27. Treatment involving circular frames is complex and expensive, and the high physiotherapy cost is not reflected in Healthcare Resource Group codes. This cost calculation will help service units, and NHS Trusts develop realistic costing plans to support treatment. Cost implications of the physiotherapy management of complex tibial fractures using the Ilizarov technique.

The use of a spirit-level to improve radiograph quality in ring fixators

The use of ring fixators in lower limb reconstruction and deformity correction both for trauma and elective procedures is now widespread. The long course of treatment requires regular outpatient review with frequent radiological imaging to assess the progression of treatment and plan correctional adjustment. Following publication of a technique using a frame mounted spirit-level to aid radiographers in accurately aligning the limb for optimal imaging we implemented a similar technique in our department and carried out a two part prospective comparative study to assess the impact on radiograph quality. Comparison was made of radiograph quality, X-rays taken, patient trips to the radiology department and X-ray exposure before and after implementation of the spirit-level guide technique in patients attending an out-patient clinic for routine follow up following ring fixator application. 26 patients were included in the control arm and 33 in the intervention group. On review, 42.3% of patients in the control group were deemed to have had suboptimal imaging compared with only 9.1% of those imaged using the spirit-level guide, a statistically significant improvement. When comparing total numbers of images taken for each group to achieve the requested number of adequate views there was less statistical significance, nor was there a statistically significant difference in radiation dose between the groups. A significant reduction in the number of inadequate images being taken, with a subsequent reduction in patients requiring return to the radiology department for re-imaging and then re-review in clinic, has clear implications for patients, clinicians and hospital efficiency. The patient journey time is reduced, less time and fewer resources are used in the radiology department and patients in clinic are seen more efficiently and with less wasted time. We conclude that the implementation of a simple frame mounted spirit-level as a guide for radiographers in the outpatient clinic significantly reduces the number of suboptimal and wasted images taken in the assessment of patients being treated by ring fixator.

Symptomatic venous thromboembolism following circular frame treatment for tibial fractures

INTRODUCTION Venous thromboembolism (VTE) is a significant cause of morbidity and mortality following tibial fractures. The risk is as high as 77% without prophylaxis and around 10% with prophylaxis. Within the current literature there are no figures reported specifically for those individuals treated with circular frames. Our aim was to evaluate the VTE incidence within a single surgeon series and to evaluate potential risk factors. METHODS We retrospectively reviewed our consecutive single surgeon series of 177 patients admitted to a major trauma unit with tibial fractures. All patients received standardised care, including chemical thromboprophylaxis within 24h of injury until independent mobility was achieved. We comprehensively reviewed our prospective database and medical records looking at demographics and potential risk factors. RESULTS Seven patients (4.0% ± 2.87%) developed symptomatic VTE during the course of frame treatment; three deep vein thrombosis (DVTs) and four pulmonary embolisms (PEs). Those with a VTE event had significantly increased body mass index (BMI) (p = 0.01) when compared to those without symptomatic VTE. No differences (p > 0.05) were observed between the groups in age, gender, smoking status, fracture type (anatomical allocation or open/closed), delay to frame treatment, weight bearing status post-frame, inpatient stay or total duration of frame treatment. CONCLUSION This study suggests that increased BMI is a statistically significant risk factor for VTE, as reported in current literature. In addition, we calculated the true risk of VTE following circular frame treatment for tibial fracture in our series is from 1.13% to 6.87%, which is at least comparable to other forms of treatment.