Jeganath Krishnan

Shoulder impingement syndrome: Preoperative health status

Eighty-one patients with chronic shoulder impingement resistant to conservative treatment completed a generic quality-of-life questionnaire (SF-36) and shoulder-specific questionnaire (Simple Shoulder Test [SST]). SF-36 data were compared with those of an Australian normative data set. Patients with chronic shoulder impingement were found to be significantly lower in all health dimensions of the SF-36 than the normal population. Results from the SST test indicated that patients were functionally very limited, particularly in being unable to work full time at their usual job and being unable to lift a weight above the head. Our results indicate that chronic shoulder impingement results in significant functional disability and a reduction in quality of life. Baseline descriptive data of this nature are important, because they provide a point of comparison for the effect of different conditions and for determining the effect of surgical treatment.

Intra-articular fractures of the distal radius: a prospective randomised controlled trial comparing static bridging and dynamic non-bridging external fixation.

This prospective randomized trial compared a non-bridging external fixator with a bridging external fixator system for the treatment of severe comminuted intra-articular fractures of the distal radius. The results did not demonstrate a statistically significant difference in the radiological and clinical outcomes achieved with these two treatments.

Intraarticular Fractures of the Distal Radius Treated with Metaphyseal External Fixation Early clinical results

Twenty-two patients with unstable Frykman grade 7 or 8 intra-articular fractures of the distal radius were treated with an external fixator. The distal pins were inserted into the distal radial fracture fragments, permitting movement of the wrist and hand. Eleven patients were male and 11 female, with a mean age of 50 years. All patients had regained full function with good range of motion at mean final follow-up of 12 months. However function, pain and range of motion had returned to acceptable levels 4 weeks after removal of the external fixator. This method of external fixation provides a reliable method of maintaining fracture reduction whilst allowing early return of function.

Frequent isolation of Propionibacterium acnes from the shoulder dermis despite skin preparation and prophylactic antibiotics

BACKGROUND In vitro, Propionibacterium acnes (P acnes) is highly susceptible to commonly used antibiotics and antiseptics, yet in vivo, it still causes postsurgical infections of the shoulder. We hypothesized that the local environment within the pilosebaceous glands protects P acnes and that incision of the skin transects these glands, exposing viable P acnes to the wound. METHODS Fifty consecutive patients undergoing open shoulder surgery were prospectively studied. Prophylactic antibiotics were administered to all patients. Microbiologic swabs of the skin surface were taken before and after skin preparation with 70% alcoholic chlorhexidine. The skin was incised, and a further swab and dermal biopsy specimen were taken. RESULTS P acnes was cultured in 21 of 50 prepreparation skin surface swabs (42%), 7 of 50 postpreparation skin surface swabs (14%), 26 of 50 dermal swabs (52%), and 20 of 50 dermal biopsy specimens (40%). There was a significantly higher incidence of P acnes growth from the skin surface (P = .009) and dermis (P = .01) of patients aged ≤50 years old and in the dermal biopsy specimens of patients undergoing revision surgery (P = .01) and a trend toward increased incidence of P acnes in men. P acnes growth from a prepreparation skin surface swab had a sensitivity of 69%, specificity of 88%, positive predictive value of 86%, and negative predictive value of 72% at predicting subsequent P acnes growth from the dermal swab or biopsy specimen. CONCLUSIONS Viable P acnes persists within the skin dermis, despite standard antimicrobial precautions. These findings suggest that incising the skin is likely to lead to deep seeding of the surgical wound, which has implications for the pathogenesis and prevention of postsurgical shoulder infections.

Number, incidence and projections of distal forearm fractures admitted to hospital in Australia

BACKGROUND This study documents the number, incidence, and relative risk (RR) of distal forearm fractures requiring admission to hospital in Australia in 1997 and estimates of the projected numbers for 2021. METHODS Distal forearm fracture numbers from 1993 to 1998 were obtained. The incidence and RR were calculated by gender and 5-year age groups for 1997. Projected numbers for 2021 were estimated using population projection data. RESULTS In 1997, fracture numbers were 12357 for male patients and 19319 for female patients. The incidence was 152 per 100000 for male patients and 157 per 100000 for female patients. The highest incidence and RR was in the 10- to 14-year age group for male patients and in the 85 years and over age group for female patients. If fracture incidence remains constant (on the basis of predicted population changes in Australia), by 2021, it is estimated that fracture numbers for people 50 years of age and over will increase by 81%, compared with 11% for people under 50. In the older age group, the number for women will be 4.7 times higher than for men. CONCLUSION This study quantifies the potential disproportionate increase in distal forearm fractures requiring admission in Australia, particularly for female patients, because of an aging population.

Cement Penetration and Stiffness of the Cement-Bone Composite in the Proximal Tibia in a Porcine Model

Purpose. To assess the stiffness of the cement bone composite and the depth and uniformity of cement penetration into the surface of the tibial component during total knee reconstruction in a porcine model. Methods. The effectiveness of 3 protocols were compared: 2 commonly used cementing techniques—finger-packing of cement on the cut surface followed by impaction, and coating of the undersurface of the prosthesis with cement followed by impaction—and a new method using a tibial cement-pressurising device. Cement penetration was measured by computed tomography; stiffness was determined by hydraulic penetration testing. Results. Cement penetration at a depth of 1 mm was significantly greater following coating the undersurface of the prosthesis than following finger-packing (p=0.008). There was no significant difference at deeper levels or between the tibial-pressurising device group and either of the 2 other groups at any level (p>0.3 in all cases). Differences in surface stiffness by tibial plateau region were found in tibiae that had been cemented using finger-packing and in those that had had their undersurface coated, but not in tibiae that had been cemented using the tibial-pressurising device. Conclusion. The tibial cement-pressurising device eliminated regional differences in stiffness seen with other cementing methods. Elimination of these differences by using this device should reduce micromotion and the incidence of aseptic loosening of tibial base plates in total knee arthroplasty.

Passive Axial Rotation of the Metacarpophalangeal Joint

We measured passive axial rotation at the metacarpophalangeal (MCP) joints of the index, long, ring and small fingers of both hands in 100 healthy subjects using a magnetic position and orientation system called an Isotrak. Large degrees of passive rotation were found, with the ring and small finger MCP joints displaying significantly greater ranges of supination than the other two joints. Supination ranges were also found to be significantly greater than the pronation values in each joint. These results support present anatomical understanding that, during prehensile activities, axial rotation of the MCP joints occurs to allow the hand to adapt to an object being held.

Local osteopenia associated with management of intra-articular distal radial fractures by insertion of external fixation pins in the distal fragment: prospective study.

Purpose. To assess the restoration of the bone mass of the distal radius following the use of implants in the distal radial fragment. Highly comminuted Frykman type 7 and 8 fractures were studied to determine whether the use of fixation pins in the comminuted distal radial fragment leads to osteopenia in the distal radial fragment after healing of the fracture. Methods. As part of a clinical trial, 30 patients with comminuted intra-articular fractures of the distal radius were treated with closed reduction, external non-bridging fixation, and early postoperative mobilisation. To detect local osteopenia, bone density measurements were taken at the distal metaphysis and mid-diaphysis following healing of the fractured radius and the contralateral unaffected radius in 12 patients. Results. The mean age of the 12 patients for whom bone density measurements were recorded was 52.5 years (range, 39–87 years). There were 9 females and 3 males included in the study. Seven patients had a Frykman type 8 fracture and 5 patients had a Frykman type 7 fracture. Significant osteopenia was absent despite the use of four 2.5-mm fixation pins in the distal fragments of the healed distal radial fracture. The median value of the maximal step was 2.8mm (range, 0–9.1mm). The median value of the intra-articular interfragmentary gap was 1.8 mm (range, 0–13.4mm). Conclusion. The findings of this study do not suggest long-term osteopenia following the use of four 2.5-mm pins in the distal fragments. The non-bridging fixator, by allowing early physical activity, possibly led to satisfactory functional and structural results.

Disseminated synovial chondromatosis of the knee treated by open radical synovectomy using combined anterior and posterior approaches.

Synovial chondromatosis of the knee is a rare benign neoplasm of the synovium. Likewise, uncertainty on management still prevails. Though rare, it nevertheless warrants greater emphasis than it receives in the literature to allow correct diagnosis and accurate early surgical intervention. It predominantly involves the anterior compartment of the knee and disseminated disease is extremely rare. The optimal approach for surgical treatment of such an extensive synovial chondromatosis of knee remains unclear. Herein, we describe a case of extensive generalized synovial chondromatosis of the knee extending into the Bakers cyst in a 30 years old female. A diagnosis of synovial chondromatosis was made by clinical evaluation and MR imaging and confirmed by histopathological examination. Patient was successfully treated by open radical synovectomy of knee using both anterior and posterior approaches in a single step procedure.

Shoulder impingement syndrome: a systematic review of clinical trial participant selection criteria

Background Shoulder impingement syndrome (SIS) is a common diagnosis for patients with pain and dysfunction of the shoulder. Variations in the signs and symptoms might lead to uncertainty regarding the definition of SIS. The aim of this review is to explore the participant selection criteria used in the literature when investigating SIS and to assess differences in criteria among treating professions. Methods This is a PRISMA systematic review of publications from 2009 to 2014 from MEDLINE, PubMed, The Cochrane Library, Embase, Scopus and CINAHL. Results Ninety-seven articles met inclusion criteria for this review. Twenty-five different surgical and nonsurgical treatments were investigated. Impingement-specific index tests were used in all studies. Exclusion index tests were used in 62% of studies. Twenty index tests were identified. Radiological investigations were reported in 53% of all studies, of which a further 53% reported using two or more radiological investigations. Conclusions This systematic review has illustrated that studies investigating SIS test for various signs and symptoms, which is in keeping with describing the condition as a ‘syndrome’. However, there are inconsistencies in participant selection criteria between health disciplines, highlighting a need for harmonization of the selection criteria in the form of an international editorial consensus.