John P. McElwain

Outcomes following quadriceps tendon ruptures

Complete rupture of the quadriceps femoris tendon is a well-described injury. There is a scarcity of literature relating to the outcome of patients with this injury after surgery. We undertook a retrospective analysis of patients who had surgical repair of their ruptured quadriceps tendon at our institution over a seven year period-totalling 27 patients. Males were more commonly affected with a M:F ratio of 8:1. The peak incidence was in the sixth decade of life. The non-dominant limb was twice as likely to be affected. Assessment consisted of completion of a functional knee questionnaire, clinical examination and isokinetic testing on a Biodex dynanometer. Symptomatic outcome following surgical repair was excellent with a mean symptom score generated of 22.7 out of a maximum of 25. 18/19 patients returned to their premorbid level of activity on average 18.1 weeks following injury. There was no difference in quadriceps girth comparing affected and unaffected limbs. Less than 5 degrees deficit in range of motion existed between affected and unaffected limbs. Approximately two-thirds of patients were the same or better when comparing peak torque/body weight, average power, maximum average peak torque and total work/body weight in affected and unaffected limbs.

Clavicle hook plate fixation for displaced lateral-third clavicle fractures (Neer type II): a functional outcome study

BACKGROUND Controversy exists with the use of the acromioclavicular hook plate for the treatment of lateral-third clavicle fractures (Neer type II). This is thought to stem from problems associated with the hook plate causing impingement symptoms, which can cause long-term limitation of movement and pain. Our aim was to evaluate the functional outcomes of patients with lateral-third clavicle fractures treated with the hook plate. METHODS We prospectively reviewed all patients who underwent surgery from July 2005 to August 2009 using our prospectively recorded electronic patient information database. All patients were assessed in the clinic to determine both Oxford and Constant shoulder scores. RESULTS We identified 36 patients who underwent surgery with the hook plate, 26 men and 10 women. The mean age was 36.2 years (range, 22-60 years). Of the patients, 46% were smokers. The median length of hospital stay was 2 days (interquartile range [IQR], 1-3). The median follow-up was 28 months (IQR, 23-37). The median time from date of injury to surgery was 7 days (IQR, 4-76). The mean time to union was 3 months (IQR, 2-4), and the union rate was 95%. In total, 92% of plates were removed. The median time to removal was 4.5 months (IQR, 3-8.75). There were no complications. Two patients presented months later after falls with fractures around the medial end of the hook plate. CONCLUSION Hook plates are an effective form of treatment for lateral third clavicle fractures. The best outcomes occur with plate removal before 6 months postoperatively, provided that the fracture has healed.

Skype: a tool for functional assessment in orthopaedic research

Skype is a free program which enables PC users to make video calls to other users with Internet access. We carried out a prospective review of all acromioclavicular joint hook plates for lateral-third clavicle fractures over a five-year period. Functional assessment with Oxford and Constant shoulder scores were carried out using Skype and compared to outpatient review using the Bland-Altman method. Of 36 patients (mean age 36 years), 33 had a computer with a video camera, all 33 had Internet access and 22 were already users of Skype. In total 29 patients were happy to take part in Skype assessment (83%). In comparison with outpatient review, there was a mean difference in the Oxford score of −0.48 (95% confidence interval −0.84, −0.12); the mean difference for the Constant score was −0.68 (95% confidence interval −1.08, −0.29). These differences were not clinically significant, confirming that Skype can be used as an alternative to goniometry in this clinical setting. A survey showed that 93% of 29 patients surveyed preferred the use of Skype for follow-up, mainly due to the convenience and cost-saving involved. The study demonstrates the potential for this new technique in providing patients with more options for follow-up.

Padding under tourniquets in tourniquet controlled surgery: Bruner's ten rules revisited

To produce a bloodless field in extremity surgery, the pneumatic tourniquet forms an essential component. It is a simple instrument that plays an important role in many orthopaedic operations. The tourniquet is considered generally safe though not without complications [1]. Proper knowledge and care are essential to its use. So its use must be entrusted only to skilful personnel. For the safe use of the tourniquet Bruner in 1951 published the ten rules [2]. Braithwaithe and Klenerman suggested modifications along the lines of Bruner’s ten original rules (Table 1) [3]. One of the rules is padding under the tourniquets. For adequate padding it is advised to have at least two layers of orthopaedic wool. Orthopaedic wool has its disadvantages in that it gets embedded in the Velcro part of the tourniquet thereby reducing its effectiveness. Removing the fibres from the Velcro is difficult and the life of a tourniquet is reduced. We advocate an alternative to the orthopaedic wool. A roll of crepe bandage can perform the same function as the wool. Our experience shows that it is no inferior to the orthopaedic wool and it has not produced any complications in the last 6 months of its use. The fibres of the bandage do not get embedded in the Velcro thereby prolonging its life and efficiency. Table 1 Braithwiate and Klenerman’s modification of Bruner’s ten rules

Retrospective review of outcome post open reduction and K-wire fixation for grade III acromioclavicular joint subluxations

There is controversy about the therapy for grade III acromioclavicular dislocation according to Tossy and Rockwood’s classification. We identified 25 patients who underwent acromioclavicular joint wiring for grade III subluxations under the care of a single consultant in the last 5-year period. All patients were asked to fill in a DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire to assess outcome following acromioclavicular joint repair, and their clinical notes were reviewed. Our results show that open reduction and Kirschner- (K) wire fixation of grade III AC joint disruptions results in good strength and range of motion of the affected shoulder. It is associated with DASH scores, which are comparable to those of the general population for the same age, indicating little residual disability. All patients returned to their pre-injury occupation, and all but one returned to previous sporting activities. Complications occurred in four patients, but only one required K-wire repositioning.RésuméLe traitement des luxations acromio-claviculaires de grade 3 selon Rockwood est controversé. Les auteurs ont étudié une série de 25 patients traités par brochage et évalué le résultat fonctionnel par un examen clinique et un questionnaire DASH. Les résultats sur la force musculaire et les amplitudes articulaires de l’épaule sont bons. Le score DASH est comparable à celui de la population générale du même âge. Tous les patients sauf un ont repris leur activité sportive. Quatre complications sont survenues, une seule ayant justifié une réintervention.

Heterotopic Ossification following acetabular fixation: Incidence and risk factors: 10-year experience of a tertiary centre

BACKGROUND Heterotopic Ossification (HO) is a well-recognized complication following acetabular fracture fixation and its presence is prognostic for suboptimal clinical outcome. There are many controversies pertaining to its aetiology, including surgical approach, associated injuries and the use of HO prophylaxis. Long term data from high volume centres is necessary to address these issues. AIM To determine the incidence of HO post open reduction and internal fixation (ORIF) of acetabular fractures and to examine the associated risk and prognostic factors. METHOD We studied a cohort of 369 consecutive acetabular fractures that underwent ORIF at our institution over a 10 year period. Data was analyzed using univariate and multivariate logistic regression. RESULTS The existence of HO was evident in 65 patients (17.62%), of these 39 (60.0%) were Class I, 16 (24.6%) were Class II, 8 (12.3%) were Class III, and 2 (3.1%) were Class IV according to Brooker Classification. We found a significant association between admission to an Intensive Care Unit (ICU) (P-value=0.039), chest injury (P-value=0.013), multiple fractures (P-value=0.005), and the time lapse between injury and operation (P-value=0.025), and some statistical significance with surgical approach, ipsilateral fractures, open fractures, tibial and patellar fractures. Age over 30 years as the only prognostic factor for severe HO. Prophylaxis with Indomethacin did not appear to confer any benefit in our patient group. CONCLUSION The risk factors for developing HO following acetabular fracture fixation are multifactorial and include admission to ICU, associated chest injuries, multiple fractures and delay between injury and surgery. Surgical approach, ipsilateral fractures and tibia and patellar fractures may also play a role. Age over thirty years was the only prognostic factor for developing severe HO.

Impact of road traffic "penalty points" on high energy pelvic trauma

Background: The penalty points system (PPS) was introduced in 2002 in an attempt to reduce the increasing rate of road traffic accident (RTA) related fatalities and serious injuries. Points are awarded based on the severity of the offence and are cumulative. A total of 12 points results in the disqualification from driving. Objective: A few studies have looked at the immediate or short term impact of PPS on trauma services or specific injuries such as spine trauma in Ireland. Little data is available on the long term effect of the PPS. The aim of this study is to see if the PPS system has had an influence on the number of pelvic injuries referred to our unit for surgical intervention and if this influence is sustained in the longer term. Materials and Methods: A retrospective review of all pelvic and acetabular injuries admitted to our unit from 1999 to 2008 was undertaken. The mechanism of injury, the site and patient demographics were noted. Results: A total of 467 patients were identified over the ten year period. 454 patients were included in the study. There was a significant male preponderance of 76%. Mean age was 36.5 years (range 16 to 83). RTAs were the cause in 74% (n = 335) of the cases. The annual work load remained similar over the years. There has been a reduction in the number of RTA related pelvic injuries. There have been notable drops in the number of these cases corresponding to the introduction of the PPS and its subsequent expansion. The number of pelvic injuries due to falls continues to rise. Conslusion: The introduction of the PPS and its subsequent expansion has had a positive influence on the number of RTA related pelvic trauma. Continued surveillance and enforcement of the PPS is important for a sustained benefit from it in the long term.

A hypoplastic patella fracture in nail patella syndrome: a case report.

IntroductionNail patella syndrome is a rare autosomal dominant hereditary condition, with an incidence of 22 per million in the United Kingdom. The syndrome’s most common features include iliac horns, hypoplastic patella and nail dysplasia.Case presentationWe report the case of a 26-year-old Caucasian man with nail patella syndrome who sustained a fracture of his right hypoplastic patella after a fall. His right knee became swollen and he was unable to extend against gravity immediately post fall. Radiographs revealed a fracture of the lower pole of his right patella with associated complete disruption of the extensor mechanism of the knee. He underwent operative fixation and his post operative course was uneventful. He was further treated post operatively with a full knee cast and graded immobilization. At six months he had regained the full range of motion at the knee joint.ConclusionsTo the best of our knowledge, this is the only case report in the literature describing a patella fracture in an individual with nail patella syndrome. We hypothesize that given the extent of pre-existing knee joint impairment in these individuals, functional outcome may be inferior, suggesting the need for more frequent follow-up.

Irish (Republic) versus British (North West) orthopaedic trainees: What are the differences?

British Trainees have gradually had their working week curtained over the last 8 years. The Republic of Ireland Trainees have not been subjected to the European Working Time Directive prior to 2009 and have therefore worked on average, more hours than their British counterparts. We wanted to see if the differing schemes had an impact on recruiting and training orthopaedic surgeons. We surveyed Republic of Ireland orthopaedic specialist registrars (SpRs) and North West (NW) British SpRs/specialist trainees (ST3 and above) to see if there were any discernable differences in working patterns and subsequent training exposure. A standard proforma was given to Irish Trainees and to NW SpRs/STs at their National or regional teaching (January/February 2009). 62% of Irish and 47% of British NW Trainees responded. Irish trainees were more likely to have obtained a post-graduate degree (p = 0.03). The Irish worked more hours per week (p < 0.001) doing more trauma operative lists (p = 0.003) and more total cases per 6 months than the NW British (p = 0.003). This study suggests that more hours worked, equals more operative exposure, without detriment to the academic side of training. Obviously it is not possible to say whether fewer operations make for a poorer surgeon, but the evidence suggests that it may be true.

Bilateral pneumothoraces complicating hip hemiarthroplasty in rheumatoid arthritis patient

Rheumatoid arthritis is a multi systemic autoimmune response which has an intra- and extraarticular manifestations. Spontaneous pneumothorax in rheumatoid patients has been reported in the literature. We report a case of a bilateral pneumothoraces following uncemented hip hemiarthroplasty in a rheumatoid arthritis patient. This has never previously been reported in the literature.RésuméL’arthrite rhumatoïde est une affection systémique auto-immune qui a des manifestations intra- et extra-articulaires. Des cas de pneumothorax spontané ont été décrits dans la littérature. Les auteurs rapportent un cas de pneumothorax bilatéral dans les suites de la pose d’une prothèse intermédiaire non cimentée de la hanche chez un patient porteur d’arthrite rhumatoïde. Un tel cas n’avait pas été décrit jusque là dans la littérature.