Jonathan S. Mulford

Proximal Row Carpectomy vs Four Corner Fusion for Scapholunate (Slac) or Scaphoid Nonunion Advanced Collapse (Snac) Wrists: A Systematic Review of Outcomes

Proximal row carpectomy (PRC) and scaphoid excision with four-corner fusion (4CF) are common motion-preserving, salvage procedures for the treatment of wrists with scaphoid nonunion (SNAC) or scapholunate advanced collapse (SLAC). A systematic review was undertaken to clarify controversies regarding which of these procedures has the better outcome. We collated 52 articles that examine outcomes for SNAC or SLAC patients undergoing PRC or 4CF. Although the lack of unbiased trials must be acknowledged, this systematic review confirms that both procedures give improvements in pain and subjective outcome measures for patients with symptomatic and appropriately staged SLAC or SNAC wrists. PRC may provide better postoperative range of movement and lacks the potential complications specific to 4CF (nonunion, hardware issues and dorsal impingement). However, the risk of subsequent osteoarthritis is significantly higher in PRC patients despite the majority being asymptomatic at the time of review. Grip strength, pain relief and subjective outcomes are similar in both treatment groups.

A prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability

Trochlear dysplasia is a developmental condition characterised by an abnormally flat or dome-shaped trochlea and is an important contributory factor to patellofemoral instability and recurrent dislocation. We studied prospectively a series of 54 consecutive patients (59 knees) with patellofemoral instability secondary to trochlear dysplasia, who were treated by a trochleoplasty by a single surgeon between June 2002 and June 2007. Pre- and post-operative scores were assessed by the patients and a satisfaction questionnaire was completed. Of the 54 patients (59 knees) in the series, 39 (44 knees) were female and 15 (15 knees) were male. Their mean age at surgery was 21 years and 6 months (14 years 4 months to 33 years 11 months). In 40 patients (42 knees) the mean follow-up was for 24 months (12 to 58). One patient was unable to attend for follow-up. An analysis of the results of those patients followed up for at least 12 months showed a statistically significant improvement in outcome (p < 0.001 for all scores). Overall, 50 patients (92.6%) were satisfied with the outcome of their procedure. The early results of trochleoplasty are encouraging in this challenging group of patients.

Assessment and management of chronic patellofemoral instability

Chronic patellofemoral instability can be a disabling condition. Management of patients with this condition has improved owing to our increased knowledge of the functional anatomy of the patellofemoral joint. Accurate assessment of the underlying pathology in the unstable joint enables the formulation of appropriate treatment. The surgical technique employed in patients for whom non-operative management has failed should address the diagnosed abnormality. We have reviewed the literature on the stabilising features of the patellofemoral joint, the recommended investigations and the appropriate forms of treatment.

Outcomes for primary anterior cruciate reconstruction with the quadriceps autograft: a systematic review

PurposeTo determine the suitability of the quadriceps autograft in primary anterior cruciate ligament (ACL) reconstruction.MethodsA systematic review was undertaken to identify all clinical studies reporting on the use of the quadriceps tendon autograft in ACL reconstructions. Studies that reported on clinical and functional outcomes, morbidity and complications were selected.ResultsSeventeen articles met our inclusion criteria with a total of 1,580 reconstructions studied. This included four comparative studies which compared the quadriceps tendon to either hamstring or patella tendon autografts. The quadriceps tendon autograft had clinical (Lachman, Pivot-shift testing) and functional outcomes (Lysholm and IKDC scores) similar to those reported for the patella tendon and hamstring grafts in the literature. Comparative studies also reported no significant difference between the grafts for any outcome measure.ConclusionsThe quadriceps tendon autograft is a promising alternative for primary ACL reconstructions with good outcomes and minimal donor site morbidity. Further studies are required, however, to determine whether the quadriceps graft is as good as or better than other autografts.Level of evidenceIV.

Three-dimensional printing in orthopaedic surgery: review of current and future applications.

Three‐dimensional (3D) printing is a rapidly evolving technology with the potential for significant contributions to surgical practice. There are many current applications for 3D printing technology with future applications being explored. This technology has applications in preoperative planning, education, custom manufacturing (implants, prosthetics and surgical guides) and exciting potential for biological applications. This article reviews the current and future applications of 3D technology in orthopaedic surgery.

Traumatic Injuries of the Distal Radioulnar Joint

Traumatic injuries of the distal radioulnar joint (DRUJ) may give rise to complex wrist pathologies. Substantial ongoing disability can arise should these injuries go unrecognized resulting in sub-optimal treatment and lack of appropriate rehabilitation. Injuries of the DRUJ may occur in isolation but more commonly are found with a fracture of the radius. These challenging DRUJ injuries may be simple or complex (irreducible or severe instability), acute or chronic. An adequate knowledge of the stabilizers of the DRUJ is essential in understanding treatment options. Traumatic instability of the DRUJ is reviewed and the anatomy and stabilizing factors are discussed. An algorithm to guide selection of treatment options in complex cases is presented.

Anterior cruciate ligament reconstruction: a systematic review of polyethylene terephthalate grafts

Background:  The ligament advanced reinforcement system (LARS) ligament is an artificial polyester ligament made from polyethylene terephthalate (PET) that is used for primary anterior cruciate ligament (ACL) reconstructive surgery. Recent media attention has resulted in a high awareness of this reconstructive option among patients; however, the outcomes compared with autograft are controversial.

Isolated volar distal radioulnar joint dislocation.

CASE REPORT A 54-year-old right hand dominant manual laborer injured his non-dominant forearm, after it was compressed between machinery roller’s positioned 3 inches apart. This injury was associated with pain, distal forearm swelling, and loss of rotation. The initial X-ray films showed no fracture, however, mal-alignment of the DRUJ was seen on the lateral view Figure 1, A and B. Appreciation of this mal-alignment was not noted until physiotherapy was commenced at 5 weeks. The absence of forearm rotation initiated further investigation. A computed tomography (CT) scan at 5 weeks postinjury, revealed an impaction fracture of the ulna head, which was trapped by the palmer lip of the distal radio-ulna articular surface (Figure 2, A and B). A closed reduction and crossed radioulnar pinning was then performed at 6 weeks. The initial intraoperative imaging of the reduction looked satisfactory (Figure 3, A and B), however, a follow-up CT scan revealed complete displacement of a portion of the ulnar head through the impaction defect (Figure 4, A and B). The patient was referred to our institution for further management. At 8-week postinjury, the senior author performed an open reduction of the DRUJ. The ulna head was exposed through the extensor carpi ulnaris subsheath. The displaced articular segment of the ulna head was exposed with care taken to preserve the volar radioulnar ligament. The articular segment was volarly dislocated. The large osteochondral fragment was reduced to its anatomic position and held with two 2-mm lag screws. The extensor carpi ulnaris subsheath was then repaired and wrist stability assessed. The DRUJ was found to be stable. Postoperative care consisted of a wrist splint with early forearm rotation. At 4-month follow-up 90% of pronation and 80% of supination had been achieved with no DRUJ instability. X-ray films at 4 months showed the fracture that had healed with no evidence of avascular changes to the previously displaced articular head segment (Figure 5). The hardware has been subsequently removed with no complications and the patient is satisfied with the outcome and has returned to manual work (Figure 6).

Short-term outcomes of local infiltration anaesthetic in total knee arthroplasty: a randomized controlled double-blinded controlled trial.

The primary objective of the study was to determine if local infiltration anaesthetic (LIA) reduced total length of hospital stay in total knee arthroplasty (TKA) patients. The study also examined whether LIA improves early pain management, patient satisfaction and range of motion in TKA patients.

Revision of isolated patellofemoral arthroplasty to total knee replacement

Background Patellofemoral arthroplasty is becoming an established treatment for isolated patellofemoral arthritis. Revision to total knee replacement occasionally is required. Lessons learned from patients requiring revision surgery and their subsequent post-revision outcomes are described. Method This study reviewed 49 patellofemoral arthroplasties in 43 patients who had revision to a total knee replacement. These cases were obtained from a cohort of 487 patellofemoral arthroplasties prospectively reviewed between 1989 and 2006. Results The most common reason for revision was progression of arthritis in the tibiofemoral joint (30 knees in 26 patients). Persistent pain from technical error was found in 11 knees (10 patients), and 4 knees in 4 patients had unexplained persistent pain. The revision procedure was straightforward with no technical difficulties. All patients had a primary cemented total knee replacement without requiring bone grafting or prosthetic augmentation. The patients reported significant improvements in the Oxford Knee Score (26/48 points) P = 0.003 and the Bristol Pain Score (25/40 points) P = 0.0001 compared with the scores before patellofemoral arthroplasty. The outcomes were less favorable than expected and were worse than those seen after a successful primary patellofemoral arthroplasty. Conclusion Reasons for patellofemoral arthroplasty failure were identified. Patellofemoral arthroplasty was easy to revise to a primary knee arthroplasty; however, good clinical results could not be guaranteed. These results emphasize the need for careful patient selection and precise surgical technique during the primary operation.