Siu-Bon Woo

Hyaluronic acid instillation following arthroscopic anterior cruciate ligament reconstruction: a double-blinded, randomised controlled study

Purpose. To assess the effect of hyaluronic acid instillation after arthroscopic anterior cruciate ligament (ACL) reconstruction for improving pain, range of movement, and function of the knee. Methods. 28 men and 4 women underwent arthroscopic ACL reconstruction for isolated ACL rupture (partial or complete) and instability after recreational sports injury 2 to 120 months earlier. They were randomised to undergo arthroscopic ACL reconstruction followed by intra-articular viscoseal instillation (13 men and 3 women) or arthroscopic ACL reconstruction alone (15 men and 1 woman). The knee injury osteoarthritis outcome score (for pain, symptoms, activities of daily living, sport and recreation function, and quality of life), range of movement, knee circumference, and analgesic use were assessed on days −1, 1, and 2, and weeks 2, 6 and 12. Results. Patient demographics were similar at baseline. At postoperative days 1 and 2, all subscales of the knee injury osteoarthritis outcome score (except for quality of life) were significantly higher in the viscoseal group. At weeks 2, 6, and 12, improvement in both groups equalised. Knee swelling (change in knee circumference) was significantly less in the viscoseal group at days 1 and 2 (p=0.009 and p=0.038, respectively, Mann-Whitney U test). Only one patient in the viscoseal group had a limited range of movement. No patient developed any adverse reaction. Conclusion. Intra-articular viscoseal instillation improved pain control and swelling 2 days after arthroscopic ACL reconstruction.

Propagation of Bisphosphonate-Related Femoral Stress Fractures Despite Femoral Nailing: A Cautionary Tale From 2 Cases

We report 2 cases of atypical femoral fracture displacement despite treatment with intramedullary (IM) nailing. Both patients had received more than 3 years of bisphosphonates. One patient had prophylactic fixation of an atypical femur fracture due to intractable pain. The other had undergone nailing previously for a traumatic shaft fracture. The patient then received bisphosphonate later and sustained an atypical fracture with the nail in place. Both femoral nails were slotted, cannulated stainless steel piriformis entry designs. These 2 cases are among the first reported failures of IM fixation in preventing displacement of a bisphosphonate stress fracture. We advice caution when using slotted nails in prophylaxis of atypical femur fractures because of its significantly reduced torsional stiffness compared to modern nonopen sectioned nails.

Femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction

Purpose. To evaluate the extent of femoral tunnel widening after quadrupled hamstring anterior cruciate ligament reconstruction using femoral cross pin fixation in contrast to bioabsorbable screw fixation augmented with Endopearl. Methods. 16 patients underwent cross pin femoral fixation and the next 15 underwent bioabsorbable screw fixation augmented with Endopearl. The patients were evaluated radiographically for femoral tunnel widening. Standard posteroanterior radiographs of the knee in full extension were taken at postoperative year 2 and 5. The tunnel width was measured at the opening, the widest and the most proximal parts of the femoral tunnel. Results. In the femoral cross pin and bioabsorbable screw fixations, the mean femoral tunnel sizes were 7.6 and 8.0 mm, respectively. The overall mean tunnel widening at all measured sites were 2.7 and 1.8 mm at the 2-year follow-up and were 2.5 and 1.8 mm at the 5-year follow-up, respectively. The femoral tunnel widening was greater in the cross pin than the bioabsorbable screw group, but only the difference in the most proximal part was significant (p=0.01 at year 2 and p<0.001 at year 5). Conclusion. Femoral tunnel widening was greater in femoral cross pin fixation, probably related to the windshield-wiper and bungee-cord effects. It usually occurred in the first 2 years after the operation and remained static thereafter.

Familial patellar dislocation associated with t(15;20) (q24;q13.1)

Patellar instability is a common debilitating injury affecting young active individuals. It accounts for approximately 3% of all knee injuries. We report a family, of which five members across three generations, who suffered from autosomal dominant familial recurrent patellar dislocation as well as short stature. All of them have recurrent patellar dislocations before the age of 15. The affected patients in all three generations have been genetically screened. Genotypical evaluation revealed a balanced translocation of chromosomes 15 and 20.

Arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons: a case report

We report on a 36-year-old man who underwent arthroscopic debridement for bilateral calcific tendinitis of the subscapularis tendons. The patient had a positive coracoid impingement test for both shoulders. Radiology showed calcific deposits at the insertion of both subscapularis tendons, close to the lesser tuberosities and just posterior to the coracoid tips. The patient underwent sequential arthroscopic coracoplasty and removal of calcific deposits in the subscapularis tendons. The patient returned to work 6 weeks after each surgery. At 2 years, the patient had no shoulder pain, with full range of motion and full power of the subscapularis muscles. The coracoid impingement test was negative for both shoulders. There was no evidence of recurrence.

Practise Makes Perfect

Recent talks of Stephen Kates1 on “Lean business model in health care” in a local symposium has reminded us the pursuit of a sustainable health care system. Lean thinking, originally used in the Toyota Production System in Japan during the 1960s, is a method of implementing performance improvement by eliminating waste and adding value to processes. Kates,1 in his recently published article on “The value of an organized fracture program for the elderly,” concluded that “a co-mananged protocol-driven fracture management program could result in a substantial savings in expenditure, length of stay, mortality, complication rates, and readmission rates.” The concept is being applied with increasing frequency across health care organisations. To push further, pooling of patients for a certain type of surgery, such as revision joint athroplasty, is the future direction. Katz2 had studied and examined 4448 revision total hip arthroplasties using the Medicare database in the United States. He concluded that lower-volume hospitals generate more revisions than that would be expected on the basis of their primary total hip arthroplasty volume, whereas higher-volume hospitals perform more revisions than that would be expected as patients who switch hospitals for the revision surgery at a similar volume or larger-volume hospital than the one in which they had their primary procedure. These data would certainly help to inform health care policy makers how to obtain optimal outcomes for patients needing both primary and revision total hip replacements. When these two statements were put together, it means that it is time to make a quest of shuffling and further injection of both funding and manpower. By doing this, we could reduce complications and the chances of second operations on our patients, given the context of rising costs and heightened patient expectations and demands; it also exert a synergistic effect on the “fitting-in” of “lean model” with sufficient caseload.

Management of Intracapsular Femoral Neck Fractures in Adults Younger Than 65 Years

Purpose: The study is to review the results of intracapsular femoral neck fractures in young adults (age< 65) treated with reduction and multiple-screw fixation from 2000 to 2007. Method: Sixty-four consecutive patients were reviewed retrospectively. The mean age of the patients at the time of injury was 53.5 (32e65) years old. All fractures were either closely or openly reduced and fixed with three 7.5-mm cancellous screws. The mean follow up period was 36.8 months (6e100). Results: We found that 9 of 64 (14.1%) patients developed osteonecrosis of femoral head on follow up. Displacement of fracture (Garden classification), initial stability of fracture pattern (Pauwel classification), and quality of reduction (Haidukewych grading) were found to have significant effect on the development of osteonecrosis, whereas the effect of patient age, time lapse of surgery, capsulotomy, hip aspiration, and postoperative weight bearing regimen were not statistically significant. Conclusion: Fracture pattern and quality of reduction govern the fate of the femoral heads in young adults with their intracapsular femoral neck fractures fixed with screws.