Vikas Khanduja

Arthroscopic hip preservation surgery: Current concepts and perspective

The technical advances in arthroscopic surgery of the hip, including the improved ability to manage the capsule and gain extensile exposure, have been paralleled by a growth in the number of conditions that can be addressed. This expanding list includes symptomatic labral tears, chondral lesions, injuries of the ligamentum teres, femoroacetabular impingement (FAI), capsular laxity and instability, and various extra-articular disorders, including snapping hip syndromes. With a careful diagnostic evaluation and technical execution of well-indicated procedures, arthroscopic surgery of the hip can achieve successful clinical outcomes, with predictable improvements in function and pre-injury levels of physical activity for many patients.This paper reviews the current position in relation to the use of arthroscopy in the treatment of disorders of the hip.

Negative pressure wound therapy for management of the surgical incision in orthopaedic surgery: A review of evidence and mechanisms for an emerging indication

Objectives The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT). Methods We undertook a literature review of this emerging indication to identify evidence within orthopaedic surgery and other surgical disciplines. Literature that supports our current understanding of the mechanisms of action was also reviewed in detail. Results A total of 33 publications were identified, including nine clinical study reports from orthopaedic surgery; four from cardiothoracic surgery and 12 from studies in abdominal, plastic and vascular disciplines. Most papers (26 of 33) had been published within the past three years. Thus far two randomised controlled trials – one in orthopaedic and one in cardiothoracic surgery – show evidence of reduced incidence of wound healing complications after between three and five days of post-operative NPWT of two- and four-fold, respectively. Investigations show that reduction in haematoma and seroma, accelerated wound healing and increased clearance of oedema are significant mechanisms of action. Conclusions There is a rapidly emerging literature on the effect of NPWT on the closed incision. Initiated and confirmed first with a randomised controlled trial in orthopaedic trauma surgery, studies in abdominal, plastic and vascular surgery with high rates of complications have been reported recently. The evidence from single-use NPWT devices is accumulating. There are no large randomised studies yet in reconstructive joint replacement. Cite this article: Bone Joint Res 2013;2:276–84.OBJECTIVES The period of post-operative treatment before surgical wounds are completely closed remains a key window, during which one can apply new technologies that can minimise complications. One such technology is the use of negative pressure wound therapy to manage and accelerate healing of the closed incisional wound (incisional NPWT). METHODS We undertook a literature review of this emerging indication to identify evidence within orthopaedic surgery and other surgical disciplines. Literature that supports our current understanding of the mechanisms of action was also reviewed in detail. RESULTS A total of 33 publications were identified, including nine clinical study reports from orthopaedic surgery; four from cardiothoracic surgery and 12 from studies in abdominal, plastic and vascular disciplines. Most papers (26 of 33) had been published within the past three years. Thus far two randomised controlled trials - one in orthopaedic and one in cardiothoracic surgery - show evidence of reduced incidence of wound healing complications after between three and five days of post-operative NPWT of two- and four-fold, respectively. Investigations show that reduction in haematoma and seroma, accelerated wound healing and increased clearance of oedema are significant mechanisms of action. CONCLUSIONS There is a rapidly emerging literature on the effect of NPWT on the closed incision. Initiated and confirmed first with a randomised controlled trial in orthopaedic trauma surgery, studies in abdominal, plastic and vascular surgery with high rates of complications have been reported recently. The evidence from single-use NPWT devices is accumulating. There are no large randomised studies yet in reconstructive joint replacement. Cite this article: Bone Joint Res 2013;2:276-84.

Current concepts in the diagnosis and management of femoroacetabular impingement

Femoroacetabular impingement is becoming increasingly recognised as a cause of hip pain in the young adult. It is thought that the condition may lead to acetabular labral tears, chondro-labral separation, chondral delamination and eventually predispose to osteoarthritis of the hip. Efforts have thus been directed to diagnosing and treating the underlying pathology and subsequent sequelae. This article presents the relevant literature with regards to the aetiology of femoroacetabular impingement, its clinical features, investigations and options of management. Finally outcomes relating to both open and arthroscopic approaches to treatment are discussed.

The arthroscopic management of femoroacetabular impingement

Femoroacetabular impingement (FAI) has recently been implicated in causing a spectrum of injury ranging from anterior hip pain, labral tears, chondral damage, and eventually perhaps to idiopathic arthritis of the hip. Three distinct types have been described: cam, pincer and mixed, with the mixed one being the commonest. Surgical treatment of femoroacetabular impingement is focused towards providing an adequate clearance to alleviate femoral abutment against the acetabular rim. This is achieved by restoring a normal femoral head–neck offset and recessing the acetabular rim if necessary. The treatment of FAI has been achieved with reasonable success by open surgical dislocation as described by the Swiss group. However, the protracted post-operative recovery coupled with the trauma sustained during the open procedure, have led to the development of an arthroscopic approach to manage this problem. The purpose of this article is to provide the reader with an up-to-date knowledge of the clinical and diagnostic aspects of FAI, to describe our arthroscopic technique in detail with its pitfalls and possible complications and to discuss the results and future of FAI.

Management of the greater trochanteric pain syndrome: a systematic review

INTRODUCTION Greater trochanteric pain syndrome (GTPS) is a debilitating condition characterized by lateral hip pain located at or around the greater trochanter. SOURCE OF DATA We performed a comprehensive search of Pubmed, Medline, Ovid, Google Scholar and Embase databases, from inception of the database to 20th of June 2011, using a variety of keywords. We identified 52 relevant abstracts of articles published in peer-reviewed journals. Fourteen studies reporting the outcomes of patients undergoing conservative and surgical management of GTPS were selected. AREAS OF AGREEMENT Significant pain relief and improved outcomes were observed after conservative and surgical management of GTPS. The modified Coleman methodology score averaged 44.7 (range from 14 to 82), evidencing an overall low-to-moderate quality of the studies. Repetitive low-energy radial shock wave therapy and home training approach provide beneficial effect over months, with almost 80% success rate at 15 months. AREAS OF CONTROVERSY Poor available data extracted from small studies do not allow definitive conclusions to be drawn on the best treatment for GTPS. GROWING POINTS Further multi-centre prospective studies are necessary to confirm the general validity of the findings reported. AREAS TIMELY FOR DEVELOPING RESEARCH Future research and trials should focus on the application and effectiveness of the various conservative modalities for management of GTPS. CONCLUSION The effectiveness of the various treatment modalities needs to be tested in carefully conducted randomized controlled trials.

Hip arthroscopy: evolution, current practice and future developments

Arthroscopic examination and treatment is an ever-increasing part of modern orthopaedic practice in this age of minimally invasive surgery. Arthroscopic procedures have been widespread in surgery of the knee and the shoulder for many years; however, the hip until relatively recently, has been largely neglected. Even now hip arthroscopy is not widely available; this may be due to the complexity of the procedure, the requirement of specialist equipment and a reportedly long learning curve. On the other hand, it has gone through a period of rapid growth over the last decade and is being performed in large numbers routinely in some centres around the world. Hip arthroscopy now provides excellent visualisation of not only the articular surfaces of the hip joint but also of the peritrochanteric or extra-articular space around the hip. Pathology of both the femoral head and the acetabulum along with the soft tissues of the hip, namely the ligamentum teres, the acetabular labrum, the synovial folds and synovium, is readily diagnosed. Modern techniques provide therapeutic options for a myriad of conditions and allow modulation of pathological processes early. Additionally hip arthroscopy is a relatively safe procedure with few complications and contraindications. However, the key to good outcomes is in the careful selection of patients and meticulous surgical technique. The aim of this review is to bring the reader up to date with an overview of the evolution of arthroscopy of the hip, review the current practice and explore possible future developments.

Evaluation and management of injuries of the tibiofibular syndesmosis

INTRODUCTION Injury to the tibiofibular syndesmosis often arises from external rotation force acting on the foot leading to eversion of the talus within the ankle mortise and increased dorsiflexion or plantar flexion. Such injuries can present in the absence of a fracture. Therefore, diagnosis of these injuries can be challenging, and often stress radiographs are helpful. Magnetic resonance imaging scans can be a useful adjunct in doubtful cases. The management of syndesmotic injuries remains controversial, and there is no consensus on how to optimally fix syndesmosis. This article reviews the mechanism of injury, clinical features and investigations performed for syndesmotic injuries and brings the reader up-to-date with the current evidence in terms of the controversies surrounding the management of these injuries. SOURCES OF DATA Embase, Pubmed Medline, Cochrane Library, Elsevier and Google Scholar (January 1950-2014). AREAS OF CONTROVERSY The management of syndesmotic injuries remains controversial, and there is no consensus on: (i) which ankle fractures require syndesmotic fixation, (ii) the number or the size and the type of screws that should be used for fixation, (iii) how many cortices to engage for fixation, (iv) the level of screw placement above the ankle plafond, (v) the duration for which the screw needs to remain in situ to allow the tibiofibular syndesmosis to heal and (vi) when should patients weight bear. AREAS OF AGREEMENT (i) A high proportion of syndesmotic fixations demonstrates malreduction of the syndesmosis, (ii) no need to remove screws routinely, (iii) two screws appear to better one alone and (iv) if syndesmosis injury is not detected or not treated long term, it leads to pain and arthritis. GROWING POINTS (i) How to assess the adequacy of syndesmotic reduction using imaging in the peri-operative period, (ii) the use of bio-absorbable materials and Tightrope and (iii) evidence is emerging not to remove syndesmotic screws unless symptomatic. AREAS OF TIMELY FOR DEVELOPMENT RESEARCH (i) A bio-absorbable material that can be used to fix the syndesmosis and allow early weight bearing, and (ii) there is a need for developing a surgical technique for adequately reducing the syndesmosis without the exposure to radiation.

Evaluation of the Modified Elmslie-Trillat Procedure for Patellofemoral Dysfunction

The goal of this study was to evaluate the Elmslie-Trillat procedure for recurrent patellar dislocation, patellofemoral pain (with extensor mechanism malalignment), or a combination of both. Thirty-two patients underwent the modified Elmslie-Trillat procedure, consisting of a lateral retinacular release and medialization of the tibial tuberosity for recurrent patellar dislocation, patellofemoral pain, or both. Twenty-nine of 32 patients were available for follow-up. All patients were evaluated clinically and radiologically. Subjective scores were evaluated using the Cox grading system and objective scores using Fulkersons functional knee score. Average patient age was 33 years. Mean follow-up was 45 months. Subjectively, using the Cox grading system, 10 patients (34%) had an excellent result, 8 (28%) had a good result, 8 (28%) had a fair result, and 3 (10%) had a poor result. All patients with patella dislocation had an excellent or good subjective result, while only 3 patients (34%) with the primary symptom of patellofemoral pain with extensor mechanism malalignment and 4 patients (44%) with a combination of both symptoms had a good or excellent result. Mean Fulkersons functional knee score was excellent for patients with dislocation only, and fair for those with only pain or both pain and dislocation. The congruence angle was corrected in all patients with this technique. There were no further dislocations in our series. Two patients required hardware removal. The Elmslie-Trillat procedure is a good surgical option for treatment of recurrent patella instability following failed conservative therapy. However, the results are not as favorable for patients with patellofemoral pain without instability.

A quick guide to survey research

Questionnaires are a very useful survey tool that allow large populations to be assessed with relative ease. Despite a widespread perception that surveys are easy to conduct, in order to yield meaningful results, a survey needs extensive planning, time and effort. In this article, we aim to cover the main aspects of designing, implementing and analysing a survey as well as focusing on techniques that would improve response rates.

The effect of femoro-acetabular impingement on the kinematics and kinetics of the hip joint

Gait analysis is an objective tool that has been used to assess and monitor treatment for many musculoskeletal conditions. Recently, it has been used to assess the impact of femoro-acetabular impingement (FAI) on the hip and lower limb movements. There have been a fairly limited number of studies published so far reporting unexpected and inconsistent results, which calls for more research to be conducted in this arena. In the light of the limited data available, it has been challenging to reconcile the contradictions in some of these results, and therefore no coherent conclusions could be drawn. In this short article, we attempt to explain some of the abnormal kinematic and kinetic patterns associated with FAI by highlighting similarities between the gait seen in early osteoarthritis (OA) and that of FAI. We also propose an approach for future research in this field and emphasise the importance of quantifying early OA in FAI based on magnetic resonance imaging (MRI) scans and the amount of chondral damage seen during open or arthroscopic surgery.