Skills and Expertise
Research Items (26)
The stability of the patellofemoral joint relies on the tenuous interplay of soft tissue and bony factors. Anatomic risk factors for instability include a shallow trochlea, an abnormally lateral tibial tubercle position, patella alta, hypermobility, or a secondary injury to the medial patellofemoral ligament (MPFL). There is an increasing interest in restoring normal anatomy to achieve stability, and at times more than 1 abnormality exists. This article describes the technique for combining a tibial tuberosity transfer and an MPFL reconstruction. The key features include planning of skin incisions to enable both operations to be undertaken, planning of the screw placement before osteotomy is performed and assessment of the joint through a superolateral portal to assess the need for MPFL reconstruction after tuberosity transfer.
- Mar 2017
Aims: The Bereiter trochleoplasty has been used in our unit for 12 years to manage recurrent patellar instability in patients with severe trochlea dysplasia. The aim of this study was to document the outcome of a large consecutive cohort of patients who have undergone this operation. Patients and methods: Between June 2002 and August 2013, 214 consecutive trochleoplasties were carried out in 185 patients. There were 133 women and 52 men with a mean age of 21.3 years (14 to 38). All patients were offered yearly clinical and radiological follow-up. They completed the following patient reported outcome scores (PROMs): International Knee Documentation Committee subjective scale, the Kujala score, the Western Ontario and McMaster Universities Arthritis Index score and the short-form (SF)-12. Results: Outcomes were available for 199 trochleoplasties in 173 patients giving a 93% follow-up rate at a mean of 4.43 years (1 to 12). There were no infections or deep vein thromboses. In total, 16 patients reported further patella dislocation, giving an 8.3% rate of recurrence. There were 27 re-operations, giving a rate of re-operation of 14%. Overall, 88% were satisfied with the operation and 90% felt that their symptoms had been improved. Conclusion: All PROMs improved significantly post-operatively except for the mental component score of the SF-12. Trochleoplasty performed using a flexible osteochondral flap is an effective treatment for recurrent patellar instability in patients with severe trochlea dysplasia and gives good results in the medium term. Cite this article: Bone Joint J 2017;99-B:344-50.
Patellar instability most frequently presents during adolescence. Congenital and infantile dislocation of the patella is a distinct entity from adolescent instability and measurable abnormalities may be present at birth. In the normal patellofemoral joint an increase in quadriceps angle and patellar height are matched by an increase in trochlear depth as the joint matures. Adolescent instability may herald a lifelong condition leading to chronic disability and arthritis. Restoring normal anatomy by trochleoplasty, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction in the young adult prevents further instability. Although these techniques are proven in the young adult, they may cause growth arrest and deformity where the physis is open. A vigorous non-operative strategy may permit delay of surgery until growth is complete. Where non-operative treatment has failed a modified MPFL reconstruction may be performed to maintain stability until physeal closure permits anatomical reconstruction. If significant growth remains an extraosseous reconstruction of the MPFL may impart the lowest risk to the physis. If minor growth remains image intensifier guided placement of femoral intraosseous fixation may impart a small, but acceptable, risk to the physis. This paper presents and discusses the literature relating to adolescent instability and provides a framework for management of these patients.
- May 2016
Background: There is a lack of information about the association between patellofemoral osteoarthritis (PFOA) and both adolescent anterior knee pain (AKP) and previous patellar dislocations. Methods: This case-control study involved 222 participants from our knee arthroplasty database answering a questionnaire. One hundred and eleven patients suffering from PFOA were 1:1 matched by gender with a unicompartmental tibiofemoral arthritis control group. Multivariate correlation and binary logistic regression analysis were performed, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. Results: An individual is 7.5 times more likely to develop PFOA if they have suffered from adolescent AKP (OR 7.5, 95% CIs 1.51 to 36.94). Additionally, experiencing a patellar dislocation increases the likelihood of development of PFOA, with an adjusted odds ratio of 3.2 (95% CIs 1.25 to 8.18). A 44-year difference in median age of first dislocation was also observed between the groups. Conclusion: This should bring into question the traditional belief that adolescent anterior knee pain is a benign pathology. Patellar dislocation is also a significant risk factor. These patients merit investigation, we encourage clinical acknowledgement of the potential consequences when encountering patients suffering from anterior knee pain or patellar dislocation.
- Dec 2015
Purpose: To classify patients with patellofemoral (PF) instability on the basis of their mechanical gait characteristics, and to relate gait deficits to patellofemoral congruence. Methods: Thirteen patients awaiting patellar stabilisation surgery were recruited for gait analysis and magnetic resonance imaging, MRI assessment of PF congruence. Patients were grouped into two subgroups (P1, P2) based on knee joint moment during stance, and their total support moments (TSMs) during stance were compared against eight healthy Control subjects. PF congruence was compared between groups from MRI data captured at 0, 20 and 40° of passive knee flexion and during dynamic extension. Results: Five patients were classified into group P1 because they demonstrated a knee extensor moment during early stance, and eight patients into group P2 because they did not. The TSM of the more affected limb in group P1 was not significantly different from Control values in early stance but the difference was significant (P<.05) in late stance. In group P2, both the less and more affected limbs were significantly different from Control TSM values in early stance, but only the more affected limb in late stance. Patellofemoral contact areas as measured by MRI were greatest for the Control patients, and least for patient group P2 especially during the active extension trials. Conclusions: Patients with patellofemoral pain and instability walked with a slightly flexed knee, avoiding extension. The MRI measurements of joint contact agreed with the patient groupings according to gait mechanics. Cartilage contact across the PF joint can be an objective measure of instability.
Reported rates of dislocation in hip hemiarthroplasty (HA) for the treatment of intra-capsular fractures of the hip, range between 1% and 10%. HA is frequently performed through a direct lateral surgical approach. The aim of this study is to determine the contribution of the anterior capsule to the stability of a cemented HA through a direct lateral approach. A total of five whole-body cadavers were thawed at room temperature, providing ten hip joints for investigation. A Thompson HA was cemented in place via a direct lateral approach. The cadavers were then positioned supine, both knee joints were disarticulated and a digital torque wrench was attached to the femur using a circular frame with three half pins. The wrench applied an external rotation force with the hip in extension to allow the hip to dislocate anteriorly. Each hip was dislocated twice; once with a capsular repair and once without repairing the capsule. Stratified sampling ensured the order in which this was performed was alternated for the paired hips on each cadaver. Comparing peak torque force in hips with the capsule repaired and peak torque force in hips without repair of the capsule, revealed a significant difference between the 'capsule repaired' (mean 22.96 Nm, standard deviation (sd) 4.61) and the 'capsule not repaired' group (mean 5.6 Nm, sd 2.81) (p < 0.001). Capsular repair may help reduce the risk of hip dislocation following HA. Cite this article: Bone Joint J 2015;97-B:141-4. ©2015 The British Editorial Society of Bone & Joint Surgery.
This study aims to identify the relationship of the radial nerve as it descends across the humerus with reference to a reliable soft tissue landmark, the tricipital aponeurosis. Following cadaveric dissection of 10 adult humerii, the radial nerve was located as it crossed the lateral midsagittal point of the humeral diaphysis. A horizontal line was then subtended medially from this point to another line subtended vertically from the lateral border of the tricipital aponeurosis. The vertical distance from this intersection to the lateral apex of the aponeurosis was recorded in three positions (full flexion, 90° of flexion and full extension). The location of the radial nerve on the posterior aspect of the humeral diaphysis to the medial apex of the tricipital aponeurosis was also noted. In 90° of flexion the radial nerve at the lateral midsagittal point of the humerus was 0.9 mm proximal to the lateral apex of the tricipital aponeurosis. Flexion and extension of the elbow changed the interval to 16.3 mm (nerve proximal) in full flexion and 7.1 mm in full extension (nerve distal). On the posterior aspect of the humerus the radial nerve was 21.8 mm proximal to the medial aspect of the tricipital aponeurosis. The aponeurosis provides a reference point from which the nerve can be easily located on the lateral aspect of the humerus intraoperatively in a range of positions, whilst the medial apex provides a guide to the location of the nerve on the posterior aspect of the arm.
- Apr 2014
Background: Various surgical strategies have been described for the treatment of cubital tunnel syndrome, including medial epicondylectomy. This aims to decompress the ulnar nerve and allow a 'mini anterior transposition'. The major concern over medial epicondylectomy is the potential for postoperative iatrogenic valgus instability. Methods: We utilized a surgical landmark for medial epicondylectomy based on the medial aspect of the ulnar nerve with the elbow in 90° of flexion in 12 cadaveric upper limbs. The size of the resultant fragment was measured and, subsequently, the medial collateral ligament was dissected and the elbow stressed to assess its integrity. Results: This technique resulted in the excision of a fragment of mean width 8 mm (range 6 mm to 11 mm) and allowed the ulnar nerve to smoothly translate anteriorly in flexion. The anterior band of the ulnar collateral ligament was macroscopically preserved in all cases and there was no valgus instability. Conclusions: The medial border of the ulnar nerve is a simple, safe and reliable surgical landmark for medial epicondylectomy. This technique offers advantages over other described methods of assessing the location at which to perform a medial epicondylectomy.
- Sep 2013
Background Rupture of the pectoralis major (PM) tendon is a rare but severe injury. Several techniques have been described for PM fixation, including a transosseus technique, placing cortical buttons at the superior, middle and inferior PM tendon insertion points. The present cadaveric study investigates the proximity of the posterior branch of the axillary nerve to the drill positions for transosseus PM tendon repair. Methods Twelve cadaveric shoulders were used. The axillary nerve was marked during a preparatory dissection. Drills were passed through the humerus at the superior, middle and inferior insertions of the PM tendon and the drill bits were left in situ. The distance between these and each axillary nerve was measured using computed tomography. ResultsThe superior drill position was in closest proximity to the axillary nerve (three-dimensional distance range 0–18.01 mm, mean 10.74 mm, 95% confidence interval 7.24 mm to 14.24 mm). The middle PM insertion point was also very close to the nerve. Conclusions Caution should be used when performing bicortical drilling of the humerus, especially when drilling at the superior border of the PM insertion. We describe ‘safe’ and ‘danger’ zones for the positioning of cortical buttons through the humerus reflecting the risk posed to the axillary nerve.
- Jul 2013
Background Blockade of the suprascapular nerve (SSN) is used frequently in shoulder surgery and in chronic shoulder pain. Anatomical landmarks may be used to locate the nerve before infiltration with local anaesthetic, with ultrasound comprising a popular method for locating the nerve. Methods Twelve cadaveric shoulders from six specimens were injected with dye using both the landmark and the ultrasound technique. The shoulders were scanned by computed tomography (CT) and then dissected to determine the accuracy of each technique. Results Using the CT scan results, we found the ultrasound group to be more accurate with respect to placing the anaesthetic needle close to the suprascapular notch (and therefore nerve), with this being statistically significant (p = 0.021). Conclusions The findings of the present study demonstrate that ultrasound-guided block is significantly more accurate than the landmark technique, therefore suggesting that ultrasound guidance be used for blockade of the SSN.
Ensuring correct rotation of the femoral component is a challenging aspect of patellofemoral replacement surgery. Rotation equal to the epicondylar axis or marginally more external rotation is acceptable. Internal rotation is associated with poor outcomes. This paper comprises two studies evaluating the use of the medial malleolus as a landmark to guide rotation. We used 100 lower-leg anteroposterior radiographs to evaluate the reliability of the medial malleolus as a landmark. Assessment was made of the angle between the tibial shaft and a line from the intramedullary rod entry site to the medial malleolus. The femoral cut was made in ten cadaver knees using the inferior tip of the medial malleolus as a landmark for rotation. Rotation of the cut relative to the anatomical epicondylar axis was assessed using CT. The study of radiographs found the position of the medial malleolus relative to the tibial axis is consistent. Using the inferior tip of the medial malleolus in the cadaver study produced a mean external rotation of 1.6° (0.1° to 3.7°) from the anatomical epicondylar axis. Using the inferior tip of the medial malleolus to guide the femoral cutting jig avoids internal rotation and introduces an acceptable amount of external rotation of the femoral component.
- May 2012
Objective: The aim of this study is to determine whether a 2-hole locking plate has biomechanical advantages over conventional screw stabilization of the syndesmosis in this injury pattern. Methods: Six pairs of fresh-frozen human cadaver lower legs were prepared to simulate an unstable Maisonneuve fracture. Each limb was compared with its pair; the syndesmosis in one being stabilized with two 4.5-mm quadricortical cortical screws, the other a 2-hole locking plate with 3.2-mm locking screws. The limbs were then mounted on a servohydraulic testing rig and axially loaded to a peak load of 800N for 12000 cycles. Fibula shortening and diastasis were measured. Each limb was then externally rotated until failure occurred. Failure was defined as fracture of bone or metalwork, syndesmotic widening, or axial migration >2 mm. Results: Both constructs effectively stabilized the syndesmosis during the cyclical loading within 0.1 mm of movement. However, the locking plate group demonstrated greater resistance to torque compared with quadricortical screw fixation (40.6 Nm vs. 21.2 Nm, respectively, P value < 0.03). Conclusion: A 2-hole locking plate (with 3.2-mm screws) provides significantly greater stability of the syndesmosis to torque when compared with 4.5-mm quadricortical fixation.
- Mar 2012
Fractures of the distal radius are common upper limb injuries, representing a substantial proportion of the trauma workload in orthopaedic units. With ever increasing advancements in implant technology, operative intervention is becoming more frequent. As growing numbers of surgeons are performing operative fixation of distal radial fractures, an accurate understanding of the relevant surgical anatomy is paramount. The flexor carpi radialis (FCR) tendon forms the cornerstone of the Henry approach to the volar cortex of the distal radius. A number of key neurovascular structures around the wrist are potentially at risk during this approach, especially when the FCR is mobilised and placed under retractors. In order to clarify the safe margins of the FCR approach, ten fresh frozen human cadaver limbs were dissected. The location of the radial artery, the median nerve, the palmar cutaneous branch of the median nerve and the superficial branch nerve were measured with respect to the FCR tendon. Measurements were taken on a centre-to-centre basis in the coronal plane at the watershed level. In addition, the distances between the tendons of brachioradialis, abductor pollicis longus and flexor pollicis longus, and the radial artery and median nerve were measured to create a complete picture of the anatomy of the FCR approach to the distal radius. The structure most at risk was the palmar cutaneous branch of the median nerve. It was located on average 3.4mm from the FCR tendon. The radial artery and the main trunk of the median nerve were located 7.8mm and 8.9mm from the tendon. The superficial branch of the radial nerve was 24.4mm from the FCR tendon and 11.1mm from the brachioradialis tendon. Operative intervention is not without complication. We believe a more accurate understanding of the surgical anatomy is key to the prevention of neurovascular damage arising from the surgical management of distal radial fractures.
The study aimed to assess tendon length change following patello-femoral replacement (PFR) surgery and total knee replacement (TKR). A retrospective analysis was conducted of 40 patients undergoing PFR surgery and 40 patients undergoing TKR and an unoperated control group. Immediate preoperative radiographs were compared with those at 1 year postoperatively. Intra/inter-observer error was assessed in four observers. In the unoperated patients the mean shortening was 0.6% (range 6% shortening to 3% lengthening). The mean shortening after PFR surgery was 0.1% of shortening (range 14% shortening to 11% lengthening). The mean shortening after TKR was 7.14% (range 25% shortening to 7% lengthening). Shortening of the patella tendon after PFR surgery occurs infrequently and less severely compared with TKR. Level 2 prognostic study.
Purpose: To verify the findings of previous studies in confirming radiographic landmarks for the femoral attachment of the medial patellofemoral ligament (MPFL), but also to define radiographic landmarks for the patellar attachment. Assess the effect of limb rotation upon these radiographic landmarks. Methods: The medial patellofemoral ligament was identified in ten fresh-frozen human cadaveric knees. A headed pin was used to mark the centre of the femoral and patellar attachments. True lateral radiographs were performed followed by lateral radiographs in 10° and 20° of internal and external rotation. Posterior-anterior and proximal-distal position of the headed pin was evaluated. Results: The femoral attachment averaged 3.8 ± 5.0 mm anterior to the posterior femoral cortical line and 0.9 ± 2.4 mm distal to the perpendicular line intersecting the posterior aspect of Blumensaat's line. The patellar attachment averaged 7.4 ± 3.5 mm anterior to the posterior patellar cortical line, 5.4 ± 2.6 mm distal to the perpendicular line intersecting the proximal margin of the patellar articular surface. There was a significant relationship between limb rotation and distance of femoral and patellar attachment from the posterior cortical line (P < 0.0001 and P < 0.0002 respectively). Conclusion: Radiographic landmarks for the femoral attachment of the MPFL identified in this study are comparable with other recent work. This study describes new radiographic landmarks for the patellar attachment of the MPFL and highlights that it is essential to acquire true lateral radiographs if these radiographic landmarks are to be interpreted accurately.
This study aimed to examine the disturbance of hand sensation in patients with carpal tunnel syndrome (CTS) and assess the usefulness of objective and subjective measures. The study included 64 patients with CTS confirmed by electrophysiological testing. Sensory assessment was made by objective (pressure aesthesiometry) and subjective (hand symptom diagram) measures in different anatomical areas. The results of the subjective and objective testing were correlated with nerve conduction studies by a kappa analysis. Sensory disturbance occurred more frequently in areas innervated by the median nerve (index finger, 94%) but also with great frequency in other areas (little finger, 39%). Pain occurred frequently in anticipated areas (wrist crease, 33%) but also in other areas (little finger, 11%). There was very poor correlation between objective measures and electrophysiological testing or subjective measures. This study does therefore not support the use of objective sensory assessment for the initial diagnosis of CTS. An atypical distribution of symptoms is a common occurrence and should not discourage diagnosis of CTS. The patient's description of symptoms remains the most important tool in diagnosis.
A study conducted to establish the most accurate combination of questionnaire and physical signs for the diagnosis of carpal tunnel syndrome. Nerve conduction studies confirmed 70 patients with having carpal tunnel syndrome who were enrolled along with 70 age- and sex-matched controls. Patients were assessed using a symptom questionnaire, Phalen's test, Hoffmann-Tinel's sign, hand elevation test, carpal compression test, tourniquet test, pressure aesthesiometry and two-point discrimination. Through multivariate analysis, the best combination of tests was tourniquet, carpal compression and Phalen's tests but the difference between these and hand elevation test alone was negligible. The hand elevation test may be used in isolation and is superior to questionnaires and other physical signs in the clinical diagnosis of carpal tunnel syndrome.
The aim of the current study was to assess the amount of the distal humerus articular surface exposed through the Newcastle approach, a posterior triceps preserving exposure of the elbow joint. Twenty-four cadaveric elbows (12 pairs) were randomized to receive one of the four posterior surgical approaches: triceps reflecting, triceps splitting, olecranon osteotomy and Newcastle approach. The ratio of the articular surface exposed for each elbow was calculated and compared. The highest ratio observed was for Newcastle approach (0.75 ± 0.12) followed by olecranon osteotomy (0.51 ± 0.1), triceps reflecting (0.37 ± 0.08) and triceps splitting (0.35 ± 0.07). The differences between Newcastle approach and other approaches were statistically significant (p = 0.003 vs. osteotomy and <0.0001 vs. triceps reflecting and splitting). The Newcastle approach sufficiently exposes the distal humerus for arthroplasty or fracture fixation purposes. Its use is supported by the current study.
We present a case a 48-year-old man who was diagnosed with an upper limb deep vein thrombosis post clavicle fracture. He was successfully investigated with a computed tomography (CT) venogram, thrombophilia was excluded, and he was subsequently treated with a 3-month course of anticoagulation. We illustrate this case with photographs and a three-dimensional colour reconstruction of a CT venogram to raise awareness of the condition. A suitable level of clinical suspicion should be maintained by the orthopaedic surgeon; delayed arm swelling with venous congestion following a clavicle fracture should be investigated with CT venography and thrombophilia should be excluded.
- Jan 2010
This is the first report in the literature of a patient treated with a DRUJ replacement after Sauvé-Kapandji procedure failed due to pain and instability. The DRUJ replacement is an unconstrained, biomechanically more advantageous implant which can confer stability in cases where soft tissues are inadequate. We describe the treatment and outcome of persistent ulnar instability with a distal radio-ulnar joint replacement following failed salvage procedures for a malunion of a distal radius fracture.
- Nov 2009
A 7-year-old girl presented with a Gartland grade III supracondylar fracture and no radial pulse. After open reduction, it was established that the brachial artery was free of the fracture site; the limb however remained nonviable. The brachial artery was then approached anteriorly and the bicipital aponeurosis was seen to kink the artery. Once the bicipital aponeurosis was released and the remaining spasm treated with arteriotomy and papaverine, a good pulse returned. Despite the fracture being reduced and the artery remaining free of it, there remained a structural impediment to flow in the brachial artery. If the pulse does not return after fixation of a supracondylar fracture, then exploration of the brachial artery is indicated. When a patient is taken to the operating room for fixation of a supracondylar fracture, the facilities and expertise to explore the brachial artery must be made available. In centers where an on-call vascular service is not available, we recommend that the orthopaedic training programs give consideration to including "exploration of the brachial artery" as a facet of orthopaedic surgical training.
- Jan 2009
Thirty-nine consecutive patients with little finger Dupuytren's contracture underwent open fasciectomy. Diseased abductor digiti minimi (ADM) pretendinous (PT) cords were identified. The mean pre-operative PIPJ contracture was 77 degrees in the PT group and 66 degrees in the ADM group. Mean residual deformity was 12 degrees in the PT group and 9 degrees in the ADM group. At six months, ten out of 27 patients had developed a recurrent deformity in the PT group (mean 24 degrees ) and seven out of 11 in the ADM group (mean 18 degrees ). There was no statistically significant difference between the two groups at any stage. Dupuytren's contracture of the little finger is as a result of an ADM cord in 29% of cases. In this series it led to an isolated contracture of the PIPJ in the majority of cases and rarely affected the MCPJ. Disease of the ADM cord was not associated with a difference in contracture or prognosis compared to a PT cord.
- Feb 2008
Extensor Carpi Radialis Longus (ECRL) avulsion is a rare injury which follows resisted wrist hyperflexion. Treatment of this condition with open reduction and internal fixation is not previously described in the literature, and treatment with plaster immobilisation or k-wire fixation requires a prolonged period of immobilisation. We believe that open reduction and internal fixation of these fractures with early mobilisation will result in the best possible wrist function. We describe a sign to raise the index of suspicion for this injury: a palpable bone lump on the dorsum of the hand in the presence of wrist extensor pain or weakness after wrist hyperflexion injury is a sign of wrist extensor avulsion.