msk AUTUMN 2012

FROM ORTHOPAEDIC SERVICES AT THE HOSPITAL OF St JOHN & St ELIZABETH MINIMAL INVASIVE PARTIAL KNEE REPLACEMENT

HJE LEADS THE WAY WITH OUR NEW UNIT ONE-STOP SHOP FOR HYPERMOBILITY

ROTATOR CUFF TEARS POINTS TO ADDRESS KEINBOCK’S DISEASE LOSS OF WRIST ACTION AND CHRONIC PAIN

FOCUS ON TENNIS: ANALYSING A TENNIS STYLE AND WRIST ACTION CAN HELP TREAT PAIN

BACK PAGE: A FULL LIST OF OUR SPECIALIST UNITS ANKLE SPRAINS: WHAT TO LOOK FOR, WHEN TO REFER, WHEN TO WAIT CONTENTS OUR ACHIEVEMENTS TINA CELEBRATES WITH US ON 4 AND OUR AIMS CASUALTY FIRST’S ANNIVERSARY V star and local FOCUS ON ANKLE SPRAINS FOR 2013 resident Tina T Hobley joined us 6 to celebrate Casualty elcome to the Winter Edition First’s !rst birthday. SPORTING HAND & of MSK magazine. Even The Holby City W actress is a great WRIST INJURIES though the year is drawing to a close, the Hospital is still supporter of St John’s forging ahead. Hospice, which receives 8 most of its funding from Works to install a new the Hospital. OUR LEADING KNEE UNIT CONSULTANTS 256-slice state-of-the-art Following a hugely CT scanner, which will successful launch in o!er the very best September 2011, the 10 quality images and private walk-in centre more advanced clinical treated more than 6,000 PARTIAL KNEE REPLACEMENTS patients in its !rst year. applications, will be Just under half the completed by the patients attending the 12 New Year. urgent care centre su"er This £1.2m investment from an orthopaedic COMPLICATIONS IN TOTAL in our Imaging Department complaint, including KNEE REPLACEMENT comes less than a year after fractures and sprains. we became the "rst private The uptake of this year’s £5 #u vaccination 14 hospital in the UK to have a o"er has been huge, 3T MRI. with adults and ROTATOR CUFF TEARS As the o#cial medical facility of UK Athletics, we were children from the age delighted at the success of the 2012 GB Olympic team after of three being o"ered 15 many of the medal-winning track and "eld athletes were the vaccine. treated at the Hospital. Even with this $ massive demand, HYPERMOBILITY: OUR ONE STOP SHOP Our reputation, especially in Orthopaedics, is spreading. average waiting times A record 293 GPs attended our Annual Symposium to still remain only a few 16 hear lectures from 15 of our leading consultants. We plan to minutes, winning many build on this success and the extremely positive feedback by new fans, including KIENBOCK’S DISEASE hosting a special hot topics Annual Symposium in March. Tina who is married Meanwhile, last month, 266 healthcare professionals with three children – attended our Hypermobility Seminar. The Hypermobility Unit, Isabella, 13, Olivia, 4 18 and led by Professor Rodney Grahame, is the UK’s only private 2-year-old Orson. specialist unit and is already attracting international interest. ST JOHN’S HOSPICE Before cutting We are also launching a Knee Unit. This will complement the cake, Tina said: our wide range of world-class orthopaedic services – we have “We have not had to 19 many specialist consultants and boast the Spine and face anything serious Shoulder Units as well as the world-renowned London Foot other than the typical BERG BALANCE ASSESSMENT and Ankle Centre. challenges that every family faces. That said, The success of the Hospital allows us to fund our on-site Holby City’s Tina Hobley and St John & St Elizabeth CEO David Marshall cut " it’s comforting to know 20 hospice, St Johns, which has just launched London’s rst the anniversary cake with Casualty First Consultant Andre van Nierop that we are so close to palliative care ambulance service. Our Hospice@Home service places like the Casualty OUR SPECIALIST UNITS & CONTACTS scooped the prestigious Domiciliary/Home Healthcare First facility.” Provider 2012 at the Laing Buisson Independent Healthcare Your fast-track referral service Our experienced Awards, beating hundreds of rivals. doctors and nurses are Casualty First is increasingly being used as a fast-track referral service by able to treat all minor I thank you for your support in 2012 and wish you a Merry physiotherapists and other health professionals. Referrals to consultants from illnesses, accidents and Christmas and a Happy New Year. this doctor-led service are accepted by all major health insurance companies, injuries and uniquely Kind regards, with most patients being seen in our outpatient department within 24 hours treat children from the of visiting the centre. DAVID MARSHALL CHIEF EXECUTIVE age of one. 2 3 ANKLE SPRAINS " WHAT TO LOOK FOR, WHEN TO REFER, AND WHEN TO WAIT

The majority of ‘problem’ MR MARK DAVIES ankles do have signi!cant potential for improvement BA (Oxon) MBBS FRCS (Orth) with appropriate assessment Clinical director and consultant including MRI and ultrasound. orthopaedic surgeon It is essential to refer a of the London Foot and Ankle Centre problem ankle if symptomatic after two months. When Tel: 020 7078 3800 making the referral to a foot Email: and ankle specialist surgeon, [email protected] you need to list occult injuries Website: How should an ankle – all the fractures, OCD www.londonfootandanklecentre.co.uk sprain be managed? (osteochondritis dissecans) Achilles or peroneal pathology. ODo not immobilise the joint. Begin %exibility (range of motion) he spectrum of injuries exercises as soon as they can be tolerated without excessive Clear indications for labelled ‘ankle sprain’ is pain. It is thought that functional stress stimulates collagen ankle surgery broader than any other Guidelines replacement. Very few ankle sprains require T term used in orthopaedics. for OAdvise a person with a sprain or strain to seek further medical surgery acutely, but some will Recovery can take two days or a advice if there is: fail to get better and require year and some patients will never assessing Lack of expected improvement after following basic home surgery – impingement fully recover. This article is written management guidelines (for example, if they continue to have OCD, instability, for example. to provide a comprehensive guide a sprained di$culty walking). Chronic ankle instability to assessing and managing an Worsening of symptoms (for example, increased pain or increases the risk of further ankle sprain, highlighting the ankle swelling). injury and weakness. key indicators for referral to an Concern regarding the nature and extent of the injury. One of the few absolute orthopaedic surgeon. OReview a sprain after a few days to assess muscle contractile indications for surgery in function, depending on the severity of the injury. patients with a sprained ankle The value of early assessment is an inferior tibio-!bular Assess the severity of the injury, including: It is important to make an joint third-degree sprain that OPain, swelling, bruising and range of movement. assessment as soon as possible Is there a fracture? causes widening of the ankle OAbility to bear weight, balance, gait. after the injury takes place. Palpate The ability to walk on the foot usually excludes a fracture. Consider mortise. To restore the ankle OTreatment measures already tried. the ankle for tenderness and neurovascular compromise if the patient reports a cold foot or describes mortise, the distal tibio!bular O Are there any complicating factors? consider what lies underneath. Early the symptoms of paresthesias. When considering whether a patient can articulation must be screwed ! OPresence of pain or bony tenderness elsewhere may indicate a X-ray is bene cial. If there is huge bear weight, you should apply a lower threshold to older patients. together. possible fracture. swelling, severe pain and inability How long to watch and wait? When the sprained ankle does not heal. Sometimes, surgery is ODeformity of a limb, or postural abnormality. to bear weight, you need to be very Up to 40 per cent of patients with ankle sprains remain symptomatic six required if the initial diagnosis OEvidence for, or indication of, damage to nerves or circulation. suspicious of a potential fracture or months after their injury. Any patient still troubled with the ankle giving was incorrect. For example, ! OWhether the person is taking medication (e.g. anticoagulants) # highly signi cant soft-tissue injury. way or swelling after two months of physiotherapy is likely to be su ering missed syndesmotic injuries which may a#ect the injury. The history of an ankle sprain from a remedial occult injury. This indicates there may be: can be disastrous and early OAny complicating illness (e.g. neuropathy, bleeding disorder, is usually that of an inversion-type OA fracture or avulsion not noted on standard radiographs intervention is very bene!cial. or history of deep vein thrombosis). Neuropathy or lack of twist of the foot followed by pain and ODamage to the articular surface of the talus ATFL and calcaneo!bular sensitivity of the foot puts the person at increased risk of $ swelling. An individual with an ankle OLateral ligament insu ciency ligament (CFL) are best treated complications. sprain can almost always walk on the OTendon injury surgically. foot, albeit carefully and with pain. OSynovial impingement 4 5 ANALYSING A TENNIS STYLE AND WRIST ACTION CAN HELP TREAT PAIN

MR NICHOLAS GODDARD One makes the diagnosis on the it is head-heavy or head-light, can MB BS FRCS nature of the symptoms. Did the have a knock-on e"ect up the problem come on suddenly or is limb. New strings and di"erent ennis can there a more insidious slow onset tension can result in problems with undoubtedly of symptoms tending to imply an the elbow. T lead to various overuse problem? How long have It is therefore relevant to look problems, the symptoms been present? How at what may have changed and particularly with the hand severe are they? What exactly are then gradually eliminate those and wrist, but it is interesting they and what treatment has taken possible causative factors and so to note that the majority of place so far? improve symptoms. This may require professional players surprisingly As far as the amateur players going back to an old racquet. It get very little in the way of upper- are concerned, probably the most is important to establish that the limb injuries. important factor is change. If one racquet is in fact the right size and Faced with a tennis player has been playing at a standard level the grip is appropriate. Too small a grip can result in problems at the wrist, too large a grip in problems at the elbow. Diagnosing the nature of a We have many diagnostic tools available to us, beginning with player’s symptoms can be simple clinical examination looking at the site of the pain. One must influenced by changes in playing remember that there are many causes of pain on the outside of habits, equipment and even the the elbow of which “tennis elbow” is merely one. Nowadays, our performance level investigations are much more sophisticated. Plain X-rays can be presenting with a particular or at the same level for a prolonged helpful but probably the MRI will complaint one must try to identify period and then suddenly develops provide the most accurate diagnosis the problem. It is important to symptoms in the wrist or elbow it is and is undoubtedly a valuable reassure or to establish whether the important to establish what exactly diagnostic tool. problem could be made worse by has changed. Sometimes the change As far as the treatment of tennis continuing playing and, crucially, can go unnoticed. A new coach, for injuries is concerned, the majority Congratulations to Andy Murray whether the player can take part in instance, can bring in a new range will respond to standard measures that important tournament. of shots. Excessive topspin is more of rest, ice, compression, elevation on winning the Having established a diagnosis likely to cause problems in the wrist and anti-in!ammatory medication. one must obviously take steps whereas a sliced backhand can Occasionally we get involved as to try to improve the situation. cause problems with the elbow. surgeons, particularly with regard Sometimes this can be by simple Technique in itself is therefore to the more recalcitrant conditions US Open tennis rest, anti-in!ammatory medication, important. A new racquet can such as torn cartilages, unstable physiotherapy, steroid injections drastically alter the way one plays. tendons and occasionally fractures. and, occasionally, by surgery. For Newer racquets are much lighter Above all, with regard to treatment one must establish exactly and perhaps more !exible than tennis, players should analyse their what is injured – whether it is the the older ones and are less likely to technique, look closely at their shots bones, the joints, the soft tissues engender problems with the elbow, and, faced with a problem, should (muscles, tendons or ligaments). Are although paradoxically they can seek appropriate help, initially from the muscles torn or in!amed? Is the cause problems with the wrist. The physiotherapists, and hopefully avoid bone broken, or is it in fact normal? weighting of the racquet, whether the surgeon’s knife. Mr Goddard has treated most of Secretary: 020 7806 4000 ex 4467 / 020 7286 3506 Email: [email protected] www.orthopaedicunit.org.uk the UK’s top ten tennis players 6 7 OUR CONSULTANTS:

Mr Raj Bhattacharya FRCS (Tr & Orth) MBBS MRCS (Ed) MRCS (Glas) MSc After starting his medical career in Lanarkshire and the North-East of England, he completed basic surgical training, Masters degree and registrar training. He undertook Fellowships in Knee Surgery and Trauma in Edinburgh, then Knee Surgery at Southampton Knee Unit before becoming Consultant at Imperial in 2010. His clinical interests include mainly complex trauma and knee injuries as well as hip and knee joint replacements. He also has active research interests in these areas, is widely published and has presented his work internationally. He is heavily involved INTRODUCING in the teaching and training of medical students at Imperial College Medical School.

OUR NEW STATE OF THE ART IMAGING

The Knee Unit uses the hospital’s state-of-the-art imaging KNEE UNIT suite, which includes the latest 256-slice CT and 3T MRI scanners. A team of specialist Consultant MSK Radiologists are on hand to provide interventional procedures and reporting within 24 hours.

Our new Phillips Brilliance iCT TVI 256 slice CT scanner, Mr Nicholas Garlick one of the !rst of its kind to be installed in a UK hospital, MBBS FRCS (Edin) FRCS provides unrivalled image quality in a fraction of the scan (Eng) FRCS (Orth) time with a reduced radiation dose. Due to the unique Having quali!ed at St con!guration of the system, the image quality is signi!cantly Bartholomew’s Medical improved for the most accurate representation of even the School, he completed registrar Visit our new Knee Unit website: most di"cult to image anatomic areas and includes Metal training at St George’s www.londonkneespecialists.co.uk Artefact Reduction for Orthopaedic implants. Hospital, Royal Free and Royal National Orthopaedic Hospital Contact: 020 7432 8297 Rotations. His lower-limb specialist training took place at the OOur new Knee Unit Mr Nicholas Goddard MBBS FRCS Royal National Orthopaedic Following graduation from St Bartholomew’s Hospital and the Charnley Mr Nimalan Maruthainar brings together many FRCS (Tr & Orth) MBBS BSc (Hons) Medical School which included further training Joint Replacement Unit, of the country’s leading He quali!ed from the Royal Free followed at the University of Vancouver, he undertook Redhill. He undertook further lower-limb specialists by basic surgical training at Norfolk and diplomas in Microsurgical Techniques and specialist training in shoulder Surgery of the Hand and Upper Limb at the to provide unparalleled Norwich. Further training at RNOH included surgery at the Royal National one year as Clinical Lecturer at the Institute of University of Paris VI. Orthopaedic Hospital, a access to top surgeons. Orthopaedics, UCL. His fellowships included He started his consultancy at the Royal Free speciality which he maintains. Our Consultants the Joint Reconstruction Unit, RNOH and Knee in 1990 where he remains. He is an honorary His main NHS consultancy are available every Unit, University of Southern California, then consultant for several organisations including Surrey County is at the Royal Free Hampstead consultant at the Royal Free since 2005. Cricket Club, Dispensaire Français, London and the Royal where he is Clinical Lead in weekday plus Previously an Honorary Senior Lecturer at UCL, he is Associate Ballet School. Orthopaedic Surgery. He Saturdays, with urgent Editor Orthopaedics and Trauma Specialist Collection, NHS Evidence He’s published over 90 articles and book chapters and 2,000 teaches students at the Royal appointments available & Trust Speciality Training Director for Trauma & Orthopaedic Surgery, medicolegal papers. He is an examiner for IMRCS (RCS), European Free and University College Royal Free. He has special interests in hip and knee arthroplasty and Diploma in Hand Surgery and MB BS (University of London). Medical Schools. on the same day or the orthopaedic aspects of lysosomal storage diseases. within 24 hours.

Mr James Youngman MBBS FRCS (Tr & Orth) Mr Robert Marston MBBS FRCS (Eng & Edin), FRCS (Orth) Graduating from Middlesex and UCL, he worked in major trauma at Whipps Cross and Obtaining his MD from St Thomas’s Hospital, he completed fellowships at the RNOH the Royal London before becoming consultant at UCLH, experienced in adult and with Johnson & Johnson as Zimmer Hip Fellow and BOA Travelling Fellow in USA and paediatric trauma. Australia. He has a major interest in treatment of knee problems including complex trauma, His main NHS post is at Imperial with honorary positions at St Luke’s Hospital and sports injuries and degenerative conditions, and advanced arthroscopic techniques Ravenscourt Park NHS Treatment Centre. ! with complex ligament reconstruction using hamstring, patella tendon or allograft. His speci c interest and expertise is lower-limb trauma and he runs the 24-hour His deformity work includes correction of long-bone deformity, either by trauma unit for the elderly at St John & St Elizabeth’s. osteotomy and acute correction using Ilizarov or Taylor spatial frames. Performing and His orthopaedic subspecialty interests are primary, complex primary and revision teaching knee-replacement techniques including complex knees with severe deformity, he carries out hip surgery. He performs knee arthroscopy, anterior cruciate ligament reconstruction degenerative hip reconstruction and revision arthroplasty. and knee replacement and some foot and ankle. 8 9 KNEE REPLACEMENT: TOTAL OR PARTIAL?

If knee arthritis is causing severe pain and restricting mobility so that quality of life is impeded, knee MINIMALLY INVASIVE replacement of some sort is appropriate. The careful clinical and radiological assessment of a patient with knee arthritis is vital in order to make the correct decision. The clinical assessment must KNEE REPLACEMENT answer the following questions:

1. Does the patient’s knee have a Mr Robert Marston looks at the functioning anterior cruciate advantages of partial replacements ligament? SURGERY 2. Is the varus deformity less than 10 degrees, and can it be corrected?

3. Has the patient got full extension or lacking a maximum of 10 degrees OLeft knee Xrays before and after partial knee full extension? replacement The clinical assessment should be followed by special X-rays which have to be speci!cally requested from the radiographer. 1. An X-ray of both the knees taken from the front with the patient standing. MR ROBERT MARSTON The gap between the bones on the inner side of the joint gives a measure of the degree MBBS BSc !Hons) of thinning of the articular cartilage and therefore the severity of the osteoarthritis. FRCS FRCS (Orth) Furthermore, one knee can be compared with the other and "nally one can make sure that there are no X-ray changes of osteoarthritis in the outer compartment of the knee. ot all patients who experience severe pain 2. A lateral view. This can give corroborative evidence as to whether the anterior and disability as a result of cruciate ligament is intact. If the tibia has slipped forward on the femur this is an Nosteoarthritis of the knee indication that the anterior cruciate ligament is not fully functional. require a total knee replacement. Approximately 25 per cent of patients in Europe have a type of arthritis in 3. A skyline view of the patellofemoral joint. This view is very good at excluding severe the knee which is suitable for partial bone on bone osteoarthritis in the patellofemoral joint and giving further information knee replacement. the plastic bearing. The advantages is preserved (knee kinematics). The as to whether there are osteophytes on the outer femoral condyle. This operation was developed in of this operation were many. result of this is that the patient feels many centres throughout Europe Firstly, the operation could be they have a natural-feeling knee f a patient "ts these criteria anterior cruciate ligament One to two per cent of patients in the 1970s but the most notable performed through an incision that because of the preserved normal they would be suitable for a can lead to both an unstable have osteoarthritis which is just success has been with the Oxford did not involve cutting into the knee kinematics. This is not the case medial Oxford unicondylar bearing and dislocation of the con"ned to the patellofemoral “unicondylar” knee replacement. This quadriceps muscle tendon. It is the in patients who undergo total knee I knee replacement. The operation bearing, or loosening of the tibial joint. In these patients a plastic was originated by the late Professor cutting into the quadriceps tendon replacement. should never be done as a component. Ignoring too much button is used to resurface the John Goodfellow (Professor of which contributes the majority of Thirdly, rehabilitation is much half-way stage to total knee in the way of patellofemoral worn-back surface of the knee Orthopaedic Surgery at the Nu!eld the pain that patients experience quicker, with patients spending one replacement. The evidence osteoarthritis can cause pain at cap and a small metal plate is Orthopaedic Centre) and when recovering from total knee to two nights in hospital rather than from the Scandinavian Knee the front of the knee which is cemented into the groove that Dr John O’Connor (a bioengineer). " replacement and gives the four or ve. They leave as soon as Register shows that partial knee particularly troublesome when the knee cap articulates with on They recognised that certain procedure its reputation as a painful they can achieve full extension of replacements have longevity patients go up and down stairs, the lower end of the thigh bone. patients had osteoarthritis limited to operation. the knee and at least 90 degrees of equal to that of a total knee inclines or rise from chairs. In summary, osteoarthritis of the inner bearing surface of the knee # Secondly, all the knee ligaments exion. Also they are able to go up replacement, eg in excess of 15 Within the 25 per cent of the knee does not mean a total joint (medial tibiofemoral surface). " remain intact. By de nition, a patient and downstairs and use one walking years. To prevent early failure the patients who have arthritis limited knee replacement in the case They developed an operation requiring a total knee replacement stick only for approximately three to assessment therefore has to be to one area of the joint there are of every patient. It is, however, whereby a small amount of worn has an absent anterior cruciate four weeks, putting all their weight exact. The outer compartment perhaps one per cent of patients important to have a careful clinical cartilage and its underlying bone was ligament since it has been eroded through the operated knee. of the knee must not be too who have arthritis limited to and radiological assessment removed from the adjacent surfaces over time by extra bone produced by Finally, the operation is much less worn otherwise osteoarthritis the outer part of the joint and a of the knee prior to making a of the inner side of the knee joint. arthritic joints (osteophytes). Some invasive. Blood loss is minimal and it will progress and a total knee mirror-image type of prosthesis decision as to what type of knee A metal plate was then cemented " surgeons also sacri ce the posterior is very unusual to require transfusion, replacement will be required. has been designed for lateral replacement is appropriate for the on to both these freshened bone cruciate ligament. In unicondylar unlike total knee replacement. The Likewise, a non-functioning compartment osteoarthritis. individual patient. surfaces and a mobile high-density replacement both these ligaments reduced requirement for blood and polyethylene bearing was snapped remain intact. Therefore the complex #uid replacement and minimal opiate into place, the curvature of the upper interaction between muscle pain relief means that patients get plate conforming to a concavity in movement and ligament restraint better much sooner. CONTACT: Secretary: 020 7806 4026; Email: [email protected]; Website: www.londonkneespecialists.co.uk 10 11 COMPLICATIONS OF TOTAL KNEE REPLACEMENT A quick concise summary of the current incidence of potential surgical complications in Total Knee Replacement WHERE DO WE CURRENTLY STAND? TABLE OF COMPLICATIONS from TKR is 0.5%. The Standardised to prevent the infection from Mortality Ratio in the UK for a becoming more deep-seated. The di#cult to signi"cantly improve their comparable population is 0.74% " incidence of super cial infection range of motion postoperatively. Early which means that one is less is around 1.5% and deep infection likely to die while having a knee around 0.5%. Intra-operative replacement than a comparable DELAYED Anaesthetic general population. The likely cause Intermediate: OCardiovascular of this fallacy is that someone Thromboembolism ORespiratory undergoing a knee replacement Deep-vein thrombosis and Swelling ORenal subsequently pulmonary has to be reasonably healthy to Swelling is normal following TKR, Surgical embolism can occur in up to 1.5% so patients should be warned that X-rays of aseptic loosening of a MR R. BHATTACHARYA be advised to have this procedure O of cases and may require hospital it may take time to resolve, often Total Knee Replacement 15 years Fractures MBBS MRCSEd MRCSGlas MSc. by his or her surgeon, thereby after implantation OHaemorrhage FRCS!Tr. & Orth." causing a healthier selection bias admission following discharge. up to six months or more. As long NICE has recently come up with an as it is not associated with other ONeurovascular damage in this group of patients. Other O otal Knee Replacement anaesthetic risks intra-operatively evidence-based guideline advising worrying symptoms such as wound Tendon damage (TKR) is one of the include cardiovascular, some form of VTE prophylaxis discharge, redness etc then there OComponent commonest orthopaedic respiratory and renal post TKR but there is still should be no cause for concern. malalignment procedures with over 70,000 complications. Intra-operative hesitation among the orthopaedic OSoft-tissue imbalance T community to embrace these performed per year in the UK alone. surgical complications include Infection Immediate post-operative Currently there are more the following: guidelines wholeheartedly due This is also possible at the OInfection to the adverse e!ect of bleeding than 150 di!erent types of knee intermediate stage and should be O as well as subsequent infection DVT/PE prosthesis available in the UK Fractures actively looked for. OHaemorrhage market. However, a close analysis in the haematoma arising from The incidence of this is 1:1000 ONeurovascular damage will reveal that only a few of these thromboprophylaxis. for TKR (compared to up to 20% ! implants actually have long-term Instability OSti ness in Total Hip Replacements). The # results with true long-term data. This can be a di cult problem to fractures can occur in the femur, Haemorrhage The National Joint Registry in diagnose as well as resolve and Delayed the tibia or the patella if it is also Bleeding may continue into the the UK captures information on patients present with varying Intermediate being replaced. postoperative period and up to all knee replacements performed 50% of patients require between symptoms like pain and even OSwelling within the UK and is a great source 1-3 units of blood. Newer practices dislocation of the implants in some OPain cases. There can be maltracking of of survival and outcome data. Haemorrhage like administering anti"brinolytic X-rays of periprosthetic fracture OSti!ness Knee replacement is performed the patella on the knee causing any treated with intramedullary $xation agents such as tranexemic acid are OInstability most commonly under tourniquet. being explored to reduce this need of these symptoms. The average blood loss during cause settles down or whether Long term for transfusion. patients become accustomed to O surgery is about 500 mls with Sti#ness Infection approximately 1.5 L of total loss the pain and stop complaining is OAseptic loosening Neurovascular damage This can be persistent at this stage. di#cult to ascertain. It is, however, around the entire peri-operative Approximately 5% of patients end OPeri-prosthetic fracture period. Neurovascular damage is often ! important to note that without a ODislocation picked up postoperatively up with sti ness following knee "rm diagnosis, revision surgery to replacement. OExtensor mechanism although this is an intraoperative resolve pain is associated with damage Neurovascular damage phenomenon. Incidence of poor outcome. X-rays of Total Knee Replacement The incidence of damage to nerves damage to artery is about 0.5% and Long term: or arteries, including major vessels damage to nerve about 2%. This Pain Extensor mechanism damage Above is a list of the common and nerves, is approximately 2.5%. can be as a result of direct damage This can be a manifestation of a There is a 1% incidence of damage complications that can occur COMPLICATIONS during surgery or as a result of Currently, the approximate diverse range of problems. The to the extensor mechanism, i.e after Total Knee Replacement. It is tourniquet, leading to tourniquet survival rate for TKR in UK is 95% Tendon damage usual causes that should be looked quadriceps or patellar tendon or worth keeping in mind that even palsy. The common peroneal nerve at 10 years and 85-90% at 15 years. Damage to the tendons and for are infection and loosening. patella in the long term. the “common” complications are is one of the more commonly Complications following TKR can ligaments of the knee occurs to Component malpositioning can actually quite rare and almost damaged nerves. be summarised broadly into Early the extent of 0.2%. This is mainly also cause pain in the long term. nine out of ten patients are Some patients su!er from chronic Periprosthetic fracture very happy after a Total Knee and Delayed. A list of the common related to the patellar tendon There is a 2% incidence of this in # regional pain syndrome after TKR Replacement. Patients should complications are provided in the and occasionally the collateral Sti ness the long term and it can usually be Approximately 2% of patients su!er but fortunately most of these be allowed to make an informed table on far right. ligaments. attributed to some form of trauma, from knee sti!ness following surgery. resolve by six months. Sometimes decision with regard to their even low-impact ones. The best indicator of postoperative no actual cause for the pain can surgery and it is useful to make EARLY Immediate post-operative: range of movement in knee be ascertained. The incidence of them aware of potential risks. Intra-operative: Infection replacement is the preoperative unexplained pain after one year Dislocation However, during the discussion These can be related to the Infection occurs in about 1-2% range of movement and in patients is in the region of 10%, taking up Depending on the type of implant these risks should be put in anaesthesia or the actual surgical of cases and may require further who have su!ered from prolonged to two years for this to resolve. used, dislocation can occur in up to perspective in terms of the overall procedure. The risk of mortality washout of the knee in an attempt knee sti!ness preoperatively, it is Whether this is because the actual 2% of cases. high success rate of TKR. 12 Secretary 07557 656 082 email: [email protected] website: www.londonkneespecialists.co.uk 13 Our Multidisciplinary Team of Consultants Include... ORheumatologists specialising in Hypermobility The Hypermobility Unit Professor Rodney Grahame CBE MD FRCP FACP Advisor to the Hypermobility Association Dr Alan Hakim BA MA MB BChir CCST FRCP he only facility of its kind, CMO of the Hypermobility Association the forward-thinking multi- Dr Hanadi Kazkaz LRCP LRCS LRCPS MRCP MSc ROTATOR disciplinary Hypermobility TUnit at the world-renowned OPaediatrician Hospital of St John and St Elizabeth is a ‘one-stop-shop’, catering for all Dr Nelly Ninis MBBS MRCP MD MSC DTM&H the medical needs of patients with OGastroenterologists CUFF Joint Hypermobility Syndrome (JHS), Professor Qasim Aziz FRCS PhD Ehlers-Danlos syndrome (EDS) and Dr Claude Botha MB ChB MRCPsych rarer forms of hypermobility. OPain Psychologists Our team is experienced in TEARS the diagnosis and management Dr Netali Levi BA (Hons) D.Clin.Psy of all musculoskeletal disorders, Dr Claire Williams DClinPsy MA and is unique in providing ONeurologist treatment and services associated Professor Christopher Mathias MBBS DPhil DSc FRCP FMedSci with such disorders under one OGeneticist and Dermatologist roof. Housed in state-of-the-art surroundings, our services and Professor Francis Michael Pope MBBCh FRCP MD clinics include a rheumatology clinic, OPodiatrist neurogastroenterology, autonomic Mrs Sophie Roberts BSc (Hons) Podiatry SRCh MChs HYPERMOBILITY The major points to address ! during physical examination of OUR ‘ONE STOP patients with suspected rotator cu" pathology include the loss of SHOP’ active or passive range of motion, painful range of motion, presence dysfunction, clinical genetics, oral of muscle atrophy, weakness, surgery and laryngology as well as specialised therapy (physiotherapy, MR PHILIP AHRENS swelling and tenderness. occupational therapy, podiatry and FRCS (Tr & Orth) pain psychology). The consultants in the unit receive referrals from the UK any eponymous tests have been described and across the world. to examine the shoulder. However, there is With great !exibility and a lack of consensus on clinical assessment The Shoulder Unit is the UK’s leading centre convenience, the unit is able to of patients with shoulder pain and for shoulder and elbow surgery. It has an call upon a wide range of services M " " international reputation for excellence in treating suspected rotator cu pathology. Rotator cu tears within the hospital, working closely are a common cause of shoulder pain and professional sportsmen and Olympic athletes, with other disciplines such as occupational disability. with the same high level of care provided to all urogynaecology, cardiology and our patients. www.shoulderunit.co.uk More than 50 per cent of individuals older than orthopaedic surgery to provide 60 have at least a partial-thickness rotator cu" tear, multi-disciplinary care and support with signi#cant impact on their quality of life, and rotator cu" pathology may be related to the close for patients with complex problems. marked functional impairment. As a large percentage relationships of structures in the shoulder, the poor Using the latest in clinical and of older individuals maintain a very active lifestyle, it is anatomical basis of the tests and the lack of their diagnostic procedures, imaging and important for clinicians to be able to accurately reproducibility. Therefore experience in performing pathology, consultants conduct a identify and appropriately manage patients with and combining clinical tests is important; and other physical examination and provide a rotator cu" tears. information, such as mechanism of injury, pain thorough evaluation of a patient’s The conclusions of published research are in behaviour and location of pain, combined with condition. Once diagnosis has agreement that most speci#c tests for rotator cu" conventional radiographic signs, is also essential to been made, treatment, support pathology are inaccurate. There is insu$cient making an accurate diagnosis. and management techniques evidence in recent literature to recommend any one are provided to make day-to-day clinical examination test for diagnosis of rotator cu" * Sports Med Arthrosc. 2011 Sep;19(3):266-78. Clinical life easier, reducing stress to the pathology *. tests for the diagnosis of rotator cu! disease. Longo UG, joints and improving quality of life. Poor diagnostic accuracy of clinical tests for Berton A, Ahrens PM, Ma!ulli N, Denaro V. Following assessment, specialist advice can be provided to the GPs and physiotherapists who routinely 020 7432 8282 email: [email protected] www.shoulderunit.co.uk manage the patient’s care.

O For appointments with any of our hypermobility consultants call outpatients on 020 7806 4060. 14 For appointments with a specialist physiotherapist call physio on 020 7806 4010. 15 management and remain symptomatic. SURGICAL CHOICES IN TREATING KIENB ÖCK'S There are several surgical options for treating the more advanced If the bones of the KIENB Ö CK’S stages of Kienböck’s disease, lower arm are uneven ranging from attempts at in length, a joint revascularising the osteonecrotic levelling procedure MR ELLIOT SORENE lunate to unloading it either by may be recommended. manipulations of carpal bones or by MBBS FRCS EDHS The radius bone may DISEASE adjustment of the relative lengths of be shortened by the radius and ulna. vascular necrosis of removing a section of Once a lunate has fragmented the lunate, Kienböck’s the bone. This levelling then various methods have been disease, is a progressive, procedure reduces the used to restore, replace or ablate debilitating disease that forces that bear down Proximal Row Carpectomy (PRC) A the lunate using techniques to bone may lead to chronic pain and loss on (compress) the graft the lunate, excise it, replace of wrist function. The aetiology of : lunate and seems to ! it with bone, muscle, vascularised Kienböck’s remains unidenti ed, halt progression of the Scapho-capitate grafts or with arti!cial materials the natural history is poorly disease. fusion ! such as silicone, ceramic and steel. de ned, and the radiographic If the lunate is (Limited wrist The salvage options of proximal appearance does not always severely collapsed or fusion) ! row carpectomy, joint replacement correlate with the clinical ndings. fragmented, it can

: or fusion have also been reported. Some progress has been made be removed with the ! Advanced Grade 3B Kienbock’s There are numerous publications in the identi cation and an two bones on either disease with lunate collapse now that report late outcomes of understanding of the progression side of the lunate. This of the avascular process and several of these interventions. Stage 3: The dead bone procedure, called a proximal row carpectomy (PRC), will relieve pain its deleterious e"ects on wrist Stage 1: X-rays may be normal begins to collapse and break while maintaining partial wrist motion. mechanics. or suggest a possible fracture. into pieces. As the bone Another procedure that eases pressure on the bone is fusion. Many patients with Kienböck’s Magnetic resonance imaging begins to break apart, the In this procedure, several of the small bones of the hand are fused disease think they have a sprained (MRI) may also be helpful in surrounding bones may begin together. If the disease has progressed to severe arthritis of the wrist and in many cases there is making the diagnosis in this to shift position. Increasing wrist, fusing the bones will reduce pain and help maintain function. a prolonged period of time until early stage. pain, weakness in gripping, The range of wrist motion, however, will be limited. they are correctly diagnosed. and limited motion may be There is also the option in certain cases of undertaking a lunate This disorder may be confused experienced. replacement. If the wrist is severely destroyed then the options are with benign cysts and traumatic total wrist arthrodesis (fusion) or total wrist replacement. fractures which can also cause some collapse of the lunate. However, these conditions are uncommon and Kienböck’s OMr Sorene has an interest in Kienböck’s disease and undertakes disease should be the !rst to be all of the most modern treatments for Kienböck’s disease including considered. arthroscopic treatment, wrist denervation, limited wrist fusions, Kienböck’s disease most often proximal row carpectomy and lunate replacement surgery. occurs between the ages of 20 and 40 and is twice as common in men. In advanced disease the symptoms are those of established WRIST REPLACEMENT osteoarthritis of the wrist. Bilateral Kienböck’s disease is uncommon. Stage 2: The lunate bone begins In Kienböck’s disease, the blood to harden. Brighter or whiter The choice of procedure will supply to the lunate is interrupted areas on X-rays indicate that the depend on several factors, including and the bone undergoes changes bone is dying. MRI or computed disease progression, activity level, and eventually collapses. tomography (CT) may be used Stage 4: The surfaces of personal goals and the surgeon’s Patients often complain of a to assess the bone. Wrist pain, adjoining bones are a"ected. experience with the procedures. In painful and sometimes swollen swelling and tenderness are One result may be generalised some cases, it may be possible to wrist. There may be a limited range common. arthritis of the wrist. return the blood supply to the bone of motion in the a"ected wrist (revascularisation). (sti"ness) and decreased grip This procedure takes a portion strength in the hand. Often there Although there is no way of disease, remain functional and with of bone (graft) from the inner can be tenderness directly over the de!nitively curing this condition, tolerable symptoms. Therefore, a bone of the lower arm. The Xrays show how wrist top of the wrist and pain or di#culty there are several nonsurgical and trial of conservative treatment with graft is lifted up on a named alignment in severely in turning the hand upward. surgical options for treating this splinting for up to three months, or blood vessel and inserted into damaged wrists can Kienböck’s disease progresses disease, depending on which casting and adjunctive analgesic the lunate, providing both be corrected by total through four stages. In its early stage the lunate has reached. or anti-in$ammatory medication, biological vascularised bone and replacement. Wrist function can be mostly retained stages, it may be di#cult to The goals of treatment are to appears to be warranted in most also a structural advantage in following wrist replacement diagnose because the symptoms relieve the pressure on the lunate patients, regardless of the stage at reconstructing the lunate. are so similar to those of a and to try to restore blood $ow presentation. Surgical intervention sprained wrist. Even X-rays of the within the bone. Many patients, should be reserved for patients CONTACT: Secretary 020 7078 3869 Email: [email protected] Web: www.londonhand.com wrist may appear normal. even with advanced Kienböck’s who fail a trial of conservative 16 17 Palliative care ambulance AWARD WINNING ASSESSING A PATIENT HOSPICE@ HOME AT HOME USING THE SERVICE! BERG BALANCE TEST OOur Hospice&Home ne of the advantages of domiciliary physiotherapy is that we are able to assess a patient within service has won a prestigious their home environment. This is particularly useful when evaluating a patient’s mobility and national award. their likelihood of falling. ! The team was awarded O A number of factors which contribute to falls in the elderly have been identi ed. These the Domiciliary/Home include lower extremity disabilities, foot problems, reduced sensation, increased reaction time and gait Healthcare Provider 2012 at and balance abnormalities. the Independent Healthcare Physiotherapists in the clinical setting often choose the Berg Balance Test to gauge balance Awards in September at impairment because it is easy to administer, takes approximately 20 minutes to complete and doesn’t ! a dinner held in Central require sophisticated equipment. The test is valid and highly speci c with a strong inter-rater reliability. London. It also correlates with platform-based measures of postural sway. They were among the The assessment consists of 14 tasks performed in a standard order. 18 winners showcasing ! companies working across Each task is scored on a ve-point scale (0-4) depending on quality of a wide range of specialities, performance or time taken to complete the task. Equipment required: a from acute hospitals to step stool, two chairs with arms, a tape measure, a stopwatch and a pen. rehabilitation units. This is the !rst time that the THE TASKS ARE: Hospice has been nominated for an award. 1. Sitting to standing 2. FANTASTIC Standing unsupported 3. Sitting unsupported ACHIEVEMENT Ready to go: The Hospice After the amazing victory ambulance drivers 4. Standing to sitting Chief Executive David 5. Transfers Marshall said: ‘This is a 6. Standing with eyes closed fantastic achievement by the 7. team and has certainly given Standing with feet together the Charity and especially St ST JOHN’S 8. Reaching forward with John’s Hospice the reward outstretched arms they deserve for their tireless 9. Retrieving object from !oor work in stressful situations.” LEADS THE WAY The award was set up 10. Turning to look behind to speci!cally recognise FOR PATIENTS 11. Turning 360 degrees outstanding quality 12. Placing alternate foot on stool and innovation in the 13. Independent healthcare new dedicated Palliative patients from hospital to St Standing with one foot in front of sector. Established in Care Ambulance was John’s Hospice and from the other 2006, they aim to laud the A launched for patients St John’s Hospice to specialist 14. Standing on one foot achievements within the known to St John’s Hospice from appointments. sector and to praise the the beginning of November. The St John’s Hospice high standards of those who This will provide increased Palliative Care Ambulance is The maximum score is 56. A high score indicates good balance deliver true excellence in comfort and responsiveness the !rst of its kind in London and a lower risk of falls, while a score of less than 45 indicates an their work. to enable patients to be and has been specially !tted increased risk of falls. Interestingly, people who score very low transferred from their home to to provide the highest levels on a Berg Balance Test (i.e. the most physically impaired) tend HIGHLY TAILORED St John’s Hospice when they are of comfort and support for not to fall because they do not take risks in the same way that APPROACH in need of an urgent or planned patients. someone with a score closer to the 45-point cut-o" might. It is Judges for the event admission. They will have a dedicated suggested that the lowest scorers use strategies to compensate organised by healthcare This new service will also team of three ambulance for their limited mobility, such as having an assistant with them, intelligence provider Laing & allow patients to be transferred drivers who have been given or using assistive devices. Buisson singled out St John’s from St John’s Hospice to comprehensive training and We must bear in mind that falls are multi-factorial and in order Hospice highlighting, “its their own home to be able to induction relating to their roles to accurately predict a patient’s risk of falling, their environment highly tailored approach to continue to receive care and in supporting patients, often at and how well they perform, their ADLs must also be examined. the very delicate subject of support there and it will also the end of life, being transferred patients dying in the comfort provide the facility to transfer between the Hospice and home. Contact: Physiotherapy department on 020 7806 4010 or email the Lead Domiciliary Physiotherapists at [email protected] or [email protected] of their homes.” www.stjohnshospice.org.uk 18 19 ORTHOPAEDIC SPECIALITY UNITS LONDON FOOT & ANKLE CENTRE Telephone: 020 7078 3800 Fax: 020 7078 3801 email: [email protected] www.londonfootandanklecentre.co.uk

SPINE UNIT SHOULDER UNIT Telephone: 0844 589 2020 Telephone: 020 7806 4004 Fax: 0844 589 6060 Fax: 020 7806 4008 email: [email protected] email: [email protected] www.thespineunit.org.uk www.shoulderunit.co.uk

KNEE UNIT HYPERMOBILITY UNIT Telephone: 020 7432 8297 The Telephone: 020 7806 4060 Fax: 020 7806 4045 Fax: 020 7806 4045 email: [email protected] email: [email protected] www.londonkneespecialists.co.uk www.thehypermobilityunit.org.uk

Our Orthopaedic Surgeons Cover All Specialities

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HOSPITAL OF ST JOHN & ST ELIZABETH O Our pro!ts help support St John’s Hospice which Tel: 020 7806 4000 cares for more than 2,000 terminally ill people and [email protected] www.hje.org.uk their families every year. 60 Grove End Road, St. John’s Wood, 20 London NW8 9NH [email protected] www.stjohnshospice.org.uk