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Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_6 | Pages 60 - 60
2 May 2024
Farrow L Clement N Meek D
Full Access

Given the prolonged waits for hip arthroplasty seen across the U.K. it is important that we optimise priority systems to account for potential disparities in patient circumstances and impact. We set out to achieve this through a two-stage approach. This included a Delphi-study of patient and surgeon preferences to determine what should be considered when determining patient priority, followed by a Discrete Choice Experiment (DCE) to decide relative weighting of included attributes.

The study was conducted according to the published protocol ([https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071](https://boneandjoint.org.uk/article/10.1302/2633-1462.310.BJO-2022-0071)). The Delphi study was performed online over 3 rounds with anonymous ranking and feedback. Included factors were voted as either Consensus in, Consensus out, or No Consensus• following an established scoring criterion. A final consensus meeting determined the prioritisation factors (and their levels) to be included in the DCE. The DCE was then conducted using an online platform, with surgeons performing 18 choice sets regarding which merited greater priority between two hypothetical patients. Results were collated and analysed using multinomial logit regression analysis (MNL).

For the Delphi study there were 43 responses in the first round, with a subsequent 91% participation rate. Final consensus inclusion was achieved for Pain; Mobility/Function; Activities of Daily Living; Inability to Work/Care; Length of Time Waited; Radiological Severity and Mental Wellbeing. 70 individuals subsequently contributed to the DCE, with radiological severity being the most significant factor (Coefficient 2.27 \[SD 0.31\], p<0.001), followed by pain (Coefficient 1.08 \[SD 0.13\], p<0.001) and time waited (Coefficient for 1-month additional wait 0.12 \[SD 0.02\], p<0.001). The calculated trade-off in waiting time for a 1-level change in pain (e.g., moderate to severe pain) was 9.14 months.

These results present a new method of determining comparative priority for those on primary hip arthroplasty waiting lists. Evaluation of potential implementation in clinical practice is now required.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_6 | Pages 36 - 36
2 May 2024
Jones R Phillips J Panteli M
Full Access

Total joint arthroplasty (TJA) is one of the commonest and most successful orthopaedic procedures used for the management of end-stage arthritis. With the recent introduction of robotic-assisted joint replacement, Computed tomography (CT) has become part of required pre-operative planning.

The aim of this study is to quantify and characterise incidental CT findings, their clinical significance, and their effect on the planned joint arthroplasty.

All consecutive patients undergoing an elective TJA (total joint arthroplasty; hip or knee) were retrospectively identified, over a 4-year period (December 2019 and November 2023). Data documented and analysed included patient demographics, type of joint arthroplasty, CT findings, their clinical significance, as well as potential delays to the planned arthroplasty because of these findings and subsequent further investigation.

A total of 987 patients (female: 514 patients (52.1%)) undergoing TJA were identified (THA: 444 patients (45.0%); TKA: 400 patients (40.5%); UKA: 143 patients (14.5%)). Incidental findings within imaged areas were identified in 227 patients (23.0%). Of these findings, 74 (7.5%) were significant, requiring further investigation or management, 40 (4.1%) of which represented potential malignancy and 4 (0.4%) resulting in a new cancer diagnosis. A single patient was found to have an aneurysm requiring urgent vascular intervention. Surgery was delayed for further investigation in 4 patients (0.4%). Significant findings were more frequent in THA patients (THA: 43 (9.7%) TKA/UKA: 31 (5.7%)

Within our cohort, 74 (7.5%) patients had significant incidental findings that required further investigations or management, with 4 (0.4%) having a previously undiagnosed malignancy. We strongly advocate that all robotic arthroplasty planning CTs are reviewed and reported by a specialist, to avoid missing undiagnosed malignancies and other significant diagnoses.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_6 | Pages 25 - 25
2 May 2024
Ajula R Mayne A Cecchi S Ebert J Edwards P Davies P Ricciardo B Annear P D'Alessandro P
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Proximal hamstring tendon avulsion from the ischial tuberosity is a significant injury, with surgical repair shown to have superior functional outcomes compared to non-surgical treatment. However, limited data exists regarding the optimal rehabilitation regime following surgical repair. The aim of this study was to investigate patient outcomes following repair of proximal hamstring tendon avulsions between a conservative (CR) versus an accelerated rehabilitation (AR) regimen.

This prospective randomized controlled trial (RCT) randomised 50 patients undergoing proximal hamstring tendon repair to either a braced, partial weight-bearing rehabilitation regime (CR=25) or an accelerated, unbraced regime, that permitted full weight-bearing as tolerated (AR=25).

Patients were evaluated pre-operatively and at 3 and 6 months post-surgery, via patient-reported outcome measures (PROMs) including the Lower Extremity Functional Scale (LEFS), Perth Hamstring Assessment Tool (PHAT) and 12-item Short Form Health Survey (SF-12). Primary analysis was per protocol and based on linear mixed models.

Both groups were matched at baseline with respect to patient characteristics. All PROMs improved (p>0.05) and, while the AR group reported a significantly better Physical Component Score for the SF-12 at 3 months (p=0.022), there were no other group differences. Peak isometric hamstrings strength and peak isokinetic quadriceps and hamstrings torque symmetry were all comparable between groups (p>0.05). Three re-injuries have been observed (CR=2, AR=1).

After proximal hamstring repair surgery, post-operative outcomes following an accelerated rehabilitation regimen demonstrate comparable outcomes to a traditionally conservative rehabilitation pathway, albeit demonstrating better early physical health-related quality of life scores, without an increased incidence of early re-injury.


Implants in total hip replacement (THR) are associated with different clinical and cost-effectiveness profiles,. We estimate the costs and outcomes for NHS patients in the year after THR associated with implant bearing materials using linked routinely collected data.

We linked NJR primary elective THR patients for osteoarthritis to HES and National PROMs. We estimated health care costs, health-related quality of life indices, and revision risks, in the year after primary and revision THRs overall. We used generalised linear models adjusting for patient and hospital characteristics and estimated 10-year cumulative probability of revision. We imputed utilities using chained equations for half the sample with missing PROMS.

We linked 577,973 elective primary THRs and 11,812 subsequent revisions. One year after primary THR, patients with the cemented THRs using cobalt chrome or stainless steel head with HCLPE liner/cup cost the NHS, on average, £13,101 (95%CI £13,080,£13,122), had an average quality-of-life score of 0.788 (95%CI 0.787,0.788), and a 10-year revision probability of 1.9% (95%CI 1.6,2.3). Compared to the reference, patients receiving a cemented THR with delta ceramic head and HCLPE liner/cup, hybrid THR with delta ceramic head and HCLPE liner/cup, and hybrid THR with alumina head and HCLPE liner/cup had lower 1-year costs (-£572 \[95% CI -£775,-£385\], -£346 \[-£501,-£192\], -£371 \[-£574,-£168\] respectively), better quality of life (0.007 \[95% CI 0.003,0.011\], 0.013 \[0.010,0.016\], 0.009 \[0.005,0.013\] respectively), and lower 10-year revision probabilities (1.4% \[1.03,2.0\], 1.5 \[1.3,1.7\], 1.6%\[1.2,2.1\] respectively).

Implant bearing materials are associated with varying mean costs and health outcomes after primary THR. Ours is the first study to derive costs and health outcomes from large, linked databases using multiple imputation methods to deal with bias. Our findings are useful for commissioning and procurement decisions and to inform a subsequent cost-effectiveness model with more granular detail on THR implant types.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_6 | Pages 12 - 12
2 May 2024
Selim A Al-Hadithy N Diab N Ahmed A Kader KA Hegazy M Abdelazeem H Barakat A
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Lag screw cut-out is a serious complication of dynamic hip screw fixation in trochanteric hip fractures. Lag screw position is recognised as a crucial factor influencing the occurrence of lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesize that it could enhance the reliability of predicting lag screw cut-out in these injuries.

A retrospective study of hip fracture cases was conducted from January 2018 to July 2022. A total of 109 patients were eligible for the final analysis. The modified TAD was measured in millimetres, based on the sum of the traditional TAD in the lateral view and the net value of two distances in the anteroposterior (AP) view. The first distance is from the lag screw tip to the opposite point on the femoral head along the lag screw axis, while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if it is inferior. Receiver operating characteristic (ROC) curve analysis was used to assess the reliability of various parameters for evaluating the lag screw position within the femoral head.

Factors such as reduction quality, fracture pattern according to the AO/OTA classification, TAD, Calcar-Referenced TAD, Axis Blade Angle, Parker’s ratio in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the novel parameter exhibited 90.1% sensitivity and 90.9% specificity for predicting lag screw cut-out at a cut-off value of 25 mm, with a p-value < 0.001.

The modified TAD demonstrated the highest reliability in predicting lag screw cut-out. A value of 25 mm may potentially reduce the risk of lag screw cut-out in trochanteric hip fractures.


The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 425 - 429
1 May 2024
Jeys LM Thorkildsen J Kurisunkal V Puri A Ruggieri P Houdek MT Boyle RA Ebeid W Botello E Morris GV Laitinen MK

Chondrosarcoma is the second most common surgically treated primary bone sarcoma. Despite a large number of scientific papers in the literature, there is still significant controversy about diagnostics, treatment of the primary tumour, subtypes, and complications. Therefore, consensus on its day-to-day treatment decisions is needed. In January 2024, the Birmingham Orthopaedic Oncology Meeting (BOOM) attempted to gain global consensus from 300 delegates from over 50 countries. The meeting focused on these critical areas and aimed to generate consensus statements based on evidence amalgamation and expert opinion from diverse geographical regions. In parallel, periprosthetic joint infection (PJI) in oncological reconstructions poses unique challenges due to factors such as adjuvant treatments, large exposures, and the complexity of surgery. The meeting debated two-stage revisions, antibiotic prophylaxis, managing acute PJI in patients undergoing chemotherapy, and defining the best strategies for wound management and allograft reconstruction. The objectives of the meeting extended beyond resolving immediate controversies. It sought to foster global collaboration among specialists attending the meeting, and to encourage future research projects to address unsolved dilemmas. By highlighting areas of disagreement and promoting collaborative research endeavours, this initiative aims to enhance treatment standards and potentially improve outcomes for patients globally. This paper sets out some of the controversies and questions that were debated in the meeting.

Cite this article: Bone Joint J 2024;106-B(5):425–429.


The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 422 - 424
1 May 2024
Theologis T Perry DC

In 2017, the British Society for Children’s Orthopaedic Surgery engaged the profession and all relevant stakeholders in two formal research prioritization processes. In this editorial, we describe the impact of this prioritization on funding, and how research in children’s orthopaedics, which was until very recently a largely unfunded and under-investigated area, is now flourishing. Establishing research priorities was a crucial step in this process.

Cite this article: Bone Joint J 2024;106-B(5):422–424.


The Bone & Joint Journal
Vol. 106-B, Issue 5 Supple B | Pages 59 - 65
1 May 2024
Liu WKT Cheung A Fu H Chan PK Chiu KY

Aims

Isolated acetabular liner exchange with a highly crosslinked polyethylene (HXLPE) component is an option to address polyethylene wear and osteolysis following total hip arthroplasty (THA) in the presence of a well-fixed acetabular shell. The liner can be fixed either with the original locking mechanism or by being cemented within the acetabular component. Whether the method used for fixation of the HXLPE liner has any bearing on the long-term outcomes is still unclear.

Methods

Data were retrieved for all patients who underwent isolated acetabular component liner exchange surgery with a HXLPE component in our institute between August 2000 and January 2015. Patients were classified according to the fixation method used (original locking mechanism (n = 36) or cemented (n = 50)). Survival and revision rates were compared. A total of 86 revisions were performed and the mean duration of follow-up was 13 years.


The Bone & Joint Journal
Vol. 106-B, Issue 5 Supple B | Pages 3 - 10
1 May 2024
Heimann AF Murmann V Schwab JM Tannast M

Aims

The aim of this study was to investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies. We asked: is there a difference in APP-PT between young symptomatic patients being evaluated for joint preservation surgery and an asymptomatic control group? Does APP-PT vary among distinct acetabular and femoral pathomorphologies? And does APP-PT differ in symptomatic hips based on demographic factors?

Methods

This was an institutional review board-approved, single-centre, retrospective, case-control, comparative study, which included 388 symptomatic hips in 357 patients who presented to our tertiary centre for joint preservation between January 2011 and December 2015. Their mean age was 26 years (SD 2; 23 to 29) and 50% were female. They were allocated to 12 different morphological subgroups. The study group was compared with a control group of 20 asymptomatic hips in 20 patients. APP-PT was assessed in all patients based on supine anteroposterior pelvic radiographs using validated HipRecon software. Values in the two groups were compared using an independent-samples t-test. Multiple regression analysis was performed to examine the influences of diagnoses and demographic factors on APP-PT. The minimal clinically important difference (MCID) for APP-PT was defined as > 1 SD.


The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 442 - 449
1 May 2024
Nieboer MF van der Jagt OP de Munter L de Jongh MAC van de Ree CLP

Aims

Periprosthetic proximal femoral fractures (PFFs) are a major complication after total hip arthroplasty (THA). Health status after PFF is not specifically investigated. The aim of this study is to evaluate the health status pattern over two years after sustaining a PFF.

Methods

A cohort of patients with PFF after THA was derived from the Brabant Injury Outcomes Surveillance (BIOS) study. The BIOS study, a prospective, observational, multicentre follow-up cohort study, was conducted to obtain data by questionnaires pre-injury and at one week, and one, three, six, 12, and 24 months after trauma. Primary outcome measures were the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), the Health Utility Index 2 (HUI2), and the Health Utility Index 3 (HUI3). Secondary outcome measures were general measurements such as duration of hospital stay and mortality.


Bone & Joint Research
Vol. 13, Issue 5 | Pages 201 - 213
1 May 2024
Hamoodi Z Gehringer CK Bull LM Hughes T Kearsley-Fleet L Sergeant JC Watts AC

Aims

The aims of this study were to identify and evaluate the current literature examining the prognostic factors which are associated with failure of total elbow arthroplasty (TEA).

Methods

Electronic literature searches were conducted using MEDLINE, Embase, PubMed, and Cochrane. All studies reporting prognostic estimates for factors associated with the revision of a primary TEA were included. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool, and the quality of evidence was assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. Due to low quality of the evidence and the heterogeneous nature of the studies, a narrative synthesis was used.


The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 501 - 507
1 May 2024
Galloway AM Keene DJ Anderson A Holton C Redmond AC Siddle HJ Richards S Perry DC

Aims

The aim of this study was to produce clinical consensus recommendations about the non-surgical treatment of children with Perthes’ disease. The recommendations are intended to support clinical practice in a condition for which there is no robust evidence to guide optimal care.

Methods

A two-round, modified Delphi study was conducted online. An advisory group of children’s orthopaedic specialists consisting of physiotherapists, surgeons, and clinical nurse specialists designed a survey. In the first round, participants also had the opportunity to suggest new statements. The survey included statements related to ‘Exercises’, ‘Physical activity’, ‘Education/information sharing’, ‘Input from other services’, and ‘Monitoring assessments’. The survey was shared with clinicians who regularly treat children with Perthes’ disease in the UK using clinically relevant specialist groups and social media. A predetermined threshold of ≥ 75% for consensus was used for recommendation, with a threshold of between 70% and 75% being considered as ‘points to consider’.


Bone & Joint Open
Vol. 5, Issue 5 | Pages 374 - 384
1 May 2024
Bensa A Sangiorgio A Deabate L Illuminati A Pompa B Filardo G

Aims

Robotic-assisted unicompartmental knee arthroplasty (R-UKA) has been proposed as an approach to improve the results of the conventional manual UKA (C-UKA). The aim of this meta-analysis was to analyze the studies comparing R-UKA and C-UKA in terms of clinical outcomes, radiological results, operating time, complications, and revisions.

Methods

The literature search was conducted on three databases (PubMed, Cochrane, and Web of Science) on 20 February 2024 according to the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Inclusion criteria were comparative studies, written in the English language, with no time limitations, on the comparison of R-UKA and C-UKA. The quality of each article was assessed using the Downs and Black Checklist for Measuring Quality.


Bone & Joint Open
Vol. 5, Issue 4 | Pages 367 - 373
26 Apr 2024
Reinhard J Lang S Walter N Schindler M Bärtl S Szymski D Alt V Rupp M

Aims

Periprosthetic joint infection (PJI) demonstrates the most feared complication after total joint replacement (TJR). The current work analyzes the demographic, comorbidity, and complication profiles of all patients who had in-hospital treatment due to PJI. Furthermore, it aims to evaluate the in-hospital mortality of patients with PJI and analyze possible risk factors in terms of secondary diagnosis, diagnostic procedures, and complications.

Methods

In a retrospective, cross-sectional study design, we gathered all patients with PJI (International Classification of Diseases (ICD)-10 code: T84.5) and resulting in-hospital treatment in Germany between 1 January 2019 and 31 December 2022. Data were provided by the Institute for the Hospital Remuneration System in Germany. Demographic data, in-hospital deaths, need for intensive care therapy, secondary diagnosis, complications, and use of diagnostic instruments were assessed. Odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality were calculated.


Bone & Joint Open
Vol. 5, Issue 4 | Pages 361 - 366
24 Apr 2024
Shafi SQ Yoshimura R Harrison CJ Wade RG Shaw AV Totty JP Rodrigues JN Gardiner MD Wormald JCR

Aims

Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma.

Methods

This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 13 - 13
23 Apr 2024
Lister J McDaid C Hewitt C Leggett H James S Sharma H
Full Access

Introduction

There are concerns that patient-reported outcome measures (PROMs) currently used for adults requiring, undergoing or after undergoing lower limb reconstruction (LLR) are not adequately capturing the range of experiences important to these patients. The ‘Patient-Reported Outcome Measure for Lower Limb Reconstruction’ (PROLLIT) study developed a conceptual framework of outcomes identified as important and relevant by adult LLR patients. This review explored whether existing PROMs address these outcomes, and exhibit content validity in this population.

Materials & Methods

A range of key PROMs was selected (n=32). Systematic and hand-searches were employed to find studies assessing content validity of these PROMs in the adult LLR population, along with PROM content and development information. A systematic review of content validity of the measures was carried out following ‘COnsensus-based Standards for the selection of health Measurement Instruments’ (COSMIN) guidance, alongside conceptual mapping of the content of the PROMs against the PROLLIT conceptual framework.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 6 - 6
23 Apr 2024
Mistry D Rahman U Khatri C Carlos W Stephens A Riemer B Ward J
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Introduction

Continuous compression implants (CCIs) are small memory alloy bone staples that can provide continuous compression across a fracture site, which change shape due to temperature changes. Reviews of CCIs in orthopaedics have documented their use in mainly foot and ankle surgery, with very limited descriptions in trauma. They could be beneficial in the management of complex or open injuries due to their low profile and quick insertion time. The aim of this case series were to clarify the use of CCIs in modern day limb reconstruction practice.

Materials & Methods

This was a single centred study looking retrospectively at prospective data for patients who were treated for an acute fracture or non-union with a CCI between September 2019 and May 2023. Primary outcome was to determine the function and indication of the CCI as judged retrospectively and secondary outcomes investigated unplanned returns to theatre for infection or CCI failure.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 17 - 17
23 Apr 2024
Mackarel C Tunbridge R
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Introduction

Sheffield Children's Hospital specialises in limb lengthening for children. Soft tissue contracture and loss of range of motion at the knee and ankle are common complications. This review aims to look at therapeutic techniques used by the therapy team to manage these issues.

Materials & Methods

A retrospective case review of therapy notes was performed of femoral and tibial lengthening's over the last 3 years. Included were children having long bone lengthening with an iIntramedullary nail, circular frame or mono-lateral rail. Patients excluded were any external fixators crossing the knee/ankle joints.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 29 - 29
23 Apr 2024
Ahmed T Upadhyay P Menawy ZE Kumar V Jayadeep J Chappell M Siddique A Shoaib A
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Introduction

Knee dislocations, vascular injuries and floating knee injuries can be initially managed by a external fixator. Fixator design constructs include the AO pattern and the Diamond pattern. However, these traditional constructs do not adhere to basic principles of external fixation. The Manchester pattern knee-spanning external fixator is a new construct pattern, which uses beam loading and multiplanar fixation. There is no data on any construct pattern. This study compares the stability of these designs.

Materials & Methods

Hoffman III (Stryker, USA) external fixation constructs were applied to articulated models of the lower limb, spanning the knee with a diamond pattern and a Manchester pattern. The stiffness was loaded both statically and cyclically with a Bose 3510 Electroforce mechanical testing jig (TA Instruments). A ramp to load test was performed initially and cyclical loading for measurement of stiffness over the test period. The results were analysed with a paired t-test and ANOVA.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 27 - 27
23 Apr 2024
Howard A Harwood P Benton A Merrel C Culmer P Bolton W Stewart T
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Introduction

Ilizarov fixators are reliant on tensioned fine wires for stability. The tension in the wires is generated using specific tensioning devices. Loss of wire tension over time may lead of loss a stability and complications. A series of in vitro experiments were undertaken to explore wire tensioner accuracy, the impact of fixation bolt torque and initial tension on loss of tension in ilizarov constructs under static and dynamic loads.

Materials & Methods

Medical grade materials were applied to a synthetic bone analogue using surgical instruments in all experiments. Bolt torque was fixed at 6, 10 or 14 Nm using a torque limiting wrench. Wire tension was assessed using a strain measurement bridge. Wires were tensioned to 90, 110 and 130kg as measured by a commercial dynamometric tensioner. Static and dynamic testing was undertaken using an instron testing machine. Cyclical loads from 50–750N were applied for 5000 cycles.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 8 - 8
23 Apr 2024
Senan R Linkogel W Marwan Y Staniland T Sharma H
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Introduction

Knee arthrodesis is a useful limb salvage technique to maintain function in patients with complex and infected total knee arthroplasties (TKA). There are a number of commonly used external fixators, but no consensus on which of these are optimal.

The aim of this study was to synthesise the current literature to guide clinical decision making and improve patient outcomes. We systematically review the literature to compare outcomes of external fixators in arthrodesis following infected TKA.

Materials & Methods

A systematic review of the literature of primary research articles investigating the use of external fixators for knee arthrodesis after an infected TKA was conducted. Relevant articles were identified with a search strategy on online databases (EMBASE and Medline) and reviewed by two independent reviewers.

Clinical outcome measures were independently extracted by two reviewers which included union rate, infection eradication rate, complication rate, time to fusion, and time in frame.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 15 - 15
23 Apr 2024
Sharkey S Round J Britten S
Full Access

Introduction

Compartment syndrome can be a life changing consequence of injury to a limb. If not diagnosed and treated early it can lead to permanent disability. Neurovascular observations done on the ward by nursing staff, are often our early warning system to those developing compartment syndrome. But are these adequate for detecting the early signs of compartment syndrome? Our aim was to compare the quality and variability of charts across the UK major trauma network.

Materials & Methods

All major trauma centres in England and Scotland were invited to supply a copy of the neurovascular chart routinely used. We assessed how such charts record relevant information. Specific primary data points included were pain scores, analgesia requirements, pain on passive stretch and decreased sensation in the first web space specifically. As secondary objectives, we assessed how late signs were recorded, whether clear instructions were included, quantitative scores and the use of regional blocks recorded.


Introduction

Schatzker V & VI tibial plateau fractures are serious life-changing injuries often resulting in significant complications including post-traumatic arthritis. Reported incidence of secondary TKA following ORIF of all tibial plateau fractures is 7.3% and 13% for Schatzker V & VI tibial. This study reports a 15-year single centre experience of CEF of Schatzker V & VI fractures including PROMs and incidence of secondary TKA. This study was approved by the local Institutional board.

Materials & Methods

All patients from 2007 – 2022 with Schatzker V or VI fractures treated with CEF were identified from a departmental limb reconstruction registry and included in this retrospective study. Patients’ demographics were collected from electronic institutional patient system. Further data was collected for secondary intervention, adverse events, and alignment at discharge. All deceased patients at the time of the study were excluded.

Each participant completed a questionnaire about secondary intervention, EQ-5D-3L and Oxford Knee Score (OKS).


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 22 - 22
23 Apr 2024
Laufer A Frommer A Gosheger G Toporowski G Rölfing JD Antfang C Roedl R Vogt B
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Introduction

Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated.

Materials & Methods

Retrospective radiological and clinical analysis of 25 patients (14 females, 11 males) who underwent intramedullary femoral lengthening with an antegrade PRECICE® lengthening nail as well as tHED of the distal femur and / or proximal tibia between 2014 and 2019. tHED was conducted by implantation of flexible staples (FlexTack™) either prior (n = 11), simultaneously (n = 10), or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4).


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 30 - 30
23 Apr 2024
Muscogliati R Muscogliati E Groom W Al-Zubaidi O Afeez A Moulder E Muir R Sharma H
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Introduction

Circular external frames (CEF) are commonly used for a wide variety of indications, often when other devices are not appropriate. Circular frames are particularly associated with pin-site infection (PSI). Currently there is a gap in the available literature surrounding the risk of frame use with in-situ prosthetic joints. This retrospective study investigated the incidence of prosthetic joint infection (PJI) in a series of patients with in-situ arthroplasties treated with CEF.

Materials & Methods

From a departmental database of 1052 frames performed from March 2007-March 2023, the outcomes of 34 patients (40 frames) with in-situ arthroplasties at the time of CEF were reviewed (mean follow-up 70 months). Patient identification was by review of all local and regional imaging. The primary outcome was development of PJI during or following CEF and subsequent need for surgical intervention. Secondary outcomes were development of superficial pin site or deep bone infection (without PJI).


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 3 - 3
23 Apr 2024
Tsang SJ van Rensburg AJ Ferreira N
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Introduction

The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection.

Materials & Methods

A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following intramedullary fixation was performed. Indications for this approach were; a soft tissue envelope not requiring reconstructive surgery, radiographic evidence of stable fixation with adequate alignment, and progression towards fracture union.


Bone & Joint Open
Vol. 5, Issue 4 | Pages 350 - 360
23 Apr 2024
Wang S Chen Z Wang K Li H Qu H Mou H Lin N Ye Z

Aims

Radiotherapy is a well-known local treatment for spinal metastases. However, in the presence of postoperative systemic therapy, the efficacy of radiotherapy on local control (LC) and overall survival (OS) in patients with spinal metastases remains unknown. This study aimed to evaluate the clinical outcomes of post-surgical radiotherapy for spinal metastatic non-small-cell lung cancer (NSCLC) patients, and to identify factors correlated with LC and OS.

Methods

A retrospective, single-centre review was conducted of patients with spinal metastases from NSCLC who underwent surgery followed by systemic therapy at our institution from January 2018 to September 2022. Kaplan-Meier analysis and log-rank tests were used to compare the LC and OS between groups. Associated factors for LC and OS were assessed using Cox proportional hazards regression analysis.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 19 - 19
23 Apr 2024
Guichet J Clementi D
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Introduction

Humans Functions (locomotion, protection of organs, reproduction) require a strong support system (bones). The ‘Osteostasis’ is the ability of maintaining the bone structure, its mechanical characteristics and function. Five principles are required for an efficient bone system:

Basic Requirements:

1) Stability and 2) Function. Repair System (like house building in desert or sea):

3) Roads (vessels), 4) Materials (calories, proteins), 5) Workers (bone cells).

Analysis of bone problems through these principles bring to optimised treatments.

Materials & Methods

Measurements (>700 lengthening, 32-year follow-up, Full WB Albizzia/G-Nails FWBAG): Bone-DEXA, WB conditions, muscle, fat, etc.

Principle-1. Solid bone replacement with a 100% biocompatible and reliable FWBAG with sports (POD0).

Principle-2. Bone, Muscle & neural integrity for function Principle-3. Vascular flow lesions induce non-healing (arteriography). Muscle activity accounts for 90% of bone blood flow, ×10 by sports. Required: Checks (arteriography) and treatments (training)

Principle-4. Food (NRV Kcal × 2–3, 20–25% proteins).

Principle-5. Maintain bone cells and increase them. Suppress ‘opening’, ‘venting’, ‘drainages’.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 9 - 9
23 Apr 2024
Ramlawi AA McClure P Assayag M
Full Access

Introduction

The practice of limb lengthening using intramedullary nails has surged in popularity in recent years. Our study explores the relationship between femur lengthening and overall height gain in adults undergoing cosmetic limb lengthening with telescoping magnetic intramedullary lengthening nails (MILNs).

Materials & Methods

Demographic information, pre- and postoperative radiographic data, and secondary outcomes, such as mechanical angles and sagittal alignment, were analyzed for 42 adult femurs MILNs (PRECICE 2, NuVasive, Inc.). Height was assessed with a digital stadiometer. Limb lengthening was defined as the amount of nail distraction seen on a calibrated weight bearing X-ray at consolidation. mLDFA, mMPTA, MAD, AMA, and femoral sagittal bow were evaluated as secondary outcomes.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 34 - 34
23 Apr 2024
Duguid A Ankers T Narayan B Fischer B Giotakis N Harrison W
Full Access

Introduction

Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. We present our experience of using fine wire frames to correct severe midfoot deformity, followed by internal beaming to maintain the correction.

Materials and Methods

Nine patients underwent this treatment between 2020–2023. Initial deformity correction by Ilizarov or hexapod butt frame was followed by internal beaming with a mean follow up of 11 months. A retrospective analysis of radiographs and electronic records was performed. Meary's angle, calcaneal pitch, cuboid height, hindfoot midfoot angle and AP Meary's angle were compared throughout treatment. Complications, length of stay and the number of operations are also described.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 12 - 12
23 Apr 2024
Jido JT Al-Wizni A Rodham P Taylor DM Kanakaris N Harwood P
Full Access

Introduction

Management of complex fractures poses a significant challenge. Evolving research and changes to national guidelines suggest better outcomes are achieved by transfer to specialist centres. The development of Major Trauma Networks was accompanied by relevant financial arrangements. These do not apply to patients with closed fractures referred for specialist treatment by similar pathways. Despite a surge in cases transferred for care, there is little information available regarding the financial impact on receiving institutions.

Materials & Methods

This retrospective study examines data from a Level 1 trauma centre. Patients were identified from our electronic referral system, used for all referrals. Transferred adult patients, undergoing definitive treatment of acute isolated closed tibial fractures, were included for a 2-year period. Data was collected using our clinical and Patient Level Information and Costing (PLICS) systems including coding, demographics, treatment, length of stay (LOS), total operative time, number of operations, direct healthcare costs, and NHS reimbursements.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 5 - 5
23 Apr 2024
Sain B Sidharthan S Naique S
Full Access

Introduction

Treatment of non-union in open tibial fractures Gustilo-Anderson(GA)-3A/3B fractures remains a challenging problem. Most of these can be dealt using treatment methods that requires excision of the non-union followed by bone grafting, masquelet technique, or acute shortening. Circular fixators with closed distraction or bone transport also remains a useful option. However, sometimes due to patient specific factors these cannot be used. Recently antibiotic loaded bone substitutes have been increasingly used for repairing infected non-unions. They provide local antibiotic delivery, fill dead space, and act as a bone conductive implant, which is resorted at the end of a few months. We aimed to assess the outcome of percutaneous injection of bone substitute while treating non-union of complex open tibial fractures.

Materials & Methods

Three cases of clinical and radiological stiff tibial non-union requiring further intervention were identified from our major trauma open fracture database. Two GA-3B cases, treated with a circular frame developed fracture-related-infection(FRI) manifesting as local cellulitis, loosened infected wires/pins with raised blood-markers, and one case of GA-3A treated with an intramedullary nail. At the time of removal of metalwork/frame, informed consent was obtained and Cerament-GTM(bone-substitute with gentamicin) was percutaneously injected through a small cortical window using a bone biopsy(Jamshedi needle). All patients were allowed to weight bear as tolerated in a well-fitting air-cast boot and using crutches. They were followed up at 6 weekly intervals with clinical assessment of their symptoms and radiographs. Fracture union was assessed using serial radiographs with healing defined as filling of fracture gap, bridging callus and clinical assessment including return to full painless weight bearing.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 18 - 18
23 Apr 2024
Guichet J Frigerio S
Full Access

Introduction

A 6cm femoral gain requires 5-Y during normal growth, but only 6–8-W surgically (x30–40 faster). In lengthening surgery, losses of muscle force (MF) and circumferences (MC) are major. Recovery is long, preventing sports till bone fusion.

Can we maintain MC and strength throughout the entire lengthening and how?

We monitored for over 30 years patients for muscle force (isokinetic), circumferences, activities (including sports) and food intake, and acted on the 5 principles of the Osteostasis.

Materials & Methods

Over 750 femoral lengthening with Full WB Nails (FWBN) got Isokinetic testing (≧1991), circumferences measurements (≧2012; 20-15-10-5-0cm above patella, max-calf, mini/max-ankle), food intake (≧2012), using MyFitnessPal App (≧2016), gradually enforced. Preoperative training along with a daily post-operative training are supervised by our trainers. Recommendations for food intake and activities were provided. Patients noted on a specific App all parameters. Compliance was noted.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 1 - 1
23 Apr 2024
Tsang SJ van Rensburg AJ Epstein G Venter R van Heerden J Ferreira N
Full Access

Introduction

The reconstruction of segmental long bone defects remains one of the holy grails of orthopaedic surgery. The optimal treatment of which remains a topic of great debate. This study aimed to evaluate the outcomes following the management of critical-sized bone defects using a classification-based treatment algorithm.

Materials & Methods

A retrospective review of all patients undergoing treatment for segmental diaphyseal defects of long bones at a tertiary-level limb reconstruction unit was performed. The management of the bone defect was standardised as per the classification by Ferreira and Tanwar (2020).


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 10 - 10
23 Apr 2024
Stanley C Sheridan GA Paige B Hoellwart JS Reif TJ Fragomen AT Rozbruch SR
Full Access

Introduction

The use of osseointegrated limb replacement prostheses for amputees are rapidly growing in popularity due to the many benefits over conventional sockets. Many institutions worldwide are beginning to provide this surgical option to their patients and are advertising the service online. The aim of this study was to assess the quality and reading level of related information available online.

Materials & Methods

A search was performed using the 3 most popular English language search engines reviewing the top 40 websites from each, using the term osseointegration on. Duplicates, videos, medical journal articles and dentistry websites were excluded. All included websites were assessed for reading using the FKGL, G-Fog and FRE. Quality was assessed using the JAMA benchmark criteria, HONC erificate and a novel 16-point scoring system developed specifically for limb replacement osseointegration.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 4 - 4
23 Apr 2024
Turley S Booth C Gately S McMahon L Donnelly T Ward A
Full Access

The requirement for the peer support groups were born out of concern for the psychological wellbeing of the paediatric patients and to assess if this would improve their wellbeing during their treatment. Groupwork is a method of Social Work which is recognised as a powerful tool to allow people meet their need for belonging while also creating the forum for group members to empower one another. Social Work meet with all paediatric patients attending the limb reconstruction service in the hospital. The focus of the Medical Social Worker (MSW) is to provide practical and emotional support to the patient and their parent/guardian regarding coping with the frame. Some of the challenges identified through this direct work include patient's struggling with the appearance of the frame and allowing peers to see the frame.

The peer support group aims to offer its attendees the opportunities to engage with fellow paediatric patients in the same position. It allowed them to visually identify with one another. We wanted to create a safe space to discuss the emotional impact of treatment and the frames. It normalises the common problems paediatric patients face during treatment. We assisted our participants to identify new coping techniques and actions they can take to make their journey through limb reconstruction treatment more manageable. Finally, we aimed to offer the parents space to similarly seek peer support with regard to caring for a child in treatment. All paediatric patients were under the care of the Paediatric Orthopaedic Consultant and were actively engaging with the limb reconstruction multi-disciplinary team (MDT). The patient selection was completed by the MDT; based on age, required to be in active treatment, or their frames were removed within one month prior to the group's commencement. Qualitative data was collected through written questionnaires and reflection from participants in MSW sessions. We also used observational data from direct verbal feedback from the MDT. In the first group, parents gave feedback due to participants age and completed written feedback forms. For our second group, initial feedback was collated from the participants after the first session to get an understanding of group expectations. Upon completion, we collected data from both the participants and the parents. Qualitative and scaling questions gathered feedback on their experience of participating in the group.

We held two peer support groups in 2022:One group for patients aged between 3–6 years in January 2022 across two sessions, which was attended by four patients. The second group for young teenage patients aged between 11–15 years in April 2022 across four sessions, which was attended by five patients. The written feedback received from group one focused on eliciting the participant's experience of the groupwork. 100% of participants identified the shared experience as the main benefit of the groupwork. 100% of participants agreed they would attend a peer support group again, and no participant had suggestions for improvement to the group. Feedback did indicate that group work at the beginning of treatment could be more beneficial. In relation to the second group, 60% of the paediatric patients and their parents returned the questionnaires. All of the parent's feedback identified that it was beneficial for their child to meet peers in a similar situation. They agreed that it was beneficial to meet other parents, so they could get support and advice from one another. On a scale between 1 and 5, 5 being the highest score, the participants scored high on the group work meeting their expectations, enjoyment of the sessions, and the group work was a beneficial aspect of their treatment. All respondents would strongly recommend groupwork to other paediatric patients attending for limb reconstruction treatment.

Overall, the MDT limb reconstruction team, found the peer support group work of great benefit to the participants and their parents. The MSW team identified that during a period on the limb reconstruction team, when a high number of patients were in active treatment, the workload of the MSW also increased reflecting this activity. Common issues and concerns were raised directly to MSW (particularly from group two) regarding numerous difficulties they experienced trying to cope with the frame. The group work facilitators created a space where the participants could get peer support, share issues caused by the frame, hear directly from others, and that they too experience similar feelings or issues. Collectively, they identified ways of coping and promoting their own wellbeing while in treatment. The participants in group two, subsequently created a group on social media, to be able to continue their newly formed friendships and to continue to update one another on their treatment journeys. The participants self-requested another group in the future. This was facilitated in November 2023, the facilitators sought more feedback from all participants and their parents after this session. These findings will contribute towards the analysis for the presentation. Peer support groupwork was presented at the hospital's foundation day and has been well received by senior management in the hospital, as a positive addition to the limb reconstruction service. The focus of the MDT in 2024, is to further develop and facilitate more peer support groups for our paediatric patients.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 7 - 7
23 Apr 2024
Williamson T Egglestone A Jamal B
Full Access

Introduction

Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups.

Materials & Methods

A consecutive series of open tibia fractures managed at a tertiary UK Major Trauma Centre between January 2021 and November 2022 were included. Patient demographics, injury characteristics, timing of antibiotic delivery, timing and method of definitive fixation, and frequency of plastic surgical presence at initial debridement were retrospectively collected. The delivery of bone ends at initial debridement was used as a proxy for adequacy of surgical debridement. The primary outcome measure was rate of fracture-related infection, secondary outcomes included rates of reoperation, nonunion, and amputation. Chi2 Tests and independent samples T-tests were used to assess nominal and continuous outcomes respectively between simple and complex injuries. Ordinal data was assessed using nonparametric equivalent tests.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 11 - 11
23 Apr 2024
Lineham B Faraj A Hammet F Barron E Hadland Y Moulder E Muir R Sharma H
Full Access

Introduction

Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures.

Materials & Methods

We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA).

137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 16 - 16
23 Apr 2024
Murray E Connaghan J Creavin K Egglestone A Jamal B
Full Access

Introduction

By utilising the inherent variability achievable with circular frames, surgeons can manage a wide spectrum of complex injuries, and can deal with deformity at multiple levels, in multiple planes. The aim of this study was to assess functional outcomes utilising patients reported outcome measures (PROMs) of patients being treated with circular (Ilizarov) frame fixation for complex lower limb injuries and assess these results in conjunction with the observed postoperative alignment of the patients’ limbs.

Materials & Methods

Cases were identified using a prospectively collected database of adult patients presenting between July 2018 and August 2021. Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Score (AOFAS), the 5-level EQ-5D (EQ5D5L), the Lysholm Knee Scoring Scale (LKSS), the Olerud-Molendar Ankle Score (OMAS), and the Tegner Activity Scale (TAS). Postoperative radiographs were analysed for fracture union and to quantify malunion (as described in Dror Paleys Principles of Deformity Correction).


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 32 - 32
23 Apr 2024
Orekan A Evans E Cloake T Ward J
Full Access

Introduction

Open fractures are complex injuries associated with substantial morbidity. These injuries are associated with harm to both physical and emotional health as well as preclusion of work, social, and leisure activities. Patient reported outcome measures (PROMs) and health related quality of life are critical indicators of successful rehabilitation following open fracture treatment. This study aimed to measure the PROMs for patients with open lower limb fractures and investigate the relationship with injury severity.

Materials & Methods

A retrospective cohort study was performed at a single major trauma centre in the UK. All adult patients with an open lower limb fracture were eligible for inclusion. Patients were identified through a search of a local Open Fracture Database. Epidemiological, clinical, and fracture classification data were obtained by reviewing case notes. Lower Extremity Function Scale (LEFS) and EQ5-D were used as PROMs and measured by a postal questionnaire, alongside return to employment data.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 28 - 28
23 Apr 2024
Hodkinson T Groom W Souroullas P Moulder E Muir R Sharma H
Full Access

Introduction

Frame configuration for the management of complex tibial fractures is highly variable and is dependent not only on fracture pattern and soft tissue condition but also surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally, larger, stiffer constructs with multiple rings per segment were thought to offer optimal conditions for bone healing, however, the concept of reverse dynamisation questions this approach.

Materials & Methods

We compared clinical outcomes in 302 consecutive patients with tibial fractures treated in our unit with either a two-ring circular frame or a three-or-more-ring (3+) frame. The primary outcome measure was time spent in frame. Secondary outcomes were the incidence of malunion and the need for further surgical procedures to achieve bone union. The groups were evenly matched for age, co-morbidities, energy of injury mechanism, fracture classification, post-treatment alignment and presence of an open fracture.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 33 - 33
23 Apr 2024
Macey A Omar HA Leitch P Vaidean T Swaine S Santos E Bond D Abhishetty N Shetty S Saini A Phillips S Groom G Lahoti O
Full Access

Introduction

Classical fixation using a circular frame involves two rings per segment and in many units this remains the norm whether using ilizarov or hexapod type frames. We present the results of two ring circular frame at King's College Hospital.

Materials & Methods

A prospective database has been maintained of all frames applied since 2007. Radiographs from frames applied prior to July 2022 were examined. Clinic letters were then used to identify complications.

Included: two ring hexapod for fracture, malunion, nonunion, arthrodesis or deformity correction in the lower limb.

Excluded: patients under 16 years old, diabetic feet, Charcot joints, soft tissue contractures, arthrodiastasis, correction of the mid/forefoot, plate fixation augmentation, fixation off a third ring.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 14 - 14
23 Apr 2024
Bell R Nayak M Perello A Allen E Lee SY Mellington A Guryel E
Full Access

Introduction

The regionalisation of major trauma in the UK has significantly improved outcomes for patients with severe, lower limb injuries. Chronic pain after complex lower limb injuries is well documented, but seems to remain a problem despite better clinical and radiological outcomes. We hypothesised that pain was mediated through the saphenous nerve, especially as most tibial injuries affected the soft tissues medially. As a proof of concept, we undertook adductor canal blocks to understand pain aetiology.

Materials & Methods

Patients with chronic pain following complex lower limb trauma or congenital deformity correction have been selected and underwent an adductor canal block by one of our trauma anaesthetist that specialises in this procedure. Their outcomes were recorded in their clinical records and patients were contacted by phone to document their experiences.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 20 - 20
23 Apr 2024
Guichet J
Full Access

Introduction

Frame HI is the #Days for device removal/cm. IM Nail HI is less relevant (31–45 D/cm).

Albizzia HI was 33 D/cm (1991–2003). Patients felt fine approximately 1M after end of lengthening (EoL), resuming normal life and sports. This sometimes resulted in implants fractures (e.g. skying before bone fusion). Ideally, the full fusion should occur at the EoL. We decided to shorten the HI to reach this target, optimising all parameters.

Materials & Methods

The evolution of care has been monitored over a 32-year clinical experience with a fully weight-bearing nails (Albizzia then G-nail). Monitoring was with X-rays, DEXA, blood bone activity, and in London with special 5G CBCT Scans. We implemented several changes in the Care of patients and measured them according to the ‘Five Principles’ (stability, function, ‘Roads-vascular supply’, ‘Materials-calories’ and ‘Workers-BFC’, with actions on food intake, activity levels and on muscle and bone vascular growths.


Bone & Joint Research
Vol. 13, Issue 4 | Pages 193 - 200
23 Apr 2024
Reynolds A Doyle R Boughton O Cobb J Muirhead-Allwood S Jeffers J

Aims

Manual impaction, with a mallet and introducer, remains the standard method of installing cementless acetabular cups during total hip arthroplasty (THA). This study aims to quantify the accuracy and precision of manual impaction strikes during the seating of an acetabular component. This understanding aims to help improve impaction surgical techniques and inform the development of future technologies.

Methods

Posterior approach THAs were carried out on three cadavers by an expert orthopaedic surgeon. An instrumented mallet and introducer were used to insert cementless acetabular cups. The motion of the mallet, relative to the introducer, was analyzed for a total of 110 strikes split into low-, medium-, and high-effort strikes. Three parameters were extracted from these data: strike vector, strike offset, and mallet face alignment.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 25 - 25
23 Apr 2024
Aithie J Oag E Butcher R Messner J
Full Access

Introduction

Genu valgum is a common presentation in paediatric patients with congenital limb deformities. The aim of this study is to assess the outcome of guided growth surgery in paediatric patients referred via our physiotherapy pathway with isolated genu valgum and associated patellar instability.

Materials & Methods

Patients were identified from our prospective patellar instability database. Inclusion criteria was acquired or congenital genu valgum associated with patellar instability in skeletally immature patients. The mechanical lateral-distal femoral angle was assessed on long leg alignment radiographs (mLDFA <85 degrees). Surgical treatment was the placement of a guided growth plate (PediPlate, OrthoPediatrics, USA) on the medial distal femoral physis (hemi-epiphysiodesis). KOOS-child scores were collected pre-operatively and post-operatively (minimum at 6 months).


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 31 - 31
23 Apr 2024
Bandopadhyay G Lo S Yonjan I Rose A Roditi G Drury C Maclean A
Full Access

Introduction

The presence of pluripotent mesenchymal cells in the periosteum along with the growth factors produced or released following injury provides this tissue with an important role in bone healing. Utilising this property, vascularised periosteal flaps may increase the union rates in recalcitrant atrophic long bone non-union. The novel chimeric fibula-periosteal flap utilises the periosteum raised on an independent periosteal vessel, thus allowing the periosteum to be inset freely around the osteotomy site, improving bone biology.

Materials & Methods

Ten patients, with established non-union, underwent fibula-periosteal chimeric flaps (2016–2022) at the Canniesburn Plastic Surgery Unit, UK. Preoperative CT angiography was performed to identify the periosteal branches. A case-control approach was used. Patients acted as their own controls, which obviated patient specific risks for non-union. One osteotomy site was covered by the chimeric periosteal flap and one without. In two patients both the osteotomies were covered using a long periosteal flap.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 21 - 21
23 Apr 2024
Brown N King S Taylor M Foster P Harwood P
Full Access

Introduction

Traditionally, radiological union of fractures treated with an Ilizarov frame is confirmed by a period of dynamization - destabilisation of the frame for a period prior to removal. Reduced clinic availability during the COVID-19 pandemic caused a shift to selective dynamisation in our department, whereby lower risk patients had their frames removed on the same day as destabilisation. This study investigates the effects of this change in practice on outcomes and complication rates.

Materials & Methods

Adult patients treated with circular frames between April 2020 and February 2022 were identified from our Ilizarov database. Patients were divided into 2 groups: - “dynamised” if their frame was destabilised for a period to confirm union prior to removal; or “not dynamised” if the decision was taken to remove the frame without a period of dynamisation, other than a short period in the clinic. A retrospective review of clinical notes was conducted to determine outcome.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 26 - 26
23 Apr 2024
Aithie J Herman J Holt K Gaston M Messner J
Full Access

Introduction

Limb deformity is usually assessed clinically assisted by long leg alignment radiographs and further imaging modalities (MRI and CT). Often decisions are made based on static imaging and simple gait interpretation in clinic. We have assessed the value of gait lab analysis in surgical decision making comparing surgical planning pre and post gait lab assessment.

Materials & Methods

Patients were identified from the local limb reconstruction database. Patients were reviewed in the outpatient clinic and long leg alignment radiographs and a CT rotational limb profile were performed. A surgical plan was formulated and documented. All patients then underwent a formal gait lab analysis. The gait lab recommendations were then compared to the initial plan.


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_5 | Pages 24 - 24
23 Apr 2024
Thompson E James L Narayan B Peterson N
Full Access

Introduction

Management of deformity involving limb length discrepancy (LLD) using intramedullary devices offers significant benefits to both patients and clinicians over traditional external fixation. Following the withdrawal of the PRECICE nail, the Fitbone became the primary implant available for intramedullary lengthening and deformity correction within our service. This consecutive series illustrates the advantages and complications associated with the use of this device, and describes a novel technique modification for antegrade intramedullary lengthening nails.

Materials & Methods

A retrospective cohort review was performed of patient outcomes after treatment with the Fitbone nail at two tertiary referral limb reconstruction services (one adult, one paediatric) between January 2021 to December 2023. Aetiology, indications, initial and final LLD, use of concomitant rail assisted deformity correction (ORDER), removal time and healing index were assessed. Complications of treatment were evaluated and described in detail, alongside technique modifications to reduce the rate of these complications.