The majority of 5th metatarsal fractures are successfully treated conservatively, with few patients requiring surgical fixation for symptomatic non-union. Tuberosity avulsion fractures are generally considered benign injuries with more distal fractures showing a propensity to develop delayed/non-union. We studied a cohort of patients who underwent surgery as treatment for non-union. We reported on outcome, rate of complications and requirement for additional surgery.

All patients who required surgery to their 5th metatarsal from June 2008 to May 2018 were included. Demographic, clinical outcome data and radiographic classification of fracture types were collected, reviewed and analysed.

35 patients had undergone surgery for 5th metatarsal fractures during this time period and 31 of these had been operated on for a painful non-union. 12 were tuberosity avulsion fractures (Lawrence and Botte Type1) and 23 were Type 2/3. 5 patients (14.3%) experienced a further symptomatic non-union after initial surgery; Type 1 fractures were 11 times more likely to result in non-union (p=0.0375). 22.9% of the group required some form of further surgery, with a significant association between Type 1 fractures and the need for further surgery (p=0.0107).

This study is the first of its kind, reporting specifically on the outcome after surgical fixation of a non-union of 5th metatarsal fractures. Overall, surgery had a good outcome with a low complication rate, though it is interesting to note that Type 1 fractures, which traditionally have a low non-union rate after conservative treatment, are associated with a significantly increased incidence of non-union if operated for symptomatic non-union.

The rising prevalence of osteoarthritis, associated with an ageing population, is expected to deliver increasing demand across Scotland for primary hip and knee arthroplasty in the future.

Understanding the scale of potential change to operative workflow is essential to ensure adequate provision of services, and prevent prolonged waiting times that can cause patient harm.

We therefore set out to provide projections of future primary hip and knee arthroplasty out to 2038 utilising historical trend data (2008–2018) from the Scottish Arthroplasty Project. All analyses were performed using the Holt's exponential smoothing projection method with the forecast package in R statistics. Results were adjusted for projected future population estimates provided by National Records of Scotland. Independent age & sex group predictions were also performed. All results are presented per 100,000 population at-risk per year (/100k/year).

The predicted rise of primary hip arthroplasty for all ages is from 120/100k/year in 2018 to 152/100k/year in 2038, a 27% increase. The predicted rise of primary knee arthroplasty for all ages is from 164/100k/year in 2018 to 220/100k/year in 2038, a 34% increase. Based on a static 3 day length of stay average this would see 4280 additional patient bed days for hips, and 7392 for knees, required nationally per year by 2038. The associated supplementary cost to the NHS is anticipated to be around £21 million per annum.

Knowledge of increasing resource utilisation and cost associated with predicted future demand for primary hip and knee arthroplasty provides key information for service organisation and delivery.

Debate surrounds the optimum operative treatment of periprosthetic distal femoral fractures (PDFFs) at the level of well fixed femoral components; lateral locking plate fixation (LLP-ORIF) or distal femoral replacement (DFR). To determine which attributed the least peri-operative morbidity and mortality we performed a retrospective cohort study of 60 consecutive unilateral PDFFs of Su types II (40/60) and III (20/60) in patients ≥60 years; 33 underwent LLP-ORIF and 27 underwent DFR. The primary outcome measure was reoperation. Secondary outcomes included perioperative complications and functional mobility status. Kaplan Meier survival analysis was performed. Cox multivariable regression analysis identified risk factors for reoperation after LLP-ORIF.

Mean length of follow-up was 3.8 years (range 1.0–10.4). One-year mortality was 13% (8/60). Reoperation rate was significantly higher following LLP-ORIF: 7/33 vs 0/27, p=0.008. For the endpoint reoperation, five-year survival was better following DFR: 100% compared to 70.8% (51.8 to 89.8 95%CI) (p=0.006). For the endpoint mechanical failure (including radiographic loosening) there was no difference at 5 years: ORIF 74.5% (56.3 to 92.7); DFR 78.2% (52.3 to 100), p=0.182). Reoperation following LLP-ORIF was independently associated with medial comminution: HR 10.7 (1.45 to 79.5, p=0.020). Anatomic reduction was protective against reoperation: HR 0.11(0.013 to 0.96, p=0.046). When inadequately fixed fractures were excluded differences in survival were no longer significant: reoperation (p=0.156); mechanical failure (p=0.453).

Reoperation rates are higher following LLP-ORIF of low PDFFs compared to DFR. Where adequate reduction, proximal fixation and augmentation of medial comminution is used there is no difference in survival between LLP-ORIF and DFR.

The aim of this study was to measure the effect of hospital case-volume on the survival of revision total knee arthroplasty (RTKA).

A retrospective analysis of Scottish Arthroplasty Project data was performed. The primary outcome was RTKA survival at ten years. The primary explanatory variable was annual hospital case-volume. Kaplan-Meier survival curves were plotted with 95% confidence intervals (CI) to determine the lifespan of RTKA. Multivariable Cox proportional hazards were used to estimate relative revision risks over time.

From 1998 to 2019, 8894 patients underwent RTKA surgery in Scotland (median age 70 years, median follow-up 6.2 years, 4789 (53.5%) females; 718 (8.8%) for infection). Of these patients, 957 (10.8%) underwent a second revision procedure on their knee. Male sex, younger age at index revision, and positive infection status were associated with need for re-revision. The ten-year survival estimate for RTKA was 87.3% (95%CI 86.5–88.1). Adjusting for gender, age, surgeon volume and infection status, increasing hospital case-volume was significantly associated with lower risk of re-revision (Hazard Ratio 0.78 (0.64–0.94, p<0.001)). The risk of re-revision steadily declined in centres performing >20 cases per year: relative risk reduction 16% with >20 cases; 22% with >30 cases; and 28% with >40 cases.

The majority of RTKA in Scotland survive up to ten years. Increasing yearly hospital case-volume above 20 cases is independently associated with a significant risk reduction of re-revision. Development of high-volume tertiary centres may lead to an improvement in the overall survival of RTKA.

The primary aim was to assess patient-reported outcomes following a humeral diaphyseal fracture. The secondary aim was to compare the outcomes of patients who achieved union after initial management (operative or non-operative) with those that achieved union after nonunion surgery.

From 2008–2017, 291 patients (mean age 55yrs [17–86], 58% [n=168/291] female) were retrospectively identified and available to complete a survey. Sixty-four (22%) were managed with primary surgery and 227 (78%) non-operatively. Outcomes (QuickDASH, EQ-5D, EQ-VAS, SF-12) were obtained at a mean of 5.5yrs (1.2–11.0).

After initial management, 229 patients (79%) united (n=62 operative, n=167 non-operative) and 62 (21%) developed a nonunion (n=2 operative, n=60 non-operative; p<0.001). Fifty-two of 56 patients (93%) achieved union after nonunion surgery. The overall mean QuickDASH was 20.8, EQ-5D 0.730, EQ-VAS 74, SF-12 PCS 44.8 and MCS 50.2. Patients who united after nonunion surgery reported a worse functional outcome (mean QuickDASH 27.9 vs. 17.6, p=0.003) and health-related quality of life (HRQoL; mean EQ-5D 0.639 vs. 0.766, p=0.008; EQ-VAS 66 vs. 76, p=0.036; SF-12 PCS 41.8 vs. 46.1, p=0.036) than those who united primarily. When adjusting for confounders, union after nonunion surgery was independently associated with poorer function (difference in QuickDASH 8.1, p=0.019) and HRQoL (difference in EQ-5D -0.102, p=0.028).

Humeral diaphyseal union after nonunion surgery was associated with poorer function and HRQoL compared to patients who united primarily. Targeting early operative intervention to patients at risk of nonunion may have an important role, given the potential impact of nonunion on longer-term outcome.

Total ankle replacement (TAR) is performed for inflammatory arthropathy, osteoarthritis and other indications. The Scottish Arthroplasty Project (SAP) began collection of data on TAR in 1998. In this study, we look at trends in the use and outcomes of TAR in Scotland.

We identified patients from the SAP who underwent TAR between 1998 and 2015 with imaging available on the National Picture Archiving and Communication System (PACS). We identified, and examined trends in implant type over the following time periods: 1998–2005; 2006–2010 and 2011–2015. Age, gender, indication, outcomes and trends in implants used for each time period were examined.

There were 499 primary TAR procedures with an overall incidence of 0.5/105 population per year. Eight implants were identified with significant changes in the numbers of each type used over time. The peak incidence of TAR was in the 6th decade and mean age of patients increased from 59 years in 1998–2005, to 65 years in 2011–15 (p<0.0001). The percentage of patients with inflammatory arthropathy was 49% in 1998–2005, compared with 10% in 2011–2015. Arthrodesis and infection rates appeared to be higher during the first time period. The male to female ratio changed over time. The incidence of TAR increased overall during the study period (r= 0.9, p=<0.0001).

This study examines a large number of TARs from an established arthroplasty registry. The rate of TAR has increased significantly in Scotland from 1998 to 2015. Indications and patient age have changed over time and could impact outcomes after ankle replacement.

Sonographic callus may enable assessment of fracture healing. The aim of this study was to establish a reliable method for three-dimensional reconstruction of sonographic callus.

Patients that underwent non-operative management of displaced midshaft clavicle fractures and intramedullary nailing of tibia fractures were prospectively recruited and followed to union. Ultrasound scanning was performed at periodical time points following injury. Infra-red tracking technology was used to map each image to a three-dimensional lattice. Criteria was fist established for two-dimensional bridging callus detection in a pilot study. Using echo intensity of the ultrasound image, semi-automated mapping was used to create an anatomic three-dimensional representation of fracture healing. Agreement on the presence of sonographic bridging callus was assessed using the kappa coefficient and intra-class-correlation (ICC) between observers.

112 clavicle fractures and 10 tibia fractures completed follow-up at six months. Sonographic bridging callus was detected in 62.5% (n=70/112) of the clavicles at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n=69/70). If absent, nonunion developed in 40.5% of cases (n=17/42)(73.4%-sensitive and 100%-specific to predict union). Out of 10 tibia fractures, 7 had bridging callus of at least one cortex at 6 weeks and when present all united. Of the three patients lacking sonographic bridging callus, one went onto a nonunion (77.8%-sensitive and 100%-specific to predict union). The ICC for sonographic callus between four reviewers was 0.82 (95% CI 0.68–0.91)

Three-dimensional ultrasound reconstruction of bridging callus has the potential to identify impaired fracture healing at an early stage in fracture management.

The aim was to determine the influence of COVID-19 on 30-day mortality in hip fracture. Secondary aims were to examine: (1) predictors of COVID-19 on presentation and later in the admission; (2) rate of hospital-acquired COVID-19; (3) predictive value of negative swabs on admission.

A nationwide multicentre retrospective cohort study of all patients with hip fracture in all 17 Scottish hospitals in March-April. Demographics, blood results, COVID-19 status, Nottingham Hip Fracture Score (NHFS), management, length of stay (LOS), and 30-day mortality were recorded.

78/833 (9.4%) patients had COVID-19 (65 swab-proven). 30-day survival with COVID-19 was lower than without (65.4% vs 91%; p<0.001). COVID-19 within 7 days of admission (likely community-acquired) was independently associated with male sex (OR 2.34, p=0.040, CI 1.04–5.25) and COVID-19 symptoms (OR 15.56, CI 6.61–36.60, p<0.001). COVID-19 within 7–30 days (probable hospital-acquired) was independently associated with male sex (OR 1.73, CI 1.05–2.87, p=0.032), NHFS □7 (OR 1.91, CI 1.09–3.34, p=0.024), pulmonary disease (OR 1.68, CI 1.00–2.81, p=0.049), ASA □3 (OR 2.37, CI 1.13–4.97, p=0.022) and LOS □9 days (OR 1.98, CI 1.18–3.31, p=0.009). 38/65 (58.5%) of COVID-19 cases were probably hospital-acquired. The false negative rate of swabs on admission was 0% in asymptomatic and 2.9% in symptomatic patients.

COVID-19 was associated with a threefold-increased 30-day mortality. Nosocomial transmission may have accounted for half of all cases. Identification of risk factors for having COVID-19 on admission, or acquiring COVID-19 later, may guide patient pathways. LOS was the only modifiable risk factor, emphasising the importance of high-quality, timely care.

Aims

The objective of this systematic review was to describe trapeziectomy outcomes and complications in the context of osteoarthritis of the base of the thumb after a five-year minimum follow-up.

Aims

Brachial plexus injury (BPI) is an often devastating injury that affects patients physically and emotionally. The vast majority of the published literature is based on surgeon-graded assessment of motor outcomes, but the patient experience after BPI is not well understood. Our aim was to better understand overall life satisfaction after BPI, with the goal of identifying areas that can be addressed in future delivery of care.

Aims

The aim of this study was to evaluate the need for hand trauma services during the COVID-19 pandemic lockdown, specifically related to surgical requirements. This will provide useful information for planning and resource allocation in the event of any further lockdown.

Aims

To assess the proportion of patients with distal radius fractures (DRFs) who were managed nonoperatively during the COVID-19 pandemic in accordance with the British Orthopaedic Association BOAST COVID-19 guidelines, who would have otherwise been considered for an operative intervention.

Aims

We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue.

Aims

The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs.