Simulation in surgical training has become a key component of surgical training curricula, mandated by the GMC, however commercial tools are often expensive. As training budgets become increasingly pressurised, low-cost innovative simulation tools become desirable. We present the results of a low-cost, high-fidelity simulator developed in-house for teaching fluoroscopic guidewire insertion.

A guidewire is placed in a 3d-printed plastic bone using simulated fluoroscopy. Custom software enables two inexpensive web cameras and an infra-red led marker to function as an accurate computer navigation system. This enables high quality simulated fluoroscopic images to be generated from the original CT scan from which the bone model is derived and measured guidewire position. Data including time taken, number of simulated radiographs required and final measurements such as tip apex distance (TAD) are collected.

The simulator was validated using a DHS model and integrated assessment tool. TAD improved from 16.8mm to 6.6mm (p=0.001, n=9) in inexperienced trainees, and time taken from 4:25s to 2m59s (p=0.011). A control group of experienced surgeons showed no improvement but better starting points in TAD, time taken and number of radiographs.

We have also simulated cannulated hip screws, femoral nail entry point and SUFE, but the system has potential for simulating any procedure requiring fluoroscopic guidewire placement e.g. pedicle screws or pelvic fixation. The low cost and 3D-printable nature have enabled multiple copies to be built. The software is open source allowing replication by any interested party. The simulator has been incorporated successfully into a higher orthopaedic surgical training program.

Evidence suggests as little as 32percnt; of those with a displaced intracapsular hip fracture who meet the NICE eligibility criteria currently undergo a total hip replacement (THR). The reason for this discrepancy is not clear. This study therefore set out to examine the reasons behind this lack of adherence to these guidelines through the use of a questionnaire to current Trauma & Orthopaedic surgery consultants across Scotland.

An invitation to take part in the survey was distributed through the Scottish Committee for Orthopaedics & Trauma (SCOT) email address list. A series of 10 questions were designed to determine the background of participants, their experience at performing hip fracture surgery (including THR) and their thoughts regarding its use in the hip fracture setting. Results were collated at the end of the study period and quantitatively analysed where possible.

There were 91 responses in total. 53percnt; of individuals said they would offer those meeting the NICE criteria a THR less than 76percnt; of the time. The most commonly used alternative was a cemented bipolar hemiarthroplasty (51percnt;). Hip surgeons were more likely to perform or supervise THR for hip fracture than non-hip surgeons (p<0.0001). There were a wide variety of reasons why people would not offer a THR including dislocation rate, technical complexity and inadequate evidence for use.

Overall this study highlights current trends and barriers in the provision of THR to hip fracture patients. This knowledge can be used to ascertain research priorities to maximise the quality of care in this setting.

Necrotising Fasciitis is a life threatening rapidly progressing bacterial infection of the skin requiring prompt diagnosis and treatment. Optimum care warrants a combination of antibiotics, surgical debridement and intensive care support. All cases of Necrotising Fasciitis over 10 years in the North East of Scotland were reviewed to investigate trends and learn lessons to improve patient care, with the ultimate aim of developing and implementing new treatment algorithms.

All cases from August 2006-February 2016 were reviewed using a combination of paper based and electronic hospital records. Data including observations, investigations, operative interventions, microbiology and clinical outcomes was reviewed and analysed with pan-specialty input from Microbiology, Infectious Disease, Trauma & Orthopaedics, Plastic Surgery and Intensive Care teams.

36 cases were identified, including 9 intravenous drug abusers. The mean LRINEC Score was 7. Patients were commonly haemodynamically stable upon admission, but deteriorated rapidly. 18/31 of cases were polymicrobial. Streptococcus Pyogenes was the most common organism in monomicrobial cases. 29/36 patients were discharged, 6 patients died acutely, giving an acute mortality rate of 17%. In total 6 amputations or disarticulations were performed from a total of 82 operations carried out on this group, with radical debridement the most common primary operation. The mean time to theatre was 3.54 hours. A grossly elevated admission respiratory rate (50 resp/min) was associated with increased mortality.

Necrotising fasciitis presents subtly, but carries significant morbidity and mortality. A high index suspicion allows timely intervention. We strongly believe that a pan-specialty approach is the cornerstone for good outcomes.

Following the neonatal examination the 6–8 week ‘GP check’ forms the second part of selective surveillance for developmental dysplasia of the hip (DDH) in the UK. We aim to investigate the effectiveness of this 6–8 week examination for DDH.

This is a observational study including all infants born in our region over 5 years. Early presentation was defined as diagnosis within 14 weeks of birth and late presentation after 14 weeks. Treatment record for early and late DDH as well as referrals for ultrasound (US) following the 6–8 week check were analysed. The attendance at the 6–8 week examination in those patients who went on to present with a late DDH was also analysed.

23112 live births, there were 141 confirmed cases of DDH. 400 referrals for ultrasound were received from GP; 6 of these had a positive finding of DDH. 27 patients presented after 14 weeks and were classified as late presentations. 25 of these patients had attended the 6–8 week examination and no abnormality had been identified. The sensitivity of the examination was 19.4%, its specificity was 98% and it had a positive predictive value of 1.5%

For many years the 6–8 week ‘check’ has been thought of as a safety net for those children with DDH not identified as neonates, however we found that 4 out of every 5 children with DDH were not identified. It is essential efforts are made to impove detection as the long term consequences of late presentation can be life changing.

Increasing demands on our emergency department (ED) has resulted in the reduction of manipulations (MUAs) at the ‘front door’. We hypothesised that MUAs undertaken in theatre is rising with adverse financial implications. We performed a retrospective audit of operating lists in our institution from 2013–2016. Cost estimates were determined by our finance department. We used the NICE guidelines on management of non-complex fractures (NG38 Feb2016) as our audit standard.

Data on 1372 cases performed over a three-month representative period during 2013–2016 was analysed. MUAs were 13% of the total theatre workload, with an annual increase in volume noted. Additionally, simple displaced distal radius fractures were routinely receiving a MUA (with or without K-wires) as a primary procedure in theatre. When this workload is combined it makes up 22% of the total theatre workload. Average theatre time was 57 minutes per case. Delays to definite procedure ranged from 8 to 120 hours. Cost of hospital admission and theatre utilisation was approximately £1000 per patient. Conversely, the cost of a MUA in the ED was estimated at £150. Given that we currently undertake around 15 manipulations in theatre a month, performing such work in the ED it would save approximately £153,000 a year to our health board.

This audit identifies that MUAs of common orthopaedic injuries undertaken in theatre can lead too significant clinical and financial costs. We have proposed a strong financial argument to management for a twice weekly ‘manipulation list’ in the ED which is currently under review.

Objectives

The aim of this systematic literature review was to assess the clinical level of evidence of commercially available demineralised bone matrix (DBM) products for their use in trauma and orthopaedic related surgery.

To analyse the management of open paediatric tibial fractures treated at a children's Major Trauma Centre (MTC), comparing fixation methods, union and complications.

We retrospectively identified all patients admitted to RMCH with an open tibia fracture between 2008 – 2016. Demographics, mechanism, inpatient stay and follow-up management were reviewed. There were a total of 44 patients, with an average age = 10 years (3–15). 93% of cases were caused by road traffic accidents, commonly pedestrian versus car. Older children were more likely to sustain higher grade injuries, requiring increased length of stay. 35 patients had primary / delayed wound closure, 1 patient required fasciotomies and 4/44 needed skin grafts and/or flap. 7 patients were treated in plaster, 9 by elastic nailing, 15 had mono-lateral fixators and 12 with circular frame. The average number of surgeries = 3 (1–7) with older children having increased risk of revision surgery. Monolateral fixators were the most common primary fixation method (n=15), however 60% required revision to ring fixator due to displacement or delayed union. The main risk factor for displacement was inadequate fracture reduction in theatre, as well as those fracture patterns involving butterfly fragments. Union (defined as RUST score = 3 on >3 cortices) was achieved in all patients (ave 6 months). Delayed union was associated with higher grade injuries, those treated with elastic nails demonstrated the longest union time (ave 7.3 months). 21/44 (47.7%) patients had complications, with pin site infection being the most commonly seen. 18% patients suffered a major complications needing further surgery.

Various fixation methods can be successfully used to treat these fractures. They demonstrate a high complication rate and often require multiple surgeries, with union taking an average of 6 months. Mono-lateral fixators demonstrate a high revision rate, particularly if the fracture is not well reduced.

Background

Temporary hemiepiphysiodesis using 8 plate guided growth has gained widespread acceptance for the treatment of paediatric angular deformities. This study aims to look at outcomes of coronal lower limb deformities corrected using temporary hemiepiphysiodesis over an extended period of follow up.

Background

With an ageing population, the incidence of traumatic injuries in those aged over 65 years is increasing. As a result, strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures is described by the BOAST4 guidelines. We describe our experience of managing elderly patients presenting with open tibial fractures to our Major Trauma Centre.

Introduction

Open fractures are managed in the UK guided by standards issued by the BOAST-4 standards. A study was undertaken to evaluate compliance with these standards in a regional trauma unit (MTU), and compared following upgrading to a Major Trauma Centre (MTC).

Introduction

The Precice nail is the latest intramedullary lengthening nail with excellent early outcomes. Implant complications have led to modification of the nail design. The aim of this study was to perform a retrieval study of Precice nails following lower limb lengthening. To assess macroscopic and microscopic changes to the implants and assess differences following design modification, with identification of potential surgical, implant and patient risk factors.

Introduction

The management of a significant bone defect following excision of a diaphyseal atrophic femoral non-union remains a challenge. Traditional bone transport techniques require prolonged use of an external fixator with associated complications. We present our clinical outcomes using a combined technique of acute femoral shortening, stabilised with a deliberately long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis to restore segment length utilising a temporary monolateral fixator.

Limb reconstruction requires high levels of patient compliance and impacts heavily on social circumstances. The epidemiology and socioeconomic description of trauma patients has been well documented, however no study has assessed the epidemiology of limb reconstruction patients. The aim of this project is to describe patients attending Limb Reconstruction Services (LRS) in order to highlight and address the social implications of their care.

All LRS cases under a single surgeon in a district general hospital were included from 2010 – 2016. Demographics, ASA grade, smoking status, mental health status and employment status were collated. Postcode was converted into an Index of Multiple Deprivation score using GeoConvert® software. Patient socioeconomic status was then ranked into national deprivation score quintiles (quintile 1 is most affluent, quintile 5 is most deprived). Deprivation scores were adjusted by census data and analysed with Student's T-test. The distance from the patient's residence to the hospital was generated through AA route planner®. Patient attendance at clinic and elective or emergency admissions was also assessed. Patient outcomes were not part of this research.

There were 53 patients, of which 66% (n=35) were male, with a mean age of 45 years (range 21–89 years). Most patients were smokers (55%, n=29), 83% (n=42) were ASA 1 or 2 (there were no ASA 4 patients). The majority of indications were for acute trauma (49%), chronic complications of trauma (32%), congenital deformity (15%) and salvage fusion (4%). Mental health issues affected 23% (n=12) of cases and 57% of working-aged patients were unemployed. Mental health patients had a higher rate of trauma as an indication than the rest of the cohort (93% vs. 76%). Deprivation quintiles identified that LRS patients were more deprived (63% in quintiles 4 and 5 vs. 12% of 1 and 2), but this failed to reach statistical significance (p=0.9359). The mean distance from residence to hospital was 12 miles (range 0.35–105 miles, median 7 miles). The patients derived from a large region made up of 12 local authorities. There was a mean of 17 individual LRS clinic attendances per patient (range: 3–42). Cumulative distance travelled for each patient during LRS treatment was a mean of 495 miles (range 28 – 2008 miles). The total distance travelled for all 53 patients was over 26,000 miles.

The results largely mirror the findings of trauma demographic and socioeconomic epidemiology, due to the majority of LRS indications being post-traumatic in this series. The high rates of unemployment and mental health problems may be a risk factor for requiring LRS management, or may be a product of the treatment. Clinicians may want to consider a social care strategy alongside their surgical strategy and fully utilise their broader MDT to address the social inequalities in these patients. This strategy should include a mental health assessment, smoking cessation therapy, sign-posted support for employment circumstances and a plan for travel to the hospital. The utilisation and cost of ambulance services was not possible with this methodology. Further work should prospectively assess the changes in housing circumstances, community healthcare needs and whether there was a return to employment and independent ambulation at the end of treatment.

Background

Severe infantile Blount's disease can result in a multiplanar deformity of the proximal tibia with both intra-articular and metaphyseal components. Correction can represent a significant surgical challenge. We describe our results using the Taylor spatial frame for acute tibial hemiplateau elevation combined with gradual metaphyseal correction in patients with severe infantile blounts with an associated physeal bony bar.

Introduction

Large numbers of patients with open tibial fractures are treated in our major trauma centre. Previously, immediate definitive skeletal stabilisation and soft tissue coverage has been recommended in the management of such injuries. We describe our recent practice, focusing on soft tissue cover, including patients treated by early soft tissue cover and delayed definitive skeletal stabilisation.

Background

Chronic acquired radial head dislocations pose a complex problem in terms of surgical decision making, especially if surgery has already previously failed. There are several underlying causes that should be investigated, including previous trauma resulting in a missed Monteggia fracture.

We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit.

An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended.

Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment).

We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100).

Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment.

Level of evidence: IV (case series)

Aims

To investigate a treatment algorithm of various Ilizarov methods in managing infected tibial non-union.

Purpose

Tibia plateau fractures are severe knee injuries which have a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had severe tibia plateau fractures which were treated with circular ilizarov frame.

BACKGROUND

Most closed tibial fractures in children can be treated conservatively. On the occasions that surgical intervention is required, there are various options available to stabilise the fracture. We would like to present our experience of using monolateral external fixators in the management of closed tibial fractures.

Introduction

Distal tibial fractures are notoriously difficult to treat and a lack of consensus remains on the best approach. This study examined clinical and functional outcomes in such patients treated definitively by circular external fixation (Ilizarov). Patients and Methods: Between July 2011 and May 2016, patients with fractures extending to within 1 muller square of the ankle were identified from our prospective Ilizarov database. Existing data was supplemented by review of clinical records. Fractures were classified according to the AO/OTA classification. Functional outcome data, including general measures of health related quality of life (SF-12 and Euroqol) and limb specific scores (Olerud and Molander Score and Lysholm scores) had been routinely collected for part of the study period. Patients in whom this had not been collected were asked to complete these by post. Adverse events were documented according to Paley's classification of: problems, obstacles and complications.

Introduction

Patient Reported Outcome Measures (PROMs) are used as outcome of many surgical treatments such as Hip and knee joint replacements, varicose vein and groin hernia surgery. Outcome scores in orthopaedics tend to be site and/or pathology specific. Trauma related pathology uses a surrogate outcome scores. A unified outcome score for trauma is needed to help with the measurement of outcomes in trauma patients and evaluate the actual impact that trauma inflicts to patients' lives.

Purpose

This study compares outcomes in patients with complete congenital fibula absence treated with an amputation protocol to those using an extension prosthesis.

Care of complex and open fractures may provide better results if undertaken in larger units, typically Major Trauma Centres (MTCs) or Orthoplastic units. Some ‘complex injuries’ may still be admitted to units lacking specialist services potentially delaying definitive treatment. The aim of this study was to analyse the referral pattern for acute inpatient transfer in an adult limb reconstruction unit for one calendar year.

Prospectively collected data from an electronic database for 2016 was reviewed. All records were evaluated for, diagnosis, time from injury to referral, nature of initial treatment, time to transfer, details of definitive surgery, and time to repatriation.

There were 91 formal electronic referrals, 84 of which considered appropriate for inpatient transfer. 74 were for fresh complex fractures, including 22 pilon fractures and 23 bicondylar tibial fractures. Median delay to request transfers for acute trauma was 3 days (0d-19d), delay from referral to transfer was 8.5 days (1d-31d) and delay from date of injury to definitive surgery was 13 days (1d-52d). 9 patients with Grade 3 open fractures and had primary debridement at the referring institution with a median delay to definitive orthoplastic surgery of 9 days (5d-20d). Only 17 of 61 per-articular fractures had spanning external fixation at the referring institution. Delay to repatriation was 8 days (0d–72d).

This study demonstrates organisational failures in acute orthopaedic care: open fractures not being primarily treated in orthoplastic centres or MTCs, delays in transfers due to bed-blocks, and significant delays in repatriation. It also demonstrates scope for improvement in clinical practice, and in particular, the need to reinforce the advantages of spanning external fixation of periarticular fractures.

Our data serves to highlight continuing problems in delivery of acute fracture care, despite widely publicised recent national guidelines.

The Fassier-Duval (FD) rod, which offers a single-entry design and allows elongation for growth, has been widely adopted in paediatric deformity correction over the past decade, although evidence is limited in literature regarding the associated complications from its use.

All FD roddings carried out in a Scottish tertiary referral centre were identified. The electronic records and radiographs of each procedure were reviewed. The follow-up duration, indications for surgery, complications arisen and further operations were recorded.

21 procedures in 11 patients were identified between 2009–2016. The mean age at operation was 6 years and 2 months. The median follow-up period was 3 years and 9 months. The main underlying pathology was osteogenesis imperfecta (71.4%, n=15). The main indication of surgery was deformity correction (61.9%, n=13). 11 (52.4%) FD roddings were for femur and the remainder were for tibia. The commonest complication was proximal migration (n=6, 28.6%). In our cohort we did not have negative telescoping or non-union. Two procedures (9.5%) were complicated by deep infections which were successfully treated. There were 3 further operations (14.3%), including one revision to a locked intramedullary nail for fracture and one below knee amputation for recurrent pseudarthrosis.

We compared our results with those from Birke and co (J Paediatr Orthop 2011) from Australia. Our results are comparable and with a longer follow-up period.

Although FD rodding allows children to maintain their mobility and prevent fractures, there are significant complications associated with its use. We hope in the future other centres can publish their results to allow improvements in surgical practice and implant design.

Objectives

External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF).

Objectives

Bisphosphonates are widely used as first-line treatment for primary and secondary prevention of fragility fractures. Whilst they have proved effective in this role, there is growing concern over their long-term use, with much evidence linking bisphosphonate-related suppression of bone remodelling to an increased risk of atypical subtrochanteric fractures of the femur (AFFs). The objective of this article is to review this evidence, while presenting the current available strategies for the management of AFFs.

Aims

The Intraosseous Transcutaneous Amputation Prosthesis (ITAP) may improve quality of life for amputees by avoiding soft-tissue complications associated with socket prostheses and by improving sensory feedback and function. It relies on the formation of a seal between the soft tissues and the implant and currently has a flange with drilled holes to promote dermal attachment. Despite this, infection remains a significant risk. This study explored alternative strategies to enhance soft-tissue integration.

Aims

The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up.

Tranexamic Acid (TA) has been shown to reduce transfusion rates in Total Knee Replacement (TKR) without complication. In our unit it was added to our routine enhanced recovery protocol. No other changes were made to the protocol at this time and as such we sought to examine the effects of TA on wound complication and transfusion rate.

All patients undergoing primary TKR over a 12 month period were identified. Notes and online records were reviewed to collate demographics, length of stay, use of TA, thromboprophylaxis, blood transfusion, wound complications and haemoglobin levels. All patients received a Columbus navigated TKR with a tourniquet. Only patients who received 14 days of Dalteparin for thromboprophylaxis were included.

124 patients were included, 72 receiving TA and 52 not. Mean age was 70. Four patients required a blood transfusion all of whom did not receive TA (p = 0.029). Mean change in Hb was 22 without TA and 21 with (p = 0.859). Mean length of stay was 6.83 days without Tranexamic Acid and 5.15 with (p < 0.001). 15% of patients (n=11) of the TA group had a wound complication, with 40% of patients (n=21) in the non TA group (p = 0.003). There was one ultrasound confirmed DVT (non TA group). No patients were diagnosed with pulmonary embolus.

In our unit we have demonstrated a significantly lower transfusion rate, wound complication rate and length of stay, without any significant increase in thromboembolic disease with the use of TA in TKR.

There is limited long term evidence to support instrumented fusion as an adjunct to decompression for foraminal stenosis in the presence of single level degenerative disc disease.

We report the long term outcome of a prospective randomised controlled trial. Forty-four patients with single-level disc disease were randomly assigned to three groups (spinal decompression (Group 1), decompression and instrumented posterolateral fusion (Group 2), or decompression and instrumented posterolateral fusion plus transforaminal interbody fusion (Group 3). Spinal disability (Dallas, Roland Morris, and Lower Back Outcome Score [LBOS]), and quality of life (EuroQol (EQ) and short form (SF-) 36 questionnaires) were assessed before and at after surgery by independent researchers.

At mean of 15 years follow up 33 (75%) patients were available for assessment. All groups observed a significant improvement in the EQ-5D at final follow up. Group 1 demonstrated significantly better functional outcome at final follow up according to the Dallas, Roland Morris, LBOS, and EQ-5D (3L and VAS) scores when compared to the other two groups (p<0.01). The SF-36 score demonstrated that group 1 had significantly better generic health scores compared to groups 2 and 3. Regression analysis was used to adjust for the differences in general health between the groups and demonstrated no significant difference between the groups in the spine specific scores: Dallas (p>0.15), Roland Morris (p>0.37), or the LBOS (p>0.32).

Fusion in combination with decompression for the treatment of foraminal stenosis and single level degenerative disc disease offers no long term functional benefit over decompression in isolation.

Risk of revision following total knee replacement is relatively high in patients under 55 years of age, but little is reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction following TKR in patients younger than 55 years of age.

We assessed 177 TKRs (157 consecutive patients) from 2008 to 2013. Data was collected on age, sex, implant, indication, BMI, social deprivation, range of motion, and prior knee surgery in addition to Oxford Knee Score (OKS) and SF-12 score. Postoperative data included knee range of motion, complications, and OKS, SF-12 score and satisfaction measures at one year.

Overall, 24.9% of patients (44/177) were unsure or dissatisfied with their TKR. Significant predictors of dissatisfaction on univariable analysis (p<0.05) included: Kellgren-Lawrence grade 1/2 osteoarthritis; indication; poor preoperative OKS; postoperative complications; and poor improvements in OKS and pain component score (PCS) of the SF-12. Odds ratios for dissatisfaction by indication compared to primary OA: OA with previous meniscectomy 2.86; OA in multiply operated knee 2.94; OA with other knee surgery 1.7; OA with BMI>40kgm-2 2; OA post-fracture 3.3; and inflammatory arthropathy 0.23. Multivariable analysis showed poor preoperative OKS, poor improvement in OKS and postoperative stiffness, particularly flexion of <90°, independently predicted dissatisfaction (p<0.005).

Patients coming to TKR when under 55 years of age differ from the ‘average’ arthroplasty population, often having complex knee histories and indications for surgery, and an elevated risk of dissatisfaction.

Competition ratios for Core Surgical Training (CST) and Higher Specialist Training in Trauma & Orthopaedic (T&O) surgery have decreased over the last 5 years. Whilst multifactorial, one reason thought to contribute to career decision- making, is junior doctors' experience whilst working in that specialty. This study aimed to identify ‘who’ is currently working on the “1st on call” tier in T&O in the UK, and what clinical activities are undertaken.

Collaborators were recruited between 12/09/2015 – 17/01/2016 via the BOTA networks. Data was prospectively collected between 18/01/2015 and 22/01/2015. Each collaborator completed a coded clinical activity diary for all doctors on the “1st on call” rota for T&O in their hospital. Activity parameters included doctor grade, rota gaps, operative and clinic exposure, on call activity, and ward cover.

221 collaborators submitted clinical activity data regarding 933 junior doctors from 100 T&O departments in the UK. 30 rota gaps were identified. The mean number of junior tier doctors was 9 (range 1–23). The “Lost Tribe” comprised Foundation Year 2 (26%), Core Surgical Trainee (19%), Trust Grade (20%), and locum doctors (13%), amongst other grades. During the study period, 2.5% of the ‘Lost Tribe’s' time was allocated to clinic, 2.7% to theatre, 27% to ward cover and 34.6% to zero sessions.

Doctors-in-training make up a minority of the workforce and as such, the T&O profession need to do more to ensure that junior doctors are exposed to clinics and operative lists to specifically address the balance between training and service delivery.

The use of Birmingham hip resurfacing (BHR) remains controversial due to the increased revision rate in female patients. We compared the outcomes of BHR in female patients to an age matched total hip arthroplasty(THA) cohort. We reviewed the pain, function and total Harris Hip Scores(HHS), and Kaplan-Meir survivorship for BHR and THA cohorts from a prospective regional arthroplasty database.

There were 234 patients in each cohort, with mean age of 51 years. The BHR cohort had significantly better function and total HHS at all points of the 5-year study, but not for the post-operative pain score. The 5-year revision rate for the BHR cohort was significantly higher than the THA cohort (6.8% vs 3.4%, p=0.001). The main reason for revision in the BHR cohort was aseptic loosening (n=8), followed by metallosis (n=3). The 5-year Kaplan-Meier survivorship was 92.6% (95% CI±1.7%) and 96.4% (95% CI±1.3%) for the BHR and THA cohort (p=0.001).

BHR can give significantly better functional outcomes than THA. The vast majority of female patients were happy with BHR and did not need further surgery at the 5-year stage. This is somewhat at odds with the recent reputation of the procedure. The 10-year result of the same cohort is warranted to provide further data. Our study is not a recommendation to still offer BHR to female patients, but rather to inject a note of realism into the debate. There are implications for future implant development in that these results do validate resurfacing as a functionally valuable option for active patients.

Scar tissue formation secondary to acute muscle injury, surgical wounding and compartment syndrome can result in significant functional impairment and predispose to further injury. The source of fibroblasts, and the molecular mechanisms driving their activation and persistence in skeletal muscle fibrosis are not known. We hypothesized that cells expressing PDGFRβ become fibroblasts in response to injury and that targeting αv integrins in these cells reduces skeletal muscle fibrosis.

We used double-fluorescent reporter mice to demonstrate that cells expressing PDGFRβ become activated myofibroblasts in response to cardiotoxin (CTX) induced skeletal muscle injury. Following injury, PDGFRβ+ cells moved from perivascular locations into the interstitium in a distribution characteristic of fibroblasts, and showed marked induction of fibroblastic genes including αSMA and collagen1 (all p<0.0001). To confirm that αv integrins present on PDGFRβ cells critically regulate skeletal muscle fibrosis we used Itgavflox/flox;PDGFRβ-Cre mice (transgenic mice in which αv integrins are ‘knocked-down’ in PDGFRβ+ cells). These mice were significantly protected from CTX induced fibrosis (p<0.01). To demonstrate potential clinical utility of targeting αv integrins, we used a small molecule inhibitor of αv integrins (CWHM12). Treatment with CWHM12 significantly reduced fibrosis when delivered from the time of injury (p<0.01) and when delivered after the fibrotic response had become established (p<0.01).

We have identified a core pathway regulating fibrosis in skeletal muscle. Pharmacologic inhibition of αv integrins has potential clinical utility in the treatment and prevention of skeletal muscle fibrosis.

Peri-prosthetic wound infections can complicate total knee arthroplasty (TKA) in 1–1.5% of cases and may require the input of a combined orthopaedic and plastic surgery team. Failure of optimal management can result in periprosthetic joint infection, arthrodesis or in severe cases limb amputation.

A retrospective 11-year review of TKA patients was undertaken in a single unit. Data was collected on a proforma and patient demographics were identified by case note analysis. Incidence of periprosthetic wound infections was recorded. A protocol to standardise treatment was subsequently developed following multidisciplinary input.

56 patients over 11 years developed periprosthetic wound infection. 33 patients were available for analysis. The male:female ratio 1:0.7 with a mean age of 70 years (range: 32–88 years). 5 (15%) developed superficial infections, 4 (12%) patients developed cellulitis requiring antibiotics, 14 (42%) with superficial wound dehiscence and 2 (6%) required washout of the prosthesis with long-term antibiotic therapy. 4 (12%) were managed without plastics involvement, one leading to arthrodesis and 4 (12%) had plastic surgical input, with one leading to arthrodesis. The mean time before plastic surgical review after initial suspicion of infection was 13 weeks.

The management of periprosthetic wound infections following TKA are variable and can require a multidiscplinary ortho-plastic approach. Early plastic surgical involvement in specific cases may improve outcome. Our proposed management protocol would facilitate in standardising the management of these complex patients.

There is comprehensive data addressing the 6 to 18-month survival in patients with pathological neck of femur (NOF) fractures due to bony metastases. However, little is known about early mortality in this group. The aim was to quantify 30 and 90-day mortality in patients with pathological NOF lesions/fractures and identify biochemical markers associated with early death.

Orthopaedic trauma lists over one year were used to identify patients with a pathological NOF fracture/lesion.

33 patients had a metastatic NOF fracture/lesion and were compared to a control group of age and gender-matched non-pathological NOF fractures. Time from referral to surgery was higher in patients with a pathological fracture compared to a pathological lesion (average 7.4 and 0.6 days, p<0.05). 30 and 90-day mortality was higher in the metastatic group compared to controls (15% 5/33 vs 9% 3/33 p<0.05, and 42% 14/33 vs 12% 4/33 p<0.01, respectively).

Patients with early mortality had lower average sodium (135 vs 138, p<0.05), creatinine (48 vs 62, p<0.05) and APTT (27 vs 32, p<0.05). They had a higher average WCC (11.3 vs 7, p<0.05) and CRP (55 vs 18, p<0.01). Metastatic patients with early mortality had lower albumin (20 vs 30, p<0.01) and haemoglobin (102 vs 121, p<0.01), which were higher in the control NOF group with early mortality (albumin 28 and haemoglobin 118 respectively, p<0.05).

Patients with pathological NOF lesions have multiple biochemical abnormalities associated with early mortality. A prospective study is proposed to assess whether correction of these abnormalities can improve survival in this group.

Soft tissue Intravenous drug abuse is known to be associated with significant health problems including soft tissue infections. Our department observed a concerning increase in the level of admissions of drug users presenting with severe soft tissue infections after injecting “Legal Highs”. These findings contributed to the body of evidence which led to the introduction of a Temporary Banning Order on these agents in Scotland in April 2015. The aim of this study was to investigate the effectiveness of banning orders on reducing patients presenting with soft tissue infections associated with intravenous drug abuse.

All admissions to the Orthopaedic trauma unit with soft tissue infections over three six-month periods in 2013, 2014 and 2015 were investigated. Those associated with intravenous drug usage were identified. Cases were reviewed to assess patient demographics, co-morbidities, infection characteristics and management.

There was a three-fold increase in hospital admissions for soft tissue infections resulting from intravenous drug use between 2013 and 2014. In 2013, 9.1% of admissions were related to use of “Legal Highs”, whilst in 2014 this had increased to 68.8%. After April 2015 there was a 28% reduction in admissions of intravenous drug use related soft tissue infections with “Legal High” associated admissions reduced to 39%.

“Legal Highs” were responsible for the dramatic increase in admissions associated with soft tissue infections resulting from intravenous drug abuse seen between 2013 and 2014. Introduction of Temporary Banning Orders for “Legal Highs” in April 2015 has been instrumental in reducing these admissions.

Lateral Epicondylitis is a common condition caused by angiofibroblastic hyperplasia of the tendinous insertion. Its treatment is varied and includes rest, physiotherapy, corticosteroid injection and surgical release. Of late, the role of Platelet Rich Plasma (PRP) injections have been explored, with positive results.

We prospectively assessed the outcomes of lateral epicondylitis treated with PRP injections and compared the outcomes of ultrasound guided and ‘blind’ injection.

This was a single centre prospective cohort study. Patient were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) Score. PRP was injected into and around the common extensor origin either with or without ultrasound guidance. The primary outcome measure was DASH score at 3 months.

45 (23F:22M) patients were recruited. The mean age was 50 years (range 35 to 79). The mean duration of follow-up was 106 days. The average pre-injection DASH score for both groups combined was 45.5 (11.7–87.5). The mean DASH score at 3 months follow-up was 27.7. The ultrasound guided injection group had a mean improvement in DASH score from 45.5 to 31.2. The “blind” injection group had a mean improvement in DASH from 44.4 to 27.7. No complications were noted. There was no statistically significant difference in improvement in DASH score between the two groups.

Our study provides further evidence to support of the use of PRP injections in the treatment of epicondylitis of the elbow. Interestingly, however, we found that the use of Ultrasound guidance does not appear to improve patient outcomes.

Aims

A fracture of the hip is the most common serious orthopaedic injury, and surgical site infection (SSI) is one of the most significant complications, resulting in increased mortality, prolonged hospital stay and often the need for further surgery. Our aim was to determine whether high dose dual antibiotic impregnated bone cement decreases the rate of infection.

Objectives

Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck.

Objectives

A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion.

Objectives

Deep bone and joint infections (DBJI) are directly intertwined with health, demographic change towards an elderly population, and wellbeing.

The elderly human population is more prone to acquire infections, and the consequences such as pain, reduced quality of life, morbidity, absence from work and premature retirement due to disability place significant burdens on already strained healthcare systems and societal budgets.

DBJIs are less responsive to systemic antibiotics because of poor vascular perfusion in necrotic bone, large bone defects and persistent biofilm-based infection. Emerging bacterial resistance poses a major threat and new innovative treatment modalities are urgently needed to curb its current trajectory.

Adequate perpendicular access to the posterolateral talar dome for osteochondral defect repair is difficult to achieve and a number of different surgical approaches have been described. This cadaveric study examined the exposure available from various approaches to help guide pre-operative surgical planning.

Four surgical approaches were performed in a step-wise manner on 9 Thiel-embalmed cadavers; anterolateral approach with arthrotomy, anterolateral approach with anterior talo-fibular ligament (ATFL) release, anterolateral approach with antero-lateral tibial osteotomy, and anterolateral approach with lateral malleolus osteotomy. The furthest distance posteriorly which allowed perpendicular access with a 2mm k-wire to the lateral surface of the talar dome was measured from the anterior aspect of the talar dome.

The mean antero-posterior diameter of the lateral talar domes included in this study was 45.1mm. An anterolateral approach to the ankle with arthrotomy provided a mean exposure of the anterior 1/3rd of the lateral talar dome. ATFL release increased this to 43.2%. A lateral malleolus osteotomy provided superior exposure (81.5% vs 58.8%) compared to an anterolateral tibial osteotomy.

Only the anterior half of the lateral border of the talar dome could be accessed with an anterolateral approach without osteotomy. A fibular osteotomy provided best exposure to the posterolateral aspect of the talar dome and is recommended for lesions affecting the posterior half of the lateral talar dome.

Alcohol-based cutaneous disinfectant use is well established in the surgical environment. However, during scrubbing, volatile alcohols are inspired into the pulmonary system. With the recent reduction in the national drink driving limit, even low levels of detected breath alcohol can have legal implications. This study aimed to determine the extent to which passive inhalation of alcohol-based surgical hand disinfectant affects estimated percentage blood alcohol concentration (%BAC) on breathalyser testing.

Over a one week period (September 2015), 24 theatre team members (13 surgeons, 6 scrub staff and 5 anaesthetists) were prospectively recruited. The mean cohort age was 43.7 years (50% female). Participants were instructed to scrub for 90 seconds with an alcohol-based hand disinfectant comprising of the active ingredients (per 100g): propan-1-ol 30.0g, propan-2-ol 45.0g and mecetroniumetilsulphate 0.2g. Estimated %BAC was recorded immediately before and after scrubbing, and every five minutes thereafter until levels returned to 0.00%BAC. Results ≥ 0.05%BAC were deemed above the Scottish legal driving limit.

All participants exceeded the 0.05%BAC threshold on immediate post scrub testing. The mean peak %BAC was 0.12% (± 0.05) with a maximum BAC documented at ≥0.20% in four subjects. In all participants, the %BAC descended to zero over a period ranging from 10–30 minutes with a mean time to zero of 16.7 (± 4.8) minutes.

Following the use of alcohol-based surgical hand disinfectant, estimated blood alcohol concentrations detected on breath sampling can rise up to four times the Scottish driving limit which may have legal and professional ramifications.

Aims

We wished to assess the feasibility of a future randomised controlled trial of parathyroid hormone (PTH) supplements to aid healing of trochanteric fractures of the hip, by an open label prospective feasibility and pilot study with a nested qualitative sub study. This aimed to inform the design of a future powered study comparing the functional recovery after trochanteric hip fracture in patients undergoing standard care, versus those who undergo administration of subcutaneous injection of PTH for six weeks.

Our unpublished data has indicated that the perivascular stem cells (PSCs) have increased chondrogenic potential compared to mesenchymal stem cells (MSCs) derived in culture. There has been a recent change in the theory that stem cells work by a paracrine effect rather than differentiation. There are minimal data demonstrating the persistence of implanted stem cells when used for engraftment. This study aimed to develop an autologous large animal model for perivascular stem cells as well as to determine if cells were retained in the articular cartilage defects.

The reactivity of anti-human and anti-ovine antibodies was ascertained using immunohistochemistry and fluorescence-activated cell sorting (FACS). A panel of antibodies were combined and used to identify and purify pericytes (CD34-CD45-CD146+) and adventitial cells (CD34+CD45-CD146-) using FACS. The purified cells were cultured and their identity checked using FACS. These cultured cells demonstrated osteogenic, adipogenic and chondrogenic potential.

Autologous ovine PSCs (oPSCs) were isolated, cultured and transfected using a GFP virus. The transfection rate was 88%. The cells were implanted into an articular cartilage defect on the medial femoral condyle using a hydrogel, four weeks following implantation the condyle was explanted and confocal laser scanning microscopy demonstrated the presence of oPSCs in the defect. Histology did not demonstrate any repair tissue at this early time point.

These data have confirmed the viability our large animal model and that the implanted stem cells were retained in the defect four weeks following implantation.

We have previously reported that fibular nailing in the elderly is associated with a significantly reduced complication rate and greater cost-effectiveness when compared to ORIF. The aim of this study was to compare the outcomes of fibular nailing to ORIF in patients under the age of 65.

100 patients aged 18 to 64 were randomly allocated between groups. Outcomes assessed over two years post-operatively included: development of wound complications or radiographic arthritis, the accuracy of reduction and patient satisfaction. The mean age was 44, 25% of patients were smokers and 35% had some form of comorbidity of whom three were diabetic. 27 injuries occurred after sport and two after assault the remainder occurred after a simple fall from a standing height.

Superficial wound infections occurred in two patients in each group. Six patients requested removal of the nail, and six patients requested plate and screw removal. Patient reported outcome scores were comparable for the two groups. Two failures of fixation occurred in the fibular nail group; one in a patient with neuropathy. One failure of fixation occurred in the ORIF group. All other patients went on to an anatomical union without complication. Patient satisfaction with the surgical scar was higher after fibular nailing (visual analogue scale mean 0.75, range 0–5) than for ORIF (mean 1.5, range 0–7).

The fibular nail allows accurate reduction and secure fixation of ankle fractures with comparable radiographic and patient-reported outcomes to ORIF at two years and a greater patient satisfaction with the appearance of the surgical scars.

Introduction

Closed avulsion of the Flexor Digitorum Profundus (FDP) from distal phalanx most commonly affects the ring finger when an extensive force is applied to a finger in active flexion. Whilst it is undoubtably reasonable to provide treatment for those who present with symptoms, there may be a cohort of people who sustain an avulsion without noticing. This study aims to quantify the effect of ring finger FDP avulsion on overall grip strength to determine the functional effect of a missed injury

There is a lack of information about the association between patellofemoral osteoarthritis (PFOA) and both adolescent Anterior Knee Pain (AKP) and previous patellar dislocations.

This case-control study involved 222 participants from our knee arthroplasty database answering a questionnaire. 111 patients suffering PFOA were 1:1 matched with a unicompartmental tibiofemoral arthritis control group. Multivariate correlation and binary logistic regression analysis was performed, with odds ratios (ORs) and 95% confidence intervals (CIs) calculated. This analysis helps us assess the effect of both variables whilst adjusting for major confounders, such as previous surgery and patient-reported instability.

An individual is 7.5 times more likely to develop PFOA if they have suffered adolescent AKP (OR 7.5, 95% CIs 1.51–36.94). Additionally, experiencing a patellar dislocation increases the likelihood of development of PFOA, with an adjusted odds ratio of 3.2 (95% CIs 1.25–8.18). A 44-year difference in median age of first dislocation was also observed between the groups.

This should bring into question the traditional belief that adolescent anterior knee pain is a benign pathology. Patellar dislocation is also a significant risk factor. These patients merit investigation, we encourage clinical acknowledgement of the potential consequences when encountering patients suffering from anterior knee pain or patellar dislocation.

25–40% of unicompartmental knee replacement (UKR) revisions are performed for unexplained pain possibly secondary to elevated proximal tibial bone strain. This study investigates the effect of tibial component metal backing and polyethylene thickness on cancellous bone strain in a finite element model (FEM) of a cemented fixed bearing medial UKR, validated using previously published acoustic emission data (AE).

FEMs of composite tibiae implanted with an all-polyethylene tibial component (AP) and a metal backed one (MB) were created. Polyethylene of thickness 6–10mm in 2mm increments was loaded to a medial load of 2500N. The volume of cancellous bone exposed to <−3000 (pathological overloading) and <−7000 (failure limit) minimum principal (compressive) microstrain (µ∊) and >3000 and >7000 maximum principal (tensile) microstrain was measured.

Linear regression analysis showed good correlation between measured AE hits and volume of cancellous bone elements with compressive strain <−3000µ∊: correlation coefficients (R= 0.947, R2 = 0.847), standard error of the estimate (12.6 AE hits) and percentage error (12.5%) (p<0.001). AP implants displayed greater cancellous bone strains than MB implants for all strain variables at all loads. Patterns of strain differed between implants: MB concentrations at the lateral edge; AP concentrations at the keel, peg and at the region of load application. AP implants had 2.2 (10mm) to 3.2 (6mm) times the volume of cancellous bone compressively strained <−7000µ∊ than the MB implants. Altering MB polyethylene insert thickness had no effect. We advocate using caution with all-polyethylene UKR implants especially in large or active patients where loads are higher.

Introduction

There is limited evidence assessing the effect of the Ankle Foot Orthosis (AFO) on gait improvements in diplegic cerebral palsy. In particular, the effect of the AFO on vertical forces during gait has not been reported. Appropriate vertical ground reaction forces are crucial in enabling children with CP to walk efficiently. This study investigated the effect of AFO application on the vertical forces in gait, particularly the second vertical peak in force (FZ2) in late stance. The force data was compared with the barefoot walk.

British national guidelines recommend agents which antagonise factor Xa or warfarin as prophylaxis of venous thromboembolism (VTE) in lower limb arthroplasty. However, they discourage the use of aspirin prophylaxis.

We conducted a prospective, multi-centre audit between two national centres, Ninewells Hospital in Dundee and the Royal Infirmary in Edinburgh to compare bleeding and VTE risk. Only Edinburgh routinely uses aspirin as VTE prophylaxis. The study comprises a number of cycles from 2013 to 2015. Consecutive groups of patients were identified prospectively using elective theatre data and information extracted from their case-notes on type of VTE prophylaxis, VTE occurrence, wound complications and length of hospital stay for a period of nine weeks post-operatively.

262 Edinburgh patients and 92 Dundee patients were included. Most Edinburgh patients were prescribed aspirin in hospital and on discharge (188/262, 71.8%), in line with local protocol. In Dundee, dalteparin was most commonly prescribed in hospital (68/92, 73.9%) and rivaroxaban on discharge (57/92, 62.0%).

The Edinburgh group had a 1.5% incidence of pulmonary embolus (PE) and a 1% rate of deep venous thrombosis (DVT), 2% had problems with wound haematoma and one patient (0.4%) required a transfusion; no wound washouts were required. In Dundee there was 0% PE, 2% DVT, 5% had problems with haematoma, 3% required transfusion and 2% required washout. There was no difference in length of hospital stay, with a mode of 4 days for both centres.

Non-fatal PE was prevented in Dundee patients but possibly at the cost of greater incidence of wound complications.

The availability of seven-day NHS services for patients is currently receiving widespread national attention. Rehabilitation services including physiotherapy and occupational therapy are not routinely available at the weekend. The aim of this pilot study was to determine if seven-day rehabilitation services led to improved outcomes for hip fracture patients.

All proximal femur fractures were included and formed into two cohorts. Data were collected prospectively in each cohort. Cohort one underwent standard five-day rehabilitation (n=79). Cohort two received seven-day rehabilitation (n=338). Both groups were followed up to 120 days.

No significant differences were observed between the cohorts for pre-fracture place of residence, ASA score or age. Combined median length-of-stay in hospital and rehabilitation improved from 28 to 21 days (p=0.054) Combined median length of stay for patients admitted from home improved from 26 to 19 days (p=0.016).

This pilot study suggests that a seven-day physiotherapy and occupational therapy service may result in decreased total length-of-stay in hospital and subsequent rehabilitation. This is a clear benefit for our patients but also for our hospitals and rehabilitation units where beds are at such a premium. A wider study across multiple institutions within NHS Scotland is now needed to investigate this further.

Isolated Weber B fractures usually heal uneventfully but traditionally require regular review due to the possibility of medial ligament injury allowing displacement. Following recent studies suggesting that delayed talar shift is uncommon we introduced a functional treatment protocol and present the early results.

86 patients presenting acutely with Weber B fractures without talar shift between January and July 2015 were included. Patients were splinted in a removable boot and allowed to weight bear. ED notes and radiographs were reviewed by an Orthopaedic consultant. Patients without signs of medial injury were discharged with an information leaflet and advice. If signs of medial ligament injury were noted or the medial findings were not documented the patient was reviewed in fracture clinic at 4 weeks post-injury. If talar shift developed the patient was to be converted to operative treatment. MOXFQ and EDQ5 scores were collected.

50 patients had signs of medial ligament injury or no documented medial findings and of these 43 attended fracture clinic. Of 36 patients without signs of medial ligament injury 28 were discharged according to protocol and 8 patients attended fracture clinic. One discharged patient re-accessed care. Of 52 patients reviewed in the fracture clinic none developed delayed talar shift and all continued with non-operative treatment. The outcome scores were comparable to those in the published literature.

We conclude the risk of delayed talar shift is low and satisfactory outcomes can be safely achieved with our functional protocol. Additional tests/imaging to establish the integrity of the medial ligament may be unnecessary.

By the end of training, every registrar is expected to demonstrate proficiency in total knee replacement (TKR). It is unclear whether functional outcomes for knee arthroplasty performed by training grade doctors under supervision of a consultant have equivalent functional outcomes to those performed by consultants.

This study investigated the functional outcomes following TKR in patients operated on by a supervised orthopaedic trainee compared to a consultant orthopaedic surgeon. Patients undergoing surgery by a consultant (n=491) or by a trainee under supervision (n=145) between 2003 and 2006 were included. There was a single implant, approach and postoperative rehabilitation regime. Patients were reviewed eighteen months, three years and five years postoperatively.

There were no significant differences in preoperative patient characteristics between the groups. There was no difference in length of stay or transfusion or tourniquet time. Both consultant (p<0.001) and trainee (p<0.001) groups showed significant improvement in AKSK and AKSF scores between preoperative and 18 month review and there was no difference in the magnitude of observed improvement between groups (AKSK p=0.853; AKSF p=0.970). There were no significant differences in either score between the groups preoperatively or at any review point postoperatively. At five years postoperative, both groups had a median OKS of 34 (p=0.921).

This is the largest reported series of outcomes following primary TKR examining functional outcome linked with grade of surgeon. It shows that a supervised trainee will achieve comparable functional outcomes at up to 5 years post operatively.

There is a paucity of published literature regarding the long-term outcomes of the modern generations of total joint arthroplasty (TJA) of the first metatarsophalangeal joint. Between 1999 and 2001, we recruited 63 patients into a randomised controlled trial of arthrodesis vs TJA. The 2 year results were published in 2005.

At a mean follow-up 15.2 years (range 13.2–17.2), all patients from the original trial were contacted. Data were collected in the form of visual analogue score for pain (VAS), visual-Analogue-Scale Foot and Ankle (VAS FA) as well as information on any revision procedures.

Data were available from all surviving patients (66 toes 53 patients). There was no difference in pain scores between the arthrodesis group and arthroplasty group 7.4 ± 15.7 vs 15.7 ± 19.7 (p=0.06). There was also no difference in the VAS FA scores as a whole 88.9 ± 12.9 vs 86.1 ± 17.1 (p = 0.47), or when divided into its 3 components (pain, function and other complaints). There was however a significant difference with regards to patient satisfaction with the arthrodesis group outperforming the TJA group: 95.5 ± 10.4 vs 83.6 ± 20.9 (p<0.01). There was a significantly higher rate of revision surgery in the TJA group when compared to the arthrodesis group (p= 0.009).

At 15 years the patients that underwent arthrodesis were more satisfied and had a greater survivorship compared to TJA, however there was no difference in outcome with regards to pain or function between the two groups. Based on the results of this study arthrodesis remains the ‘gold standard’ due to excellent pain relief, high function and low risk of revision surgery.

Objectives

The monitoring of fracture healing is a complex process. Typically, successive radiographs are performed and an emerging calcification of the fracture area is evaluated. The aim of this study was to investigate whether different bone healing patterns can be distinguished using a telemetric instrumented femoral internal plate fixator.

Objectives

The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment.

Objectives

The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison.

Objectives

The biomembrane (induced membrane) formed around polymethylmethacrylate (PMMA) spacers has value in clinical applications for bone defect reconstruction. Few studies have evaluated its cellular, molecular or stem cell features. Our objective was to characterise induced membrane morphology, molecular features and osteogenic stem cell characteristics.

Objectives

Patient-reported outcome measures (PROMs) are often used to evaluate the outcome of treatment in patients with distal radial fractures. Which PROM to select is often based on assessment of measurement properties, such as validity and reliability. Measurement properties are assessed in clinimetric studies, and results are often reviewed without considering the methodological quality of these studies. Our aim was to systematically review the methodological quality of clinimetric studies that evaluated measurement properties of PROMs used in patients with distal radial fractures, and to make recommendations for the selection of PROMs based on the level of evidence of each individual measurement property.

Background

Approximately half of all hip fractures are displaced intracapsular fractures. The standard treatment for these fractures is either hemiarthroplasty or total hip arthroplasty. The recent National Institute for Health and Care Excellence (NICE) guidance on hip fracture management recommends the use of ‘proven’ cemented stem arthroplasty with an Orthopaedic Device Evaluation Panel (ODEP) rating of at least 3B (97% survival at three years). The Thompsons prosthesis is currently lacking an ODEP rating despite over 50 years of clinical use, likely due to the paucity of implant survival data. Nationally, adherence to these guidelines is varied as there is debate as to which prosthesis optimises patient outcomes.

ERAS (Enhanced recovery after surgery) programs have been widely adopted in elective orthopaedic practice. Early discontinuation of Intravenous (IV) fluids in order to promote mobilisation and subsequent discharge is a key feature of such programs. However concerns have been raised regarding whether such an approach results in an increased risk of acute kidney injury (AKI).

We set out to determine the incidence of AKI in patients undergoing hip or knee arthroplasty treated as part of an ERAS program where IV fluids are removed before leaving the recovery room. Investigate whether there is a difference in incidence between patients with a pre-operative eGFR ≥ 60 or < 60 (ml/min/1.73m2). In addition to whether patients who sustain an AKI have a longer post-operative hospital stay.

The pre and post-operative blood results of patients undergoing elective total hip and total knee replacements were retrospectively analysed to determine whether they had suffered an AKI during admission. The patient's notes were reviewed for other known causes of peri-operative AKI and the length of their hospital stay.

The overall Incidence of AKI was 9.4%. There was a significant association found between pre-operative eGFR and development of an AKI p = 0.002. The incidence of AKI was 5.8% in patients with a pre-operative eGFR ≥ 60 vs 33.3% in those with an eGFR < 60. The development of an AKI was associated with a longer hospital stay p = 0.042. The median length of hospital stay was 7 days for those who suffered an AKI vs 5 days for those who did not.

Patients undergoing elective lower limb arthroplasty with a pre-operative eGFR < 60 treated as part of an ERAS program where fluids are discontinued before leaving the recovery room are at high risk of developing an AKI. Further studies are required to ascertain whether a longer duration of IV fluids is effective in reducing the incidence of AKI in this group.

Cephalasporin antibiotics have been commonly used for prophylaxis against surgical site infection. To prevent Clostridium difficile, the preferential use of agents such as flucloxacillin and gentamicin has been recommended. The aim of this study was to investigate the bone penetration of these antibiotics during hip and knee arthroplasty, and their efficacy against Staphylococcus aureus and S. epidermidis.

Bone samples were collected from 21 patients undergoing total knee arthroplasty (TKA) and 18 patients undergoing total hip replacement (THA). The concentration of both antibiotics was analysed using high performance liquid chromatography. Penetration was expressed as a percentage of venous blood concentration. The efficacy against common infecting organisms was measured using the epidemiological cut-off value for resistance (ECOFF).

The bone penetration of gentamicin was higher than flucloxacillin. The concentration of both antibiotics was higher in the acetabulum than the femoral head or neck (p=0.007 flucloxacillin; p=0.021 gentamicin). Flucloxacillin concentrations were effective against S. aureus and S. epidermis in all THAs and 20 (95%) TKAs. Gentamicin concentrations were effective against S.epidermis in all bone samples. Gentamicin was effective against S. aureus in 11 (89%) femoral samples. Effective concentrations of gentamicin against S. aureus were only achieved in 4 (19%) femoral and 6 (29%) tibial samples in TKA.

Flucloxacillin and gentamicin was found to effectively penetrate bone during arthroplasty. Gentamicin was effective against S. epidermidis in both THA and TKA, while it was found to be less effective against S. aureus during TKA. Bone penetration of both antibiotics was less in TKA than THA.

Mesenchymal stem cells (MSCs) reside around blood vessels in all organs. This reservoir of progenitors can be ‘recruited’ in response to injury. The ability to manipulate stem cells therapeutically within injured tissue provides an attractive alternative to transplantation. Stem cells are regulated by neighbouring cells. We hypothesized that endothelial cells (ECs) influence MSC differentiation into bone and fat.

MSCs were sorted from fat using fluorescent activated sorting. Their capacity to differentiate into bone, fat and cartilage was used to confirm MSC phenotype. MSCs and ECs were cultured in two-dimensions (standard culture dishes) and three-dimensions (vascular networks suspended in gel). Cocultures were exposed to osteogenic and adipogenic media. The role of EC-released factors on MSC differentiation was determined using a system in which cells share media but do not contact. Wnt pathway modulators were used to investigate the role of Wnt signalling.

MSCs differentiated into bone, fat and cartilage. MSCs and ECs integrated in two- and three-dimensions. MSCs and ECs formed vessel-like structures in three-dimensions. When cultured with ECs, MSC differentiation to bone was accelerated while differentiation to fat was inhibited. This effect on osteogenesis was maintained when cells shared media but did not contact. Coculture with Wnt modulators confirmed that this effect is in part, mediated through Wnt signalling.

Our data suggest that ECs influence MSC differentiation. Therapeutic targeting of EC-MSCs signalling may enable manipulation of MSCs in vivo avoiding the need for cell transplantation. This could enable trauma and orthopaedic patients who have healthy resident stem cells to self-repair.

Current knowledge regarding outcomes following surgical treatment of Morton's neuroma remains incomplete. This is the first prospective study to report the pre- and post-operative patient reported outcomes and satisfaction scores following excision of interdigital Morton's neuroma.

Over a seven year period, 99 consecutive patients (112 feet) undergoing surgical excision of Morton's neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. Patient recorded outcomes and satisfaction were measured using the Manchester-Oxford Foot Questionnaire (MOXFQ), Short Form-12 (SF12) and a supplementary patient satisfaction survey three months pre and six months post-operatively.

Statistically significant differences were found between the mean pre- and post-operative MOXFQ and physical component of the SF-12 (p<0.05). No difference in outcome was identified in patients in whom multiple neuromas were operated compared to single site surgery. However, revision surgery proved to statistically worsen MOXFQ outcomes post-operatively p<0.004. Overall satisfaction was reported as excellent (49%) or good (29%) by the majority of patients but 10% were dissatisfied with poor (8%) or very poor (2%) results expressed. Only 64% were pain free at the time of follow-up and 8% of patients MOXFQ scores worsened.

These findings illustrate that overall, patient reported outcomes following resection of symptomatic Morton's neuroma are acceptable but may not be as favourable as earlier studies suggest. Caution should be taken when considering revision surgery which has shown to be a poor prognostic indicator. Contrary to current knowledge, multiple site surgery can be safely undertaken.

Scheuermann's kyphosis is a structural deformity of the thoracic or thoracolumbar spine, which can result in severe pain, neurological compromise and cosmetic dissatisfaction. Modern surgical techniques have improved correction through a posterior-only or antero-posterior approach but can result in significant morbidity.

We present our results of the surgical management of severe Scheuermann's kyphosis by a single surgeon with respect to deformity correction, global balance parameters, functional outcomes and complications at latest follow-up. We included 49 patients, of which 46 had thoracic and 3 had thoracolumbar kyphosis. Surgical indications included persistent back pain, progressive deformity, neurological compromise and poor self-image. Fourty-seven patients underwent posterior-only and 2 antero-posterior spinal arthrodesis utilising Chevron-type osteotomies and hybrid instrumentation. Mean age at surgery was 16.0 years with mean postoperative follow-up of 4.5 years. Mean kyphosis corrected from 92.1o to 46.9o (p<0.001). Concomitant scoliosis was eliminated in all of the 28 affected patients. Coronal and sagittal balance was corrected in all patients. Mean blood loss was 24% total blood volume. Mean operation time was 4.3 hours with mean inpatient stay of 9 days. SRS-22 questionnaire improved from a mean preoperative score of 3.4 to 4.6 at 2 years, with high treatment satisfaction rates. Complications included one toxic septicaemia episode but otherwise no wound infections, no junctional deformity, no loss of correction and no requirement for re-operation.

Posterior spinal arthrodesis with the use of hybrid instrumentation can safely achieve excellent correction of severe Scheuermann's kyphosis helping to relieve back pain, improve functional outcomes and enhance self-image.

This study assessed whether patient satisfaction with their hospital stay influences the early outcome of total knee replacement (TKR).

During a five year period patients undergoing primary TKR at the study centre had prospectively outcome data recorded (n=2264). Patients with depression (p=0.04) and worse mental wellbeing (p<0.001), according to the short form (SF)-12, were more likely to be dissatisfied with their hospital stay. Decreasing level of satisfaction with their hospital stay was associated with a significantly worse post-operative OKS (p<0.001) and SF-12 score (p<0.001). Multivariable regression analysis confirmed that the patients perceived level of satisfaction with their hospital stay was an independent predictor of change in the OKS (p<0.001) and SF-12 score (p<0.001) after adjusting for confounding variables. Patient satisfaction with their TKR was significantly influenced by their hospital experience, decreasing from 96% in those with an excellent experience to 42% in those with a poor experience. Food, staff/care, and the hospital environment were the most frequent reasons of why patients rated their hospital experience as fair or poor.

A patient's perception of their inpatient hospital experience after surgery is an important modifiable predictor of early functional outcome and satisfaction with TKR.

There is debate whether a home run screw (medial cuneiform to 2nd metatarsal base) combined with k-wire fixation of 4th & 5th rays is sufficient to stabilise Lisfrance injuries or if fixation of the 3rd ray is also required. Unlike the 2nd, 4th and 5th TMTJ, stabilisation of the 3rd requires either intra-articular screw or a cross joint plate which both risk causing chondrolysis and/or OA.

Using 8 Theil embalmed specimens, measurements of TMTJ dorsal displacement at each ray (1st to 5th) and 1st – 2nd metatarsal gaping were made during simulated weight bearing with sequential ligamentous injury and stabilisation to determine the contribution of anatomical structures and fixation to stability.

At baseline mean dorsal TMTJ displacement of the intact specimens during simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st-2nd IM Gap was 0mm. After transection of the Lisfranc ligament only, there was 1st-2nd intermetatarsal gaping (mean 4.5mm), but no increased dorsal displacement. After additional transection of all the TMTJ ligaments dorsal displacement increased at all joints (1st: 4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires virtually eliminated all displacement. Further transection of the 3rd/4th inter-metatarsal ligaments increased mean dorsal displacement of the 3rd ray to 2.5mm. K-wire fixation of the 3rd ray completely eliminated dorsal displacement.

The results suggest that stabilising the 2nd and 4/5th TMTJs will stabilise the 3rd if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments (3rd-4th) are intact the 3rd ray does not need to be stabilised routinely.

Objectives

Current studies on the additional benefit of using computed tomography (CT) in order to evaluate the surgeons’ agreement on treatment plans for fracture are inconsistent. This inconsistency can be explained by a methodological phenomenon called ‘spectrum bias’, defined as the bias inherent when investigators choose a population lacking therapeutic uncertainty for evaluation. The aim of the study is to determine the influence of spectrum bias on the intra-observer agreement of treatment plans for fractures of the distal radius.

The number of clinical negligence claims in the UK is constantly increasing. As a specialty, trauma and orthopaedic surgery has one of the highest numbers of negligence claims.¹ This study analyses NHS Litigation Authority (NHSLA) claims in trauma and orthopaedics between 2004 and 2014.

A formal request was made to the NHSLA under the Freedom of Information Act in order to obtain all data related to claims against orthopaedic surgery. It was found that the number of claims, and percentage of successful claims, has been constantly increasing over this period, with compensation paid of over £349 million.* Errors in clinical management accounted for the highest number of closed claims (2933 claims), costing over £119 million.*

The level of compensation paid out has a significant financial impact on the NHS. Reforms need to be made in order to tackle the high cost of legal fees generated by these claims, which further drain the limited resources available to the NHS.

There is an increasing trend towards radial head replacement (RHR) or fixation for complex radial head fractures. These injuries are identified by grossly displaced fragments or elbow instability. The aim of this study was to examine the outcome of a surgical protocol that emphasised delayed radial-head excision (RHE) as the procedure of choice. When the humero-ulnar joint was congruent, intervention was delayed 10 to 14 days to allow time for ligamentous healing. RHR was performed if instability was demonstrated on-table.

A retrospective study was performed to identify the outcome of patients undergoing surgery for a radial head fracture between 2008 and 2014. There were 18 Mason Type III and 18 Mason Type IV injuries. There was an associated coronoid fracture in 17 patients. RHE was performed in 28 patients, of which the reoperation rate was 2 (7.1%). RHR was performed in 15 patients, of whom 4 (27%) had reintervention. RHR was most common in the Type III coronoid fractures. The cumulative reoperation rate was 9.3% at six months and 15.4% at two years. The median Oxford Elbow Score (OES) was 85.4 (IQR 73.4 to 99.5). Time from injury was the only predictor of the Oxford Elbow Score (p=0.04).

This surgical protocol resulted in a reduced need for RHR, a low reintervention rate, and satisfactory function. RHR should be reserved for cases where stability cannot be achieved on-table. Stability can be maximised by delaying RHE until early ligamentous healing occurs.

The best surgical treatment of lateral epicondylitis remains uncertain. Recently radiofrequency microtenotomy (RFMT) has been proposed as a suitable surgical treatment. We aim to compare open release with RFMT and present the results of our randomised controlled trial.

Patients with symptoms of tennis elbow for at least 6 months who had failed to respond to conservative management were included in the trial. They were randomised to open release or RFMT. Outcome measures included grip strength, pain and DASH scores.

41 patients were randomised, 23 to RFMT and 18 to open release, 2 patients withdrew from the study. Our results show that both treatments give a significant benefit at all time points for DASH and pain scores, but only open release gives a significant improvement in grip strength. Comparing the two treatments the only significant difference is the open group have better pain scores at 6 weeks, but this is not seen at later follow up.

In conclusion both groups have shown benefit from the treatments, but one is not shown to be clearly superior.

Calcaneal fracture fixation over the past decade has been practised via an extensile lateral incision. This can be complicated by infection and wound breakdown.

We have developed a new technique for fixation of the calcaneal fractures – MACO. We utilise a 4 cm sub fibular incision to aid joint visualisation and fracture reduction. Fixation is via percutaneous screws.

We analysed our prospectively collected database. 26 fractures were fixed over an 18 month period at Glasgow Royal Infirmary by three consultant surgeons. 22 patients were male and half were smokers. Mean follow up was 5 months (range 1.5 – 18 months).

The mean age of our patients is 41 (range 25–68). The mean pre operative Bohler's angle was 16.7 degrees. Gissane's angle was similarly abnormal with a mean of 129 degrees.

The average duration of surgery was 73 minutes (range 45–100 minutes). Post operatively, Bohler's angle was improved. The mean was 29 degrees. There was no significant difference with Gissane's angle. The mean was 128 degrees.

There were no superficial wound infections. One patient was troubled by wound breakdown with subsequent deep infection. There was no need for metalwork removal in our series of patients. Two patients developed post traumatic osteoarthritis of the sub talar joint. Only one has required sub talar joint fusion.

We conclude that the novel technique which we describe is successful in restoring calcaneal anatomy with few complications. Further follow up is needed to determine the long term outcomes of such surgery.

A multicentre retrospective study of 879 total hip replacements (THR) was undertaken to investigate any differences in outcome between trainee surgeons and consultants. The effect of trainee supervision was also assessed. The primary outcome measures were survivorship and the Harris Hip Score (HHS). Length of stay was a secondary outcome.

Patients were evaluated pre-operatively and at 1, 3, 5, 7 and 10 years post-operatively. Surgical outcome was compared between junior trainees, senior trainees and consultants. The effect of supervision was determined by comparing supervised and unsupervised trainees. There was no significant difference in post-operative HHS among consultants, senior and junior trainees at 1 year (p=0.122), at 3 years (p=0.282), at 5 years (p=0.063), at 7 years (p=0.875), or at 10 years (p=0.924) follow up. Additionally there was no significant difference in HHS between supervised and unsupervised trainees at 1 year (p=0.220), 3 years (p=0.0.542), 5 years (p=0.880), 7 years (p=0.953) and 10-year (p=0.787) follow-up. Comparison of surgical outcome between the supervised and unsupervised trainees also shows no significant difference in hospital stay (p=0.989), or implant survival years (p=0.257). This study provides evidence that when trainees are appropriately supervised, they can obtain equally good results compared with consultants when performing THR.

Paget's disease of bone (PDB) is the second most common metabolic bone disease. Osteoarthritis (OA) affects one-third of patients with PDB. The incidence of THR (total hip replacement) and TKR (total knee replacement) is 3.1- and 1.7-fold higher in PDB patients compared to non-affected age-matched controls. No large studies or joint registry reports exist describing the outcomes following THR or TKR in patients with PDB.

The objectives of this study were to investigate the outcomes following THR and TKR in patients with PDB using national joint registry data. 144 THR and 43 TKR were identified using the Scottish Arthroplasty Project from 1996–2013.

For THR, the most common early post-operative surgical complications were haematoma formation (1.4%), and surgical site infection (1.4%). The absolute incidence during follow-up of dislocation was 2.8%, and revision hip arthroplasty was performed in 2.8% of cases. Implant survival of the primary prosthesis was 96.3% (CI: 92.8 – 99.8) at 10-years, and patient survival was 50.0% (39.6 – 60.4) at 10-years.

For TKR, the most common early post-operative surgical complication was surgical site infection (2.3%). The absolute incidence during follow-up of revision knee arthroplasty was 4.7%. On survival analysis, implant survival of the primary prosthesis was 94.5% (CI: 87.1 – 100) at 10-years, and patient survival was 38.3% (16.7 – 59.9) at 10-years.

This is the largest reported series of outcomes following primary THR and TKR in patients with PDB. PDB patients are not at increased risk of surgical complications following primary THR or TKR compared to non-PDB patients.

Background

The Schatzker classification is applied in the management of tibial plateau fractures. The unique pattern of Schatzker VI fractures requires recognition for proper fixation.

Background:

Developing a successful outpatient service for Ilizarov frame removal provides both patient and cost benefits. Misinformation and patient trepidation can be detrimental to recovery and influence choices. Education may play an important role in tailoring an efficacious service.

Background:

Charcot arthropathy is a condition related to the loss of protective sensation of a joint. It normally presents in its early inflammatory phase, followed by bone destruction. Recognised treatment for this is total contact casting (TCC). However, in a small group this may be unsuccessful in preventing deformity progression. TCC can also be difficult in the presence of recalcitrant ulceration and deformed feet.

The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 – 2010 were contacted and interviewed. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation in the same period. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria, of which 30 patients (61%) were followed-up. Ten of the 30 patients required revision surgery, 3 of which involved conversion to a circular frame. Twenty-two of the 30 patients (73%) recovered sufficiently to complete a basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.

We define the long-term outcomes and rates of further operative intervention following displaced Bennett's fractures treated with Kirschner (K)-wire fixation.

We prospectively identified patients who were treated for displaced Bennett's fractures over a 13 year period between 1996 and 2009. Electronic records for these patients were examined and patients were invited to complete a Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in addition to a patient satisfaction questionnaire.

We identified 143 patients with displaced Bennett's fractures treated with K-wire fixation and followed them up at a mean of 13 years. The mean patient age at the time of injury was 33.2 years. At the time of follow up, 11 patients had died and 1 had developed dementia and was unable to respond. 9 patients had no contact details. This left 122 patients available for recruitment. Of these, 60 did not respond leaving a study group of 62 patients. Patients reported excellent functional outcomes and high levels of satisfaction at follow up. Mean satisfaction was 89% and the mean DASH score was 3.2. The infection rate was 3%. None of the 122 patients had undergone salvage procedures and none of the responders had changed occupation or sporting activities.

Long-term patient reported outcomes following displaced Bennett's are excellent. Fusion surgery or trapeziectomy was not undertaken for any patient in this series nor did this injury result in sporting or occupational changes. The rate of infection is low and similar to the literature for other surgical procedures with percutaneous K-wires.

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.

The mean age of the patients at exchange nail surgery was 37 years. The median time to exchange nailing from primary fixation was 8.4 months. Multiple causes for non-union were found in 14 (35.0%) cases, with infection present in 12 (30.0%) patients. Further exchange procedures were required in nine (22.5%) cases, one patient (2.5%) required the use of another fixation modality, to achieve union. Union was ultimately achieved in 35 (94.5%) patients. The median time to union was 9.4 months after the exchange nail procedure. Univariate analysis confirmed that cigarette smoking and infection were predictive of failure (p<0.05). Multi-regression analysis found that Gustilo-Anderson grade, presence of dead bone or a gap and infection were predictive of exchange nail failure (p <0.05).

Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. Patients with infection required more than one procedure. Smoking, infection and the presence of dead-bone or a gap at the fracture site were associated with an increased risk of further fixation surgery.

Articular cartilage has very poor repair potential, however it has an extraordinary capacity to withstand physiological mechanical loads in an intact joint. The nature and extent of chondrocyte death in articular cartilage following many forms of injury (trephine, scalpel, osteotome, sutures and drilling) has been characterised, but the ability to bear mechanical injury from iatrogenic surgical interventions is still unknown.

A standard arthroscopic probe was moved at varying physiological pressures along the articular cartilage of joint before staining with fluorescent dyes to allow live/dead cell imaging using laser confocal scanning microscopy and imaging software, Image J. Bovine metatarsal phalangeal joints and fresh human cadaveric femoral condyles were used.

The probe caused statistically significant chondrocyte death in bovine cartilage (p=0.02). Mild pressure 5% cell death, moderate (standard arthroscopic technique pressure) 22% and severe pressure 38%. A similar result was seen in human tissue with 24% cell death at moderate pressure compared to a control (p=0.0699).

The widely assumed benign arthroscopic probe produces significant cell death in articular cartilage when used at standard operating pressures.

Early weight-bearing of patients with ankle fractures is associated with good outcomes. There are a number of potential advantages to early mobilisation including reduced hospital stay and earlier return to work and regular daily activities. However, many surgeons have not incorporated this into their routine ankle fracture protocol, particularly for patients managed operatively; potentially due to concerns regarding loss of reduction. We hypothesised that ankle fractures managed fully weight-bearing would have good outcomes and a low rate of loss of reduction.

All ankle fractures presenting to our department over a 15-month period were studied prospectively. Patients were instructed to mobilise fully weight-bearing as able, either immediately postoperatively (for those fractures considered unstable that underwent operative intervention), or at the first fracture clinic review (if stable and managed conservatively). Only patients with syndesmotic injuries and those with neuropathy or psychiatric illness were excluded. The effectiveness of this management protocol was assessed by clinical and radiographic review following fracture union.

847 patients were included, of whom 25% were over the age of 65. 33% of fractures were unstable and therefore managed operatively, 66% were stable and therefore managed in casts or with functional bracing. In every case the radiographs showed maintenance of anatomical mortise and fracture reduction at the time of union, good patient reported outcomes were also recorded.

Early weight-bearing of patients with ankle fractures, whether managed conservatively or operatively, results in very low rates of loss of reduction and should be considered routine management for the majority of patients.

The aim of this study was to document the outcome following either early or delayed fixation for complex (AO-OTA type 43.C) fractures of the tibial plafond. From our trauma database we identified all patients who sustained a complex intra-articular fracture of the distal tibia over an 11-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary outcome measure was the development of early complications following surgery. The secondary outcome measure was the long-term patient reported outcome.

There were 102 type C pilon fractures in 99 patients with a mean age of 42yrs (16–86) and 75.5% (n=77) were male. 73 (71.6%) patients underwent primary open reduction internal fixation (ORIF), with 20 (19.6%) undergoing primary external fixation with delayed ORIF. 34 complications were recorded in 28 (27.5%) patients. There were 18 (17.6%) infections, with a deep wound infection in 9 (8.8%) patients and a superficial wound infection in 9 (8.8%). Risk factors for developing infection were multiple co-morbidities (p=0.008), an open fracture (p=0.008), and primary external fixation with delayed ORIF (p=0.023). At a mean of 6 years (0.3–13; n=53) post injury the mean FAOS score was 76.2 (0–100), the mean FADI score was 75.7 (0–100), and 72% (n=38) of patients were satisfied.

This is the largest series in the literature documenting the outcome following fixation for type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated a satisfactory outcome using primary early fixation in the vast majority of cases.

The natural history of primary anterior glenohumeral dislocation in adolescent patients remains unclear and no consensus exists for management of these patients. The study objectives were to report the natural history following primary anterior glenohumeral joint dislocation in adolescent patients and to identify risk factors for repeat dislocation.

We reviewed prospectively-collected clinical and radiological data of 133 adolescent patients (mean age 16.3 years (range 13–18); 115 male patients (86.5%)) diagnosed with primary anterior glenohumeral joint dislocation and managed nonoperatively from 1996 to 2008 at our institution (mean follow-up 95.2 months (range 1–215)).

During follow-up, 102 (absolute incidence of 76.7%) patients experienced repeat dislocation. Median time interval between primary and repeat dislocation was 10 months (CI: 7.4 – 12.6). On survival analysis, 59% (CI: 51.2 – 66.8%) of patients remained stable one year following initial injury, 38% (CI: 30.2 – 45.8%) after two years, 21% (CI: 13.2- 28.8%) after five years, and 7% (CI: 1.1–12.9%) after 10 years. Neither age nor gender significantly predicted repeat dislocation during follow-up.

In conclusion, adolescent patients with primary anterior glenohumeral joint dislocations have a high rate of repeat dislocation, which usually occurs within two years of initial injury, and these patients should be considered early for operative stabilisation.

Several low energy osteotomy techniques are described in the literature but there is limited evidence comparing healing indices. We present a retrospective review of two techniques to evaluate an optimum method.

Introduction:

The developing world often lacks the resources to effectively treat the most serious injuries, potentially resulting in severe complications of orthopaedic trauma, including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are now a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide.

Background:

The Exogen Ultrasound Device is licensed for fracture non-union under NICE guideline MTG-12. Reimbursement is offered if there is no fracture union after 250 days of treatment as per manufacturer guidelines. Quoted healing rates vary between 62% and 100%: we compare our results to these.

Background:

Potential injury to the common peroneal nerve at the level of the fibula head/neck junction during fine wire insertion in stabilization of proximal fibula, is a recognised complication. This study aims to relate the course of the common peroneal nerve to fibula head transfixion wire.

We conducted a multicentre two arm double blind randomised controlled trial to assess efficacy of pulsed ultrasound for accelerating the rate of bone healing. Sixty-two skeletally mature adults undergoing limb lengthening, of between 2.5cm to 10cm by distraction osteogenesis, at the proximal tibia using an Ilizarov frame were randomised to either an active or a placebo (control) ultrasound device.

Primary outcome measure was time ready for removal of frame after adjusting for distraction length (days/cm) for both intension to treat (ITT) and per protocol (PP) patients. The time at which the frame was removed was determined by the maturation of the regenerate bone. Secondary outcomes were return to weight bearing and covariates affecting time to frame removal.

The baseline characteristics of the two groups were well balanced, and 90% of patients were managed and followed up as PP. There was no difference in the time to frame removal between the two groups for the ITT (5.0days/cm, p=0.23) or the PP (10.1days/cm, p=0.054). There was no difference in return to weight bearing between the two groups, after adjusting for distraction length, for the ITT or PP patients (p>0.5). Smoking was the only covariate identified to increase the frame removal time (hazard ratio 0.46, 95% confidence interval 0.22 to 0.96; p=0.04).

This trial demonstrated no difference in bone healing between those who underwent pulsed ultrasound and those who did not. Smoking was observed to have a significant inhibitory effect on bone healing.

Adipose tissue is an attractive source of mesenchymal stem cells (MSCs) as it is largely dispensable and readily accessible through minimally invasive procedures such as lipoaspiration. Until recently MSCs could only be isolated in a process involving ex-vivo culture. Pericytes (CD45−, CD146+, and CD34−) and adventitial cells (CD45−, CD146−, CD34+) represent two populations of MSCs (collectively termed perivascular stem cells or PSCs) that can be prospectively purified using fluorescence activated cell sorting (FACS). We performed FACS on lipoaspirate samples from n=129 donors to determine the frequency and yield of PSCs and to establish patient and processing factors that influence yield.

The mean number of stromal vascular fraction (SVF) cells from 100ml of lipoaspirate was 37.8×106. Within the SVF, mean cell viability was 82%, with 31.6% of cells being heamatopoietic (CD45+). Adventitial cells and pericytes represented 31.6% and 7.9% of SVF cells respectively. As such, 200ml of lipoaspirate would theoretically yield 24.5 million MSCs –a sufficient number to enable point-of-care delivery for use in several orthopaedic applications. The yield and prevalence of PSCs were minimally affected by donor age, sex and BMI. Storing lipoaspirate samples for up to 72 hours prior to processing had no significant deleterious effects on MSC yield or viability.

Our study confirms that pure populations of MSC-precursors (PSCs) can be prospectively isolated from adipose tissue, in sufficient quantities to negate the necessity for culture expansion while widening possible applications to include trauma, where a time delay between extraction and implantation excludes their use.

The posterior approach to the hip avoids violating abductors and has presumed functional advantages. The anterolateral approach risks abductor damage, but has reportedly lower dislocation rate.

To determine effects of surgical approach on function and dislocation after primary and revision THR 3274 primary THRs and 66 first time revision THRs were investigated from the arthroplasty database (2000–2008).

2682 (82%) primary THRs were via anterolateral approach, 592 (18%) by posterior. Post primary dislocation rate was 50/2682 (1.9%) for anterolateral and 26/592 (4.4%) for posterior. Posterior approach had significantly better Harris Hip Scores: 91 vs 88 (P = 0.000) and function: 40 vs 37 (P = 0.000). Of the 66 revisions THRs, 30 were anterolateral and 36 posterior. Dislocation rates were 2/30 (6.7%) and 4/36 (11.1%) respectively. There was no significant difference in Harris Hip Score or Harris Hip Function 1 year after revision based on revision surgery approach. However there was a significant difference in Harris Hip Function 1 year after revision based on the approach for primary surgery (Anterolateral 30 vs Posterior 37, P=0.008) and a similar trend in Harris Hip Score (Anterolateral 79 vs Posterior 85, P = 0.198) and patients who had posterior approach for both primary and revision had the best scores overall.

The clinical relevance of the modest, but statistically significant difference in Harris hip score after primary THR is unclear. That primary approach has an impact on function after revision suggests the posterior approach should be considered in younger patients likely to require revision in the future.

Background:

Acute deformity correction with the help of osteotomies and stabilisation with intramedullary (IM) nail is a recognised technique. We present our case series of long bong deformity correction using an innovative technique that aids accurate correction after osteotomy and insertion of IM nail.

Background:

Paley et al has developed the multiplier method for predicting leg length. It is a tool that is used clinically to predict leg length discrepancy. The method is also a way of comparing different populations, to identify differences in growth trajectory. This has been done by identifying the differing multipliers for girls and boys. However it has not been used to identify trends in populations separated by time. Tanner showed that in the first half of the twentieth century girls went from an average age of menarche of 15 in 1900, to 13 in 1970, how this has affected growth trajectory over the last 50 years has not been studied.

Background:

Segmental defects of long bones are notoriously demanding and difficult to treat. We evaluate nine cases where the Masquelet induced membrane technique to substitute bone loss has been used. We discuss the method compared to other types of bone reconstruction and share our tips and tricks to reduce treatment time and improve patient comfort.

Background:

Lower limb reconstruction is performed in trauma centres where uplifted tariffs support the treatment of severely injured patients. Calculation of Healthcare Resource Groups (HRG4) codes is affected by the accuracy of clinical coding, determining the financial viability of this service in a district general hospital (DGH).

Background:

Little is known about the forces carried by the Taylor Spatial Frame (TSF) hexapod fixator. Our aim was to measure the TSF resultant force and how this changed during the consolidation phase.

Background:

Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires.