Introduction: Upper root injuries (C5–C6±C7) account for 75 % of all obstetric brachial plexus palsies (OBPP). Among them, about thirty percent develop a medial contracture of the shoulder due to an imbalance between strong internal rotators and weak external rotators. This causes glenohumeral deformities. To decrease the internal contracture it had been proposed either to release the subscapularis (Sever procedure) or to perform a capsular release (Fairbank procedure). Arthroscopic capsular release was proposed in young patient to reduce the medial contracture. Material & methods: Six children with an average age of 23 months and 1 case aged 12 years old, had a medial contracture of the shoulder secondary to a C5–C6 ( 3 cases) or C5–C7 (4 cases) obstetrical palsy. An arthroscopic evaluation of the deformities was performed in 3 cases. Next a surgical subscapularis release was applied in association with a latissimus dorsi transfer. An arthroscopic evaluation of the joint associated with an arthroscopic capsular release (release of the coracohumeral ligament) was performed in 4 cases. In addition, the latissimus dorsi was transfered. Pre and Post operative passive external rotation were measured in degrees in R1 position. Pre and post operative medial rotation were evaluated according to the Mallet classification. A comparative evaluation of the glenohumeral deformities were performed between pre-operative MRI and arthroscopic results. Results: An arthroscopic evaluation of the glenohumeral joint was performed in 6 cases. In one case the arthroscopic evaluation could not be performed. In the 6 cases, arthroscopy confirmed the MRI lesion : 3 posterior subluxations, 1 posterior luxation and 2 normal joints. The subscapularis release allowed an increase in the passive lateral rotation of an average of 50°. However, a decrease of 1 point in the medial rotation was noted according to Mallet evaluation. The coracohumeral ligament arthroscopic release allowed an increase in the passive lateral rotation of an average of 60° without decreasing the passive medial rotation. Whatever the method used, a reduction of the subluxation of the glenohumeral joint was obtained. Discussion & Conclusion: Medial contracture of the shoulder may begin in the first two years of life and an early reduction with muscular release and transfers was proposed. However, the precise nature of the progressive limitation of the external passive rotation remains unclear. Is the limitation due to a contracture of the medial rotators or a capsular retraction or a combination of both? Harryman demonstrated the role of the rotator interval capsule and coracohumeral ligament in limiting the external rotation. Our hypothesis was that capsular retraction occurred before the muscular contracture. As a result we decided to perform a capsular release in patients under 24 months. The results on the passive external rotation were similar with both methods. Although, the technique of an arthroscopic release was difficult and demanding, it appears that this technique is beneficial as it allows an evaluation of the joint deformity and treatment of the contracture in the same time. Arthroscopic release is a safe but demanding technique which allows an increase in the external passive rotation in OBPP. It should be noted that this technique requires a significant practice

We reviewed 1060 cases of OBPP prospectively at the Peripheral Nerve Injury Unit over 20 years. Data was collected for birth weight, maternal age, maternal height, maternal weight, duration of labour and associated difficulties, presentation, mode of delivery, neonatal problems, birth rank, race and social class. The mean birth weight was 4.23 kg (Range 0.63–9.49 SD 0.72) compared to 3.47 Kg nationally [p < 0.05]. There was an association between severity of lesion and increase in birth weight. Maternal age was 29.0 years in OBPP group [Range 14–43 SD 5.4] compared to 26.8 nationally [p < 0.05]. In 46.7% of the brachial plexus group, the mothers were > 30 years old. This was compared to 29.7% nationally. The difference in maternal Body Mass Index (BMI) between patient group [27 with Range 14–44 SD 3.5] and national average of 25 was significant [p< 0.05]. Hypertension [11.8%] and diabetes [11.2%] were significantly [p< 0.05] higher than the national rate [6.4% and 1% respectively]. Shoulder dystocia occurred in 56% of the cases and was strongly associated with OBPP [p< 0.05]. Mean duration of labour nationally was 5.4 hours; in the patient group 10.8 hours [p< 0.05]. Breech presentation was more than three times the national average [p< 0.05]. Caesarean sections [2%] were less than national average [18%]. Instrumental deliveries [40.3%] were four times more than national rate. [P < 0.05]. The incidence of Neonatal asphyxia [22%] and Special Care Baby Unit [15.3%] was significantly [p< 0.05] higher than the national average [2% and 8% respectively]. Other factors did not prove to be statistically significant. These included; Social class, birth rank and ethnic origin. We found that Birth weight, shoulder dystocia and body mass index are the most significant risk factors for obstetric brachial plexus plasy

Introduction: Shoulder relocation is commonly performed for the subluxating or dislocated shoulder secondary to Obstetric Brachial Plexus Palsy (OBPP). We have observed that even when relocation is performed at a young age, remodelling of the immature, dysplastic glenoid is often unreliable, resulting in recurrent incongruity and requiring treatment of the glenoid dysplasia. Methods and results: In a series of 19 patients, we used a posterior bone block to buttress the deficient glenoid at the time of shoulder relocation. At a mean follow up of 28 months (6–73 months), we describe failure in at least 50% with erosion of the bone block, progressive subluxation and resultant pain. A different technique of glenoplasty is now used. An osteotomy of the glenoid is performed postero-inferiorly, elevating the glenoid forward to decrease its volume. Bone graft, often taken from an enlarged and resected coracoid is then packed into the osteotomy and the whole assembly is held with a plate. In a series of 11 patients with a mean age of 6.7 years (1–18 years) we describe good results at short term followup, suggesting that this is a technique warranting further investigation. Conclusion: We believe that where a deficient glenoid is found at surgery for relocation of the shoulder in OBPP, a glenoplasty should be performed at the same time whatever the age of the patient, as glenoid remodelling will not reliably occur. We no longer advocate posterior bone block in these cases as it has a significant failure rate

Purpose of study: Glenoid dysplasia occurs early in the shoulders of some children affected by obstetric brachial plexus palsy (OBPP). Prompt treatment can reverse the deformity. A program has been devised to examine these children’s shoulders by ultrasound and the early results are described. Method: Since March 2006, all neonates born in New-castle upon Tyne with a diagnosis of OBPP have been referred to the hip ultrasound clinic. The shoulders were examined clinically for range of movement and signs of instability. A static and dynamic ultrasound examination was then performed. Treatment of subluxed shoulders involved splinting the shoulder in adduction and external rotation for six weeks after injection of the internal rotator muscles with botulinum toxin, as recommended by Ezaki and co-workers. Results: To date, six infants have been screened. Two had significant instability with ultrasonographic evidence of early glenoid dysplasia and have been treated. One had mild glenoid dysplasia with restricted external rotation which improved with physiotherapy alone. Three were clinically and ultrasonographically normal. Conclusions: The early experience of this program confirms the high incidence of shoulder dysplasia in the neonatal period in these children, as reported by others. The examination is safe and relatively easy. In the early stages of the condition the treatment to date has been simple and effective. We plan to continue with ultrasound screening for shoulder dysplasia in neonates with OBPP

Aims. The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement. Methods. This is a cross-sectional study using an anonymous 13-section web-based survey distributed to female-identifying T&O trainees, speciality and associate specialist surgeons (SASs) and locally employed doctors (LEDs), fellows, and consultants in the UK. Demographic data was collected as well as closed and open questions with adaptive answering relating to attitudes towards childbearing and experiences of fertility and complications associated with pregnancy. A descriptive data analysis was carried out. Results. A total of 226 UK female T&O surgeons completed the survey. All regions of the UK were represented. Overall, 99/226 (44%) of respondents had at least one child, while 21/226 (9.3%) did not want children. Median age at first child was 33 years (interquartile range 32 to 36). Two-thirds (149/226; 66%) of respondents delayed childbearing due to a career in T&O and 140/226 (69%) of respondents had experienced bias from colleagues directed at female T&O surgeons having children during training. Nearly 24/121 (20%) of respondents required fertility assistance, 35/121 (28.9%) had experienced a miscarriage, and 53/121 (43.8%) had experienced obstetric complications. Conclusion. A large proportion of female T&O surgeons have and want children. T&O surgeons in the UK delay childbearing, have experienced bias and have high rates of infertility and obstetric complications. The information from this study will support female T&O surgeons with decision making and assist employers with workforce planning. Further steps are necessary in order to support female T&O surgeons having families. Cite this article: Bone Jt Open 2023;4(12):970–979

Aim: To investigate the natural history and the impact of reconstruction in shoulder deformities due to obstetrical brachial plexus palsy. Methods: Pre and postoperative CT scans of bilateral upper extremities of 28 patients with obstetrical palsy were studied. The age during the preoperative CT scan ranged from 1.5 months to 10 years (average: 4 ± 3 years). 17 patients had Erbñs palsy and 11 global plexus involvement. Eighteen had primary shoulder reanimation mainly via intraplexus neurotization. Palliative surgery in 25 patients included trapezius transfer for shoulder abduction, adductors release and rerouting of the latissimus dorsi and terres major for external rotation, scapula stabilization and rotational osteotomy of the humerus. The CT measurements included: humeral head retroversion, spinoscapular angle, glenoid fossa inclination, congruence of the humeral head to the glenoid and distance of the lower angle of the scapula from the midline. Results: Preoperatively the humeral head was subluxated or dislocated posteriorly and had decreased retroversion. The hypoplastic scapula had winging and increased distance from the midline, while the glenoid fossa was more retroverted. Postoperatively all the above measurements were improved. Conclusions: Novel measurements on CT scans of bilateral shoulders provide valuable information. Surgical intervention signiþcantly improves the functional anatomy and the dynamics of the shoulder joint

Despite the impressive advancements in prenatal planning and assessment, obstetrical brachial plexus palsy remains an unfortunate consequence of difficult childbirth. Although the majority of infants with plexopathy recover with minor or no residual functional deficits, a number of children do not regain sufficient limb function and develop significant functional limitations, bony deformities and joint contractures. Recent developments in the technique of microsurgical reconstruction of peripheral nerve injuries proved to be effective in selected cases of children with obstetrical brachial plexus injury. Many of these children and those who were defined as having minor injury will remain with considerable functional limitation and deserve late orthopaedic reconstruction. Based on that, we developed a multidisciplinary Brachial Plexus clinic gathering a microsurgeon, a pediatric orthopaedic surgeon, an electrophysiologist clinician, physiotherapists and occupational therapist in order to assess and evaluate these children. A total of 105 children were seen and followed up in our clinic during the last 2 years. Most of these children were referred to our clinic from other centers and from physiotherapists treating these children on an out-patient basis. We report the orthopaedic reconstruction operations performed in 9 cases of residual functional disabilities in children born with obstetric palsy. 4 patients had latissimmus dorsi and teres major transfer. 2 patients had derotation osteotomy of the humerus. 1 patient had Steindler flexorplasty of the elbow. 2 patients had open reduction and capsulorrhapy for a dislocated shoulder. Video assessment of these children was performed before and after the operation. Function was also analyzed before and after operation by a physiotherapist and an occupational therapist. Significant functional improvement was achieved, to the satisfaction of patients and parents

Introduction. The case of Montgomery in 2015 considered standards of risk disclosure, whether alternative treatments had been discussed, standards of professional performance, and the importance of patient autonomy. Methods. A survey was devised to investigate orthopaedic surgeons' knowledge of the law of consent and risk disclosure and distributed by Survey Monkey. Results. 194 respondents from a total of 365 consultant orthopaedic surgeons contacted (53%). 85% of respondents were aware that Montgomery is primarily an obstetric case, 14.5% thought it was a spinal surgery case, and 1 respondent (0.5%) thought it was a paediatric surgery case. 99% correctly defined the Bolam test, but 57% erroneously believed that Bolam was still applicable in consent cases. 7% of respondents believed that it was not necessary to disclose a risk of surgery if the risk was less than 1%, and 4% of respondents if the risk was less than 10%. The legal test of materiality was correctly identified by 86% of respondents where a reasonable person in the patient's position would be likely to attach significance to the risk. 5% erroneously believed that provision of a standardised, printed information booklet provides sufficient risk disclosure for the individual patient to give their informed consent. 97% were aware that the surgeon must discuss reasonable alternative treatments including ‘no treatment’. Only 28% were aware that when a surgeon refers a patient for an interventional radiology procedure, it is the referring doctor who should formally hold and document the initial consent discussion. Discussion. General awareness of Montgomery was satisfactory, including the need to discuss alternative treatments including ‘no treatment’, and the qualitative concept of material risk. There was less understanding that material risk is independent of any quantitative rate of occurrence. Over half of consultants erroneously believed that the Bolam test was still applicable in consent cases. Small numbers of respondents erroneously thought that an information booklet constituted sufficient information disclosure. There was widespread misunderstanding that if a consultant surgeon refers an individual for an interventional radiology investigation it is in fact for the referring doctor to hold the initial consent discussion. Further training is required in respect of several issues raised by Montgomery

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

The aim was to compare the efficacy of selective ultrasound-screening (SUSS) for developmental dysplasia of the hip (DDH) to clinical screening alone, by comparing outcomes in a contemporary group with those from a 40 year old cohort. This was a retrospective cohort study. The department's DDH and surgical databases were used to identify all cases of DDH, and all cases of surgery for DDH during the study period (2009–13). Patients born outside our region, and teratologic cases were excluded from analysis. The Obstetric database provided the total number of live births over the five-year period. This data was used to calculate the incidence of late-diagnosis (age over 3 months) DDH and the rate of surgery for DDH in our region. These results were compared to those of a similar study from our institution published in 1977, after the introduction of universal clinical screening. Relative risk (RR) was calculated for the two groups, and analysed for statistical significance. The incidence of late-diagnosis DDH over the recent 5-year study period was 0.66/1000 live births, compared to 0.6/1000 in the control group. The RR for late-diagnosis DDH was not significantly different between the two groups (RR 1.14, 95% CI 0.6 to 2.2). The rate of surgery for DDH was 0.86/1000, compared to 0.9/1000 live births in the control group. The RR for surgery for DDH in the current study population compared to the historic control was 0.97, but this difference was not statistically significant (95% C.I. 0.57 to 1.68; p=0.92). Despite advances in screening for DDH over the last 40 years, neither the incidence of late diagnosis DDH, nor rates of surgery for DDH in our region have changed. Whilst previous studies have demonstrated that SUSS does not eliminate late-presenting DDH, this study suggests it confers no advantage over clinical screening alone

Introduction. Neonatal fractures are often quite distressing to parents and medical teams involved. Their management can be daunting due to the small size of the patient, the concern of the new parents and the fear of the obstetric staff about litigation and deformity or long term disability of the neonate. Aim. This study assesses the radiological and functional outcome of neonatal fractures up to two years post injury. Methods. We reviewed the notes of neonates at our hospital who sustained fractures spanning a 4 year period. Clavicle and humeral fractures were treated in a swaddling bandage for 3 weeks. Femoral fractures were treated in a gallows traction for 2–3 weeks. Xrays were taken once weekly. Patients were examined two years following their injury and function of the affected limb was assessed and compared with the unaffected side. Radiographs of the previously fractured bones were also taken at the 2 years follow up. Results. Eighteen (18) neonates sustained fractures predominantly due to birth trauma. There were four clavicle fractures, one fracture of a humerus, three femoral and 10 skull fractures. All seven (7) patients extremity fractures healed satisfactorily clinically and radiologically, with no residual deformity, limb length discrepancy or functional impairment at 2 years follow up. All parents were very satisfied with the outcome. Discussion and Conclusion. Neonatal fractures occur in <1% of births. Causes include birth trauma and congenital bone disease. Neonates with fractures are referred for Orthopaedic management which can be intimidating due to the infrequency of management of this cohort of patients. In our study all of our neonates with long bone fractures had good radiological results and no functional deficit when reviewed after 2 year. Clinicians can be reassured that neonatal fractures have a propensity to heal rapidly without residual functional or radiological abnormality as long as alignment is grossly maintained initially

Introduction: There are protocols on the management of polytrauma in obstetric patients. However, there is little information about osteo-articular injuries sustained in these patients. The object of this study is to review the management of these patients and to suggest a guideline. Material and method: Inclusion criteria: Pregnant patients treated during the last 6 years, treated as inpatients in our center during pregnancy due to osteo-articular injuries. Variables studied: Gestational age, mechanism of injury, fracture type, management, termination of pregnancy and sequelae. Results: We treated 13 patients with 21 fractures in our center, with an incidenc of 2,13 fractures/10.000 births. The mechanism of injury was low degree trauma in 6 cases (60% 3rd trimester) and high-degree in 7 (83% 1st and 2nd trimester). There was a predominance of lower extremity fractures, especially tibia and fibula (7 cases) and pelvis (3 cases). Gestational age was 1st trimester (3 cases), 2nd trimester (5 cases), 3rd trimester (5 cases). 10 women were treated surgically, 8 before finishing gestation. Gestation ended as and induced abortion (3 cases, 1 due to fetal death and 2 due to teratogenic risk), and birth (10 cases, all alive, 50% eutocic). Only 3 babies needed type II or type III neonatal reanimation. CONCLUSIONS: Pregnant women can get injured by low-energy trauma, especially during the third trimester. Pregnancy does not necessarily compromise surgical management of fractures. We review diagnostic and therapeutic management strategies for these patients

The purpose was to review the results of latissimus dorsi and teres major transfer in a group of children with shoulder disability due to brachiaI plexus palsy. Whilst their incidence has steadily declined, obstetric brachial plexus palsies are a continuing problem in paediatric orthopaedic practice. Lesions of the upper plexus (C4, C5, C6) are characterised by a loss of abduction and external rotation at the shoulder. The L’Episcopo procedure and its variants aim to address this by transfer of the latissimus dorsi and teres major. There have been conflicting reports in the literature as to the functional benefit of such procedures. A retrospective review of such procedures performed by one surgeon at a paediatric orthopaedic tertiary referral centre in New Zealand. Patients were assessed pre- and post-operatively in terms of range of movement and function. The Mallet scoring system was also used. Eight patients were examined by an independent observer up to 120 months following surgery (average 52 months). In most cases significant increases in range of movement, function and Mallet scores were noted. With regard to complications, where the paresis is severe to the extent that it is causing shoulder subluxation, tendon transfer surgery is contra-indicated. The L’Episcopo procedure was largely successful in restoring improved function to the shoulder girdle in this group of patients

Purpose of the study: A stiff shoulder in internal rotation is a classical complication of obstetrical injury to the brachial plexus. The condition generally associates glenohumeral dysplasia. In 2003, Pearl proposed arthroscopic release of the shoulder, with or without latissimus dorsi transfer as an alternative to an open procedure. We report a series of 13 patients who underwent this procedure. Material and method: From 2004 to 2007, 13 children aged 1 to 11 years (range 3.5) underwent surgery. The procedure was an arthroscopic tenotomy of the intra-articular portion of the subscapularis associated with release of the anterior capsuloligament structures without tendon transfer. A thoracobrachial resin cast maintained the shoulder in maximal external rotation for six weeks. The functional outcome was assessed on the basis of the passive and active range of motion and the Mallet score. Pre and postoperative MRI was used to assess glenohumeral dysplasia and check its correction. Results: Mean follow-up was 23 months (range 5–40). There were no complications. Mean immediate postoperative gain was 53 (range 30–70) for external rotation (RE1). On average, passive RE1 improved from −5.4 to +57.7. Eight patients (61%) recovered active external rotation (57.5 on average). Mean active abduction improved from 45.8 to 56.5. Active internal rotation declined in 38% of the shoulders. The Mallet score improved in 69% of the shoulders. The best results were observed for children aged less than 4 years. There was one failure, related to major dyplasia which could not be reduced with an open procedure. Correction of the glenohumeral dysplasia was noted on 7 of the 9 MRI performed and the retroversion angle of the glenoid improved from −28.2 to −25.6, on average. Discussion: Open techniques are aggressive and only variably effective. A majority of our patients (8/13) achieved improved passive and active RE1 solely with the arthroscopic procedure. Correction of the glenohumeral dysplasia with growth appears to correspond to the clinical improvement but further follow-up is needed. Conclusion: Our results are comparable with those reported by Pearl. This is a minimally invasive easy-to-perform technique. For children aged less than 4 years, systematic tendon transfer does not appear to be necessary

Objective: Search for operation timing and methods for obstetrical brachial plexus injury(OBPI). Methods: Thirty-two children with upper OBPI were treated by microsurgical procedure from October 1997 through April 2001, The average time of operation is 10 months of age, ranged from 3 months to 24 months, of which 19 were below 6 months while 13 were over 6 months. Surgical procedure included neurolysis (n=11), coaption after resection of the neroma without function(n=6), phrenic nerve transfer to anterior cord of upper trunkor musculocutaneous nerve (n=7) and intercostal nerves transfer to musculocutaneous nerve (n=6). The children were underwent operation by microsurgical technique and 7–0 or 9–0 nylon were used for nerve suture. Results: Thirty cases were followed-up 21 months postoperatively, the excellent and good rate is 76.7%(23/30). The results of the children under 6 months is better than that over 6 months . Conclusions: We concluded that the microsurgical operation might be considered at 3 to 6 months of age in infants who have shown little or no improvement in elbow flexion . Patients undergoing neurolysis and nerve coaption had more favorable outcome than those undergoing neurotization. The appropriate procedure must be selected according to the findings of exploration

The vertebral canal reaches maturity early in life. The size of the lumbar spinal canal was evaluated to determine normal values for vertebral canal size. For our prospective cross-sectional study 95 women with a singleton pregnancy between 16 and 41 weeks of gestation were recruited during their routine anomaly scan. After defining the region of interest on the 2D ultrasound image, volume scanning was performed and the rendered volume was displayed in three orthogonal planes on the screen. Area and volume of the vertebral canal in L1, L3 and L5 were calculated. Area and volume of the vertebral canal showed a close correlation to gestational age. Advancing gestational age was characterised by a statistically significant increase in all volumetric and conventional 2D measurements. No major differences regarding area and volume measurements could be found between upper and lower spine. Sonographic evaluation of the fetal spine plays an important role in obstetric anomaly scans. Prenatal diagnosis may also lead to interesting aspects concerning back pain in adults. A small vertebral canal is considered to be one of the causes for back pain in later life but these syndromes are multi-factorial. Since interpedicular diameter of the spinal canal at the level of L1-L4 at birth is approximately 70 % of the adult size, any kind of intrauterine growth impairment will affect further development. Further data will show if our normal values will have significance in the early detection of disorders of the vertebral canal

Studies have shown significantly shorter hospital stays and earlier return to mobilization when epidural analgesia was used in lower extremity surgeries. This study quantified the effects of epidural analgesia on lower extremity kinetics and kinematics during gait. There were no significant differences found in hip, knee, or ankle joint moments or angles between baseline (no drug) and epidural trials, using two different drugs. These findings indicate that epidural analgesia does not alter normal gait in healthy subjects, suggesting that patients requiring epidural analgesia following orthopaedic surgery may also be able to participate in rehabilitation without significant epidural-related changes in gait. Epidural analgesia has been used post-operatively following chest, abdominal and lower extremity surgery, with significantly shorter hospital stay and earlier return to mobilization demonstrated. This study quantified the effects of epidural analgesia on lower extremity kinetics and kinematics during gait. Ten healthy volunteers were tested on different days with two drugs. With the catheter (L3-L4 intervertebral space) in place but prior to drug administration, gait was assessed. Testing was repeated 30 min after drug administration. Motion and ground reaction force data were recorded during walking with a four-camera video-based system (Motion Analysis Corp) and force platform (Kistler). No significant differences existed in 3-D hip, knee, or ankle joint moments or angles among baseline (no drug) and drug trials. These findings indicate that epidural analgesia does not alter normal gait in healthy subjects, suggesting that patients requiring epidural analgesia following orthopaedic surgery may also be able to participate in rehabilitation without significant epidural-related changes in gait. It is well documented that early mobilization and rehabilitation following orthopaedic surgery improve healing and shorten hospital stay. However, pain often limits full participation. Epidural analgesia appears to be an appropriate mode of pain relief that, despite somatosensory changes, may allow normal gait. Epidural analgesia in healthy volunteers does not alter lower extremity kinetics or kinematics, suggesting that it may be an effective mode of pain relief that will allow better participation in therapy following orthopaedic surgery. Funding: McCaig Professorship Program Development Fund, Wood Professorship, The Foothills Hospital Obstetric Anesthesia Research Fund, The National Science and Engineering Research Council of Canada, and The University of Calgary Biomedical Engineering Program

Aims

Orthopaedic infection is a potentially serious complication of elective and emergency trauma and orthopaedic procedures, with a high associated burden of morbidity and cost. Optimization of vitamin D levels has been postulated to be beneficial in the prevention of orthopaedic infection. This study explores the role of vitamin D in orthopaedic infection through a systematic review of available evidence.

To investigate the fears of female patients of child bearing age, who required surgical stabilisation for pelvic fractures, and to assess the outcomes of subsequent pregnancy. Between 1990 & 2002 from a prospectively kept database in our institution, patients sustaining pelvic fractures requiring surgery who were women under 35 years of age at the time of injury were identified and included in this study. Patient’s medical records and radiographs (birth canal status) were reviewed and data collected. All the patients were attempted to be contacted by telephone and a questionnaire completed recording the type of pelvic injury, previous obstetric history, fears regarding future pregnancy, pregnancy outcomes, Euroqol pain scores pre & post fracture and painkiller usage. Those who were unable to be contacted by telephone, were followed up by a postal questionnaire. The mean time of follow up from injury was 4.2 years (range 1 to 12 years). Out of 554 patients, 197 (36%) were women and of these, 54 (27%) patients were less than 35 years old at the time of injury. A telephone questionnaire was completed on 31 patients [57 % (study group)], results from the postal questionnaire are being collated. The mean age of the study group at injury was 23.3 years (range 6 to 34 years). There were 14 (45 %) isolated ace-tabular fractures and 17 (55 %) pelvic ring fractures. 11 (36 %) had previously had children prior to the injury, and 22 (71 %) had planned to have children in the future, prior to fracture. 23 (74 %) had expressed fears related to their future ability to have children. Out of 8 (26 %) patients who had subsequent pregnancies, only 1 (12.5%) had a normal vaginal delivery. Out of the rest, 3 (37.5%) patients had investigations for pelvic disproportion; 2 (20%) went on to elective caesarean section for disproportion; 1 patient requested an elective section after concerns regarding delivery; 1 patient had a ventouse assisted delivery for delayed second stage; 1 patient had an ectopic pregnancy; 1 patient had a miscarriage at 18 weeks gestation and 1 patient had infertility problems. 4 out of 31 (13%) patients were advised against future pregnancy and one patient underwent a tubal ligation following this advice. Pelvic fractures represent a serious group of injuries; after initial recovery, many female patients have serious concerns regarding future pregnancy. A number will go on to have further pregnancies, and many will suffer the risk of complications following their pelvic injury

Introduction

There is widespread variation in the management of rare orthopaedic disease, in a large part owing to uncertainty. No individual surgeon or hospital is typically equipped to amass sufficient numbers of cases to draw robust conclusions from the information available to them. The programme of research will establish the British Orthopaedic Surgery Surveillance (BOSS) Study; a nationwide reporting structure for rare disease in orthopaedic surgery.