There is no agreement as to the superiority or specific indications for cast treatment, percutaneous pinning or open fracture fixation for Bennett's fractures of the thumb metacarpal. We undertook this study to compare the outcomes of treatment for patients treated for Bennett's fracture in the medium term.

We reviewed 33 patients treated in our unit for a bennett's fracture to the thumb metacarpal with closed reduction and casting. Each patient was matched with a patient treated surgically. Patients were matched for sex, age, Gedda grade of injury and hand dominance. Patients were reviewed at a minimum of 5-years and 66-patients were reviewed in total. Patients were examined clinically and also asked to complete a DASH questionnaire score and the brief Michigan hand questionnaire. Follow up plain radiographs were taken of the thumb and these were reviewed and graded for degenerative change using the Eaton-Littler score.

Sixty-six patients were included in the study, with 33 in the surgical and non-surgical cohorts respectively. The average age was 39 years old. In each cohort, 12/33 were female, 19/33 were right-handed with 25% of individuals injuring their dominant hand. In each coort there were 16 Grade 1 fractures, 4 Grade 2 and 13 Grade 3 fractures. There was no difference between the surgically treated and cast-treatment cohorts of patients when radiographic arthritis, pinch grip, the brief Michigan Hand Questionnaire and pain were assessed at final review. The surgical cohort had significantly lower DASH scores at final follow-up. There was no significant difference in the normalised bMHQ scores.

Our study was unable to demonstrate superiority of either operative or non-operative fracture stabilization. Patients in the surgical cohort reported superior satisfaction and DASH scores but did not demonstrate any superiority in any other objectively measured domain.

Fractures of the distal radius are common, and form a considerable proportion of the trauma workload. We conducted a study to examine the patterns of injury and treatment for adult patients presenting with distal radius fractures to a major trauma centre serving an urban population.

We undertook a retrospective cohort study to identify all patients treated at our major trauma centre for a distal radius fracture between 1 June 2018 and 1 May 2021. We reviewed the medical records and imaging for each patient to examine patterns of injury and treatment. We undertook a binomial logistic regression to produce a predictive model for operative fixation or inpatient admission.

Overall, 571 fractures of the distal radius were treated at our centre during the study period. A total of 146 (26%) patients required an inpatient admission, and 385 surgical procedures for fractures of the distal radius were recorded between June 2018 and May 2021. The most common mechanism of injury was a fall from a height of one metre or less. Of the total fractures, 59% (n = 337) were treated nonoperatively, and of those patients treated with surgery, locked anterior-plate fixation was the preferred technique (79%; n = 180).

The epidemiology of distal radius fractures treated at our major trauma centre replicated the classical bimodal distribution described in the literature. Patient age, open fractures, and fracture classification were factors correlated with the decision to treat the fracture operatively. While most fractures were

Extended patient waiting lists for assessment and treatment are widely reported for planned elective joint replacement surgery. The development of regionally based Elective Orthopaedic Centres, separate from units that provide acute, urgent or trauma care has been suggested as one solution to provide protected capacity and patient pathways. These centres will adopt protocolised care to allow high volume activity and increased day-case care. We report the plan to establish a new elective orthopaedic centre serving a population of 2.4 million people. A census conducted in 2022 identified that 15000 patients were awaiting joint replacement surgery with predictions for further increases in waiting times

The principle of care will be to offer routine primary arthroplasty surgery for low risk (ASA 1 and 2) patients at a new regional centre. Pre-operative assessment and preparation will be undertaken digitally, virtually and/or in person at local centres close to the where patients live. This requires new and integrated pathways and ways of working. Predicting which patients will require perioperative transfusion of blood products is an important safety and quality consideration for new pathways. We reviewed all cases of hip and knee arthroplasty surgery conducted at our centre over a 12-month period and identified pre-operative patient related predictive factors to allow us to predict the need for the perioperative transfusion of blood products.

We examined patient sex, age, pre-operative haemaglobin and platelet count, use of anti-coagulants, weight and body mass index to allow us to construct the Imperial blood transfusion tool.

We have used the results of our study and the transfusion tool to propose the patient pathway for the new regional elective orthopaedic centre which we present.

We have previously reported on the medium-term outcomes following a non-operative protocol of a short period of splinting followed by early movement to treat simple dislocations of the elbow.

We undertook extended follow up of our original patient study group to determine whether the excellent results previously reported were maintained in the very long-term. A secondary question was to determine the rate and need for any late surgical intervention.

We attempted to contact all patients in the original patient study group. Patients were requested to complete the Oxford elbow score (OES), the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and a validated patient satisfaction questionnaire. Patients were requested to attend a face-to-face assessment where they underwent a clinical examination including neurovascular assessment, range-of-motion and an assessment of ligamentous stability.

Seventy-one patients (65%) from the original patient study group agreed to participate in the study.

The mean duration of follow-up was 19.3 years. At final follow-up patients reported excellent functional outcome scores and a preserved functional range of movement in the injured elbows. The mean DASH score was 5.22 points and the mean Oxford Elbow Score was 91.6 points. The mean satisfaction score was 90.9 points.

Our study shows that the excellent outcomes following treatment with a protocol of a short period of splinting and early movement remain excellent and are maintained into the very long term. These findings support our hypothesis that this treatment protocol is appropriate and suitable for most patients with simple dislocations of the elbow. The role for primary ligamentous repair for this patient group should be carefully considered. Work to more clearly define the anticipated benefits of surgery for specific patient groups or injury patterns would help to support informed decision making.

We undertook this study to investigate the outcomes of surgical treatment for acute carpal tunnel syndrome following our protocol for concurrent nerve decompression and skeletal stabilization for bony wrist trauma to be undertaken within 48-hours.

We identified all patients treated at our trauma centre following this protocol between 1 January 2014 and 31 December 2019. All patients were clinically reviewed at least 12 months following surgery and assessed using the Brief Michigan Hand Outcomes Questionnaire (bMHQ), the Boston Carpal Tunnel Questionnaire (BCTQ) and sensory assessment with Semmes-Weinstein monofilament testing.

The study group was made up of 35 patients. Thirty-three patients were treated within 36-hours. Patients treated with our unit protocol for early surgery comprising nerve decompression and bony stabilization within 36-hours, report excellent outcomes at medium term follow up.

We propose that nerve decompression and bony surgical stabilization should be undertaken as soon as practically possible once the diagnosis is made. This is emergent treatment to protect and preserve nerve function. In our experience, the vast majority of patients were treated within 24-hours.

The response to the COVID-19 pandemic has raised the profile and level of interest in the use, acceptability, safety, and effectiveness of virtual outpatient consultations and telemedicine. These models of care are not new but a number of challenges have so far hindered widespread take-up and endorsement of these ways of working. With the response to the COVID-19 pandemic, remote and virtual working and consultation have become the default. This paper explores our experience of and learning from virtual and remote consultation and questions how this experience can be retained and developed for the future.

Cite this article: Bone Jt Open 2021;2(5):301–304.

Aim

Restarting elective services presents a challenge to restore and improve many of the planned patient care pathways which have been suspended during the response to the COVID-19 pandemic. A significant backlog of planned elective work has built up representing a considerable volume of patient need. We aimed to investigate the health status, quality of life, and the impact of delay for patients whose referrals and treatment for symptomatic joint arthritis had been delayed as a result of the response to COVID-19.

There is currently no information regarding long-term outcomes following total hip replacement (THR) for hip fracture in patients selected in accordance with national guidelines. We define the long-term outcomes and compare these to short-term outcomes in the same previously reported cohort.

We prospectively identified patients who underwent THR for a displaced hip fracture over a 3-year period from 2007–2010. These patients were followed up at 10 years using the Oxford hip score(OHS), the Short-form 12(SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously assessed at 2 years. We identified 128 patients. Mean follow up was 10.4 years. 60 patients(48%) died by the time of review and 5 patients(4%) developed dementia and were unable to respond. 3 patients were untraceable. This left a study group of 60 patients with a mean age of 81.2.

Patients reported excellent outcomes at 10 year follow up and, when compared with short-term outcomes, there was no statistically significant change in levels of satisfaction, OHS, or SF-12. The rates of dislocation(2%), deep infection(2%) and revision(3%) were comparable to those in the literature for elective THR. Mortality in the hip fracture group at 10 years is lower than that of elective registry data.

Long-term outcomes for THR after hip fracture in selected patients are excellent and the early proven benefits are sustained. Our data validates the selection process of national guidelines and confirms low complication rates. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

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.

We define the medium-term outcomes following total hip replacement (THR) for hip fracture. There is currently no information regarding longer term clinical and patient reported outcomes in this group of patients selected in accordance with national guidelines.

We prospectively identified patients who underwent THR for a displaced hip fracture over a three year period between 2007 and 2010. These patients were followed up at 5 years using the Oxford hip score, Short-form 12(SF-12) questionnaire and satisfaction questionnaire.

We identified 128 patients. Mean follow up was at 5.4 years with a mean age of 76.5 years. 21 patients (16%) had died, 12 patients (9%) had developed dementia and 3 patients had no contact details, leaving a study group of 92 patients. 74 patients(80%) responded. Patients reported excellent functional outcomes and satisfaction at 5 years (mean Oxford Hip Score 40.3; SF-12 Physical Health Composite Score 44.0; SF-12 Mental Health Composite Score 46.2; mean satisfaction 90%). The rates of dislocation (2%), deep infection (2%) and revision (3%) were comparable to those quoted for elective THR. When compared with 2 year follow up, there was no statistically significant change in outcome.

Medium-term outcomes for THR after hip fracture are excellent and the early proven benefits of this surgery are sustained. Mortality rates are equivalent to elective THR registry data and significantly lower than overall mortality rates following hip fracture. Our data validates the selection process detailed in national guidelines and confirms the low complication rate. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

Background

There is increasing interest in the use of Total Hip Replacement (THR) for reconstruction in patients who have suffered displaced intracapsular hip fractures. Patient selection is important for good outcomes but criteria have only recently been clearly defined in the form of national guidelines. This study aims to investigate patient reported outcomes and satisfaction after Total Hip Replacement (THR) undertaken for displaced hip fractures and to compare these with a matched cohort of patients undergoing contemporaneous THR for osteoarthritis in order to assess the safety and effectiveness of national clinical guidelines.

This study describes the long term clinical and patient reported outcomes following simple dislocation of the elbow.

We identified all adult patients treated at our trauma centre for a simple dislocation of the elbow over 10 years. 140 patients were identified and 110 (79%) patients were reviewed at a mean of 88 (95% CI 80–96) months after injury. This included clinical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, an Oxford Elbow questionnaire and a patient satisfaction questionnaire.

Patients reported long-term residual deficits in range of movement. The mean DASH score was 6.5 (95% CI 4 to 9). The mean Oxford Elbow score was 43.5 (95% CI 42.2 to 44.8). The mean satisfaction score was 85.6 (95% CI 82.2 to 89). Sixty-two patients (56%) reported persistent subjective stiffness of the elbow. Nine (8%) reported subjective instability and 68 (62%) complained of continued pain. The DASH, Oxford Elbow and satisfaction scores all showed good correlation with absolute range of movement in the injured elbow. After multivariate analysis, a larger elbow flexion contracture and female gender were both independent predictors of worse DASH scores. Poorer Oxford Elbow scores and overall satisfaction ratings were predicted by reduced flexion-extension arc of movement.

Patients report good long term functional outcomes after simple dislocations of the elbow. These are not entirely benign injuries. There is a high rate of residual pain and stiffness. Functional instability is less common and does not often limit activities.

Introduction

Although the majority of adult distal humeral fractures are successfully treated with ORIF, the management in frail patients, often elderly with multiple co-morbidities and osteoporotic bone, remains controversial. Elbow replacement is frequently recommended if stable internal fixation cannot be achieved, especially in low, displaced, comminuted fractures. The “bag-of-bones” method ie early movement with fragments accepted in their displaced position, is rarely considered as there has been little in the literature since 10 successful cases were reported by Brown & Morgan in 1971 (JBJS 53-B(3):425–428). We present the experience of three units in which conservative management has been actively adopted in selected cases.

A rolled-up finger from a surgical glove has been described in the literature and commonly used as a tourniquet during procedures on digits. The National Patient Safety Agency (NPSA) issued a rapid response report in December 2009 that recommended the use of CE marked finger tourniquets and prohibited the use of surgical gloves for this purpose. This study aimed to measure the pressures exerted by a range of digital tourniquets.

A Tekscan FlexiForce¯ pressure sensor was used to measure the surface pressures under different types of finger tourniquet applied to a cylinder representing a finger. The tourniquets tested were the Toe-niquet^™, the T-Ring^™ and a tourniquet made using a rolled up surgical glove finger.

The pressure exerted by these tourniquets varied between types and depended on the size of model finger. The lowest mean pressures were produced by the T-Ring(tm) and glove finger tourniquet on a small finger (146 and 120 mmHg), while the highest pressures were produced by the Toe-niquet(tm), which produced 663 and 1560mmHg on the small and large finger models respectively. There was a significant overall difference between tourniquet type (p<0.001) and finger size (p<0.001).

Wide variability in surface pressures is a function of material type, product design and finger size. It is difficult to anticipate and regulate pressures generated by non-pneumatic tourniquets. Tourniquet safety must also focus on procedural issues, ensuring the removal of the tourniquet at the end of procedure, through increased use of surgical checklists.

The Winston Churchill Memorial Trust was established in 1965 on Sir Winston's death as a national memorial and living tribute to him, and funded by many thousands of people who contributed to a public subscription. This now funds Travelling Fellowships to allow Churchill Fellows to travel abroad and learn lessons that can be brought back to benefit the local community and ultimately the UK as a whole. Both authors were recipients of this prestigious 2009 Fellowship in the category of “Treatment & Rehabilitation of Traumatic Injuries”. Over fifteen weeks we visited hospitals in Germany, Canada, and the USA with expertise in the early care, reconstruction and rehabilitation of the combat casualties of our NATO Allies. We aimed to learn lessons from their experience, exchange ideas and to make contacts. We visited the US military hospital in Landstuhl Regional Medical Center, Germany, the University of Alberta Hospital and Glenrose Rehabilitation Hospital and the two major centres of US military care at the Walter Reed Army Medical Center/National Naval Medical Center in Washington DC, and the Brooke Army Medical Center in San Antonio Texas. We present our experience from this Fellowship, some of the lessons we have learnt and the problems that we face in common with our NATO allies.

The suture properties associated with a successful tendon repair are: high tensile strength, little tissue response, good handling characteristics and minimal plastic deformation. Plastic deformation contributes to gap formation at a tendon repair site. Gaps greater than 4mm are prone to failing. This study investigates whether the plastic deformation demonstrated by two commonly used suture materials can be reduced by manual pre-tensioning.

Twenty sutures of both Prolene 3/0 (Ethicon, UK) and Ethibond 3/0 (Excel, Johnson and Johnson, UK) were tested. Half of the sutures in each group were manually pre-tensioned prior to knot tying and half were knotted without pre-tensioning. All knots were standard surgical knots with six throws. The suture lengths were measured before and after a standardised cyclical loading regime on an Instron tensile tester. The regime was designed to represent the finger flexion forces produced in a typical rehabilitation programme. All sutures were subsequently tested to their ultimate tensile strength.

After cyclical loading the pre-tensioned sutures demonstrated a mean increase in suture length of 0.7% (range 0.1-1.9%). The sutures not pre-tensioned showed a mean increase of 5.4% (range 3.3-7%). This equates to 87% less plastic deformation (p <0.05 Students' T-test) upon pre-tensioning. There were no differences with Ethibond. Pre-tensioning had no effect on ultimate tensile strength for either group.

Manual pre-tensioning reduces plastic deformation in Prolene 3/0 sutures without affecting the ultimate tensile strength. This simple technique could theoretically diminish gap formation at the site of a tendon repair.

Introduction: The suture properties associated with a successful tendon repair are: high tensile strength, little tissue response, good handling characteristics and minimal plastic deformation. Plastic deformation contributes to gap formation at a tendon repair site. Gaps greater than 4mm are likely to fail. This study investigates whether the plastic deformation demonstrated by two commonly used suture materials can be reduced by manual pre-tensioning.

Methods: Twenty sutures of both Prolene 3/0 (Ethicon, UK) and Ethibond 3/0 (Excel, Johnson and Johnson, UK) were tested. Half of the sutures in each group were manually pre-tensioned prior to knot tying and half were knotted without pre-tensioning. All knots were standard surgical knots with six throws. The suture lengths were measured before and after a standardised cyclical loading regime on an Instron tensile tester. The regime was designed to represent the finger flexion forces produced in a typical rehabilitation programme. All sutures were subsequently tested to their ultimate tensile strength.

Results: After cyclical loading the pre-tensioned sutures demonstrated a mean increase in suture length of 0.7% (range 0.1–1.9%). The sutures not pre-tensioned showed a mean increase of 5.4% (range 3.3–7%). This equates to 87% less plastic deformation (p < 0.05 Students’ T-test) upon pre-tensioning. There were no differences with Ethibond. Pre-tensioning had no effect on ultimate tensile strength for either group.

Conclusions: Manual pre-tensioning reduces plastic deformation in Prolene 3/0 sutures without affecting the ultimate tensile strength. This simple technique could theoretically diminish gap formation at the site of a tendon repair.

Introduction: Patient-reported outcome and satisfaction scores have become increasingly important in evaluating successful surgery. There is continued enthusiasm for metal-on-metal resurfacing of the hip, particularly as an alternative to total hip replacement (THR) in young, active patients with osteoarthritis. However, although mid-term survivorship data is promising, it remains unclear whether patient-reported outcomes following resurfacing match those following THR.

Patients and Methods: This case-matched control study compared patient-reported outcome and satisfaction data following hip resurfacing and total hip arthroplasty. Thirty-three consecutive patients selected for hip resurfacing were compared with 99 patients undergoing cemented total hip replacement (THR), matched for age, sex and pathology. Participants completed a Short-Form 12 Health Survey (SF-12) and Oxford Hip Score (OHS) questionnaire pre-operatively and 6 months post operatively, with an additional patient satisfaction questionnaire.

Results: There was no difference in length of hospital stay. Both groups reported improved outcome scores, with mean OHS improvements of 19.5 (95% CI: 17.0–22.1), and 20.6 (95% CI: 18.6–22.5) following resurfacing and THR respectively. There were similar improvements in SF-12 PCS of 14.2 (95% CI: 9.5 to 14.2) and 15.2 (95% CI: 13.2 to 18.2) for the resurfacing and THR groups respectively. The improvement in outcome scores did not differ between the two groups on multivariate regression analysis (P=0.509 for OHS, P=0.629 for SF-12 PCS). Both groups reported high levels of satisfaction, which tended to be better in patients undergoing hip resurfacing (97.0% vs 92.9%), with resurfacing patients reporting better pain relief (P=0.022) and better heavy lifting (P=0.038) at 6 months.

Discussion: This study shows that the short-term patient-centred outcome scores for hip resurfacing are at least as good as for conventional hip replacement, with slightly higher levels of satisfaction.

Objectives: To review the changing pattern of orthopaedic injury encountered by deployed troops with regard to the importance of hand trauma.

Methods: A literature review of orthopaedic practice in recent conflict. The search period extended from 1990–2007. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded according to Levels of Evidence.

Results: 210 published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. The evidence is overall level 5 with the majority of papers comprising reviews, individual sub-unit experiences, historical perspectives and individual database analyses.

The evolving importance of extremity trauma is clear from the quantity of its reporting. The paucity of life threatening cavity trauma is highlighted. Casualty survival off the battlefield is increasing perhaps due to the impact of personal protective equipment. The combination of changing ballistics and increasing survivability leads to an apparent increase in limb threatening and complex hand trauma being encountered by military surgeons.

Despite being rarely reported in isolation, the proportion of complex hand trauma is broadening with an increase in open fractures and mutilated soft tissue injuries resultant from high and low energy transfer ballistics.

Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Sporting activities and inappropriate use of equipment are responsible for soft tissue and bony injury with considerable morbidity.

The literature was analysed with regard to the classification of hand trauma. Articles relating to recent conflicts were notable for their lack of classification of these injuries.

The bulk of papers retrieved concerning military hand trauma management were published prior to the conflicts of the last decade. It is within these papers that classification and treatment priorities including the nature of debridement and fracture stabilisation are discussed and highlighted as core knowledge.

Conclusion: The nature of injuries sustained by troops in conflict is evolving. Changing survivability is resulting in increasingly complex hand trauma presenting to military surgeons.

Despite a culture of ensuring that today’s trauma surgeons learn from mistakes made by their predecessors, in the field of hand trauma this is not the case.

A comprehensive review of changing orthopaedic conflict related injury patterns with special regard to hand trauma and the key learning points from historical literature are highlighted. Proposals for improving management are discussed with regard to improved training opportunities and dialogue between military trauma surgeons.

To review the changing pattern of orthopaedic injury encountered by deployed troops with special regard to the importance of hand trauma sustained in conflict and non- war fighting activities.

Literature review relating to recent military operations (1990–2007) encompassing 100 conflicts worldwide. A subsequent search was performed to identify papers relating to hand injuries from 1914 to the present day. Papers were graded by Oxford Centre for Evidence-based Medicine Levels of Evidence.

Two hundred and ten published works were analysed. Review of the literature revealed a lack of statistical analysis and a tendency towards the anecdotal. These works were primarily level five evidence comprising reviews, correspondence, sub-unit experiences and individual nation database analyses.

The importance of extremity trauma is clear. The combination of changing ballistics and increasing survivability off the battlefield leads to a previously under emphasised increase in complex hand trauma.

Hand trauma is also shown to occur in deployed troops during activities unrelated to war fighting. Articles concerning military hand trauma management were mainly published prior to the conflicts of the last decade. Within these papers injury classification and treatment priorities are highlighted as core knowledge for trauma surgeons.

This paper provides a review of conflict related injury patterns with special regard to hand trauma. The key learning points from historical literature are highlighted. Proposals for improving management of these injuries from battlefield to home nation are discussed with regard to training opportunities and dialogue to ensure past lessons are not forgotten.