Introduction

The condition of the soft tissues surrounding an ankle fracture influences timing and treatment of injuries. Conventional treatment used an open approach to facilitate anatomical reduction and rigid internal fixation. Intramedullary devices for fibular fractures provide a safe alternative in patients in which the condition of the soft tissue envelope or the patient's co-morbidities may benefit from a less invasive approach. We compared outcomes for patients treated with open reduction internal fixation (ORIF) with those undergoing treatment with fibular nails (FN)

The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic.

These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines.

We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre.

We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated.

331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an intramedullary fixation while 35% had arthroplasty performed. There was a 51:49 split male to female with Prostate, Lung and Breast being the predominant primary tumours. Concurrent spinal metastatic disease was noted in 62% of patients while visceral mets were seen in 37%. Mortality rate was 65% with an average prognosis of 388 days (1.06years) while average mortality was noted within 291 days (0.8 years).

Proximal femoral metastatic disease accounts for a large volume of the overall mets burden. There is an overall tendency towards conservative management and of those requiring surgery IM nailing was the treatment of choice. The data would indicate that outcomes for these patients are guarded and on average worse than those predicted.

Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility.

IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm.

We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime.

IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation.

Aims

The COVID-19 pandemic has triggered transformative change in how clinicians interact with their patients. There has been a shift away from face-to-face toward virtual consultations. However, the evidence to support this change in practice is unclear. The aim of this study was to systematically review the evidence base for virtual consultations for orthopaedics.

Abstract

Introduction and Objective

Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. There is an evolving understanding that poorer outcomes could be associated with non-weight bearing protocols and immobilisation. Traditional non-weight bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The aim of this systematic review and meta-analysis is to compare the complication rate and functional outcomes of early weight-bearing (EWB) versus late weight-bearing (LWB) following open reduction and internal fixation of ankle fractures.

Introduction and Objective

Wide awake local anaesthetic no tourniquet (WALANT) is being used for a wide variety of hand and wrist surgery. It has recently been used in distal radius fracture fixation. The purpose of this systematic review and meta-analysis was to assess the effectiveness of the WALANT technique in open reduction internal fixation.

Introduction and Objective

Ankle fractures are common and affect young adults as well as the elderly. An unstable ankle fracture treatment typically involves surgical fixation, immobilisation, and modified weight-bearing for six weeks. Non-weight bearing (NWB) cast immobilisation periods were used to protect the soft tissue envelope and osteosynthesis. This can have implications on patient function and may reduce independence, mobility and return to work. Newer trends in earlier mobilisation compete with traditional NWB doctrine, and weak consensus exists as to the best postoperative strategy. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates.

Introduction

This study was performed to investigate the efficacy of steroid and local anaesthesia (LA) in reducing post-operative pain in lumbar discectomy.

Introduction: This study is performed to investigate the efficacy of steroid, local anaesthesia (LA) or combination of both in reducing post operative pain in lumbar discectomy.

Materials and Methods: The study was ethically approved. Patients undergoing primary single level lumbar discectomy were randomised by a closed envelope system into 4 groups of 1ml of steroid and 1ml of LA, 1ml of steroid and 1ml of saline, 1ml of LA and 1ml of saline and 2mls of saline as control. 10mg of adcortyl in 1ml and 1ml of 0.5% marcaine were used. Combinations of above were applied topically over the nerve root prior to closure. Preoperative, day 1 and eight weeks post operative visual analogue pain score were recorded. 10cm visual analogue pain score chart was used. 24 hours post operative opiate analgesia requirements and duration of inpatient stay were recorded. Data was analysed using Student t-test and Fisher exact t-test.

Results: No significant differences seen in the mean pre operative pain score between all groups. Mean Day 1 post operative pain and analgesia requirement in steroid and LA, steroid only, LA only and control group were 0.9, 2.5, 2.1 and 3.3 respectively. Mean opiate analgesia requirement 24 hours post operatively were 32.4mg, 54mg, 32.4mg and 56.8mg respectively. Mean inpatient stay were 2.2day, 3.91day, 4.62day and 3.63day respectively. At 8 weeks post operatively, no significant differences in the pain score in all groups.

Conclusions: Significant post operative pain reduction was achieved in the steroid and local anaesthesia group compared with other groups (p< 0.05). The results are reflected as well in significant reduction in the post operative analgesia requirement (p< 0.05) and the significant reduction in inpatient stay. (p< 0.05) We recommended the use of perioperative steroid and LA infiltration in lumbar discectomy. Improved post operative pain control reduces post operative opiate analgesia requirement and reduced inpatient stay.

Introduction: The goals of TKR are restoration of the mechanical axis, joint line and Q –angle. Reproduction of the offset of the extensor mechanism during arthroplasty is less well understood. The lever arm of the extensor mechanism is primarily affected by femoral component position, patella tracking and overall patellar thickness. Changing this lever arm alters quadriceps muscle and patellofemoral joint reaction force. Some TKR designs purposefully aim to increase this offset in order to reduce PFJ contact pressures. Overstuffing the PFJ will however adversely affect outcome.

The aims of this study were to measure and compare the pre and postoperative quadriceps lever arm and its effect on function in a consecutive series of patients undergoing TKR.

Methods: Fifty consecutive patients who had an LCS TKR without patellar resurfacing by a single surgeon were reviewed. Patient demographics were recorded. We measured the pre and post-operative quadriceps lever arm using comparable lateral radiographs and digital imaging software. Functional outcome in these patients was determined using the American Knee Society Score pre and 6-months post-operatively. Patients were specifically questioned regarding the presence or absence of anterior knee pain

Results: Quadriceps lever arm was on average 6 mm greater post-operatively than pre-op but this difference was not significant [t-test]. The functional outcome in these patients was independent of any change in quadriceps lever arm.

Conclusions Reproduction of normal biomechanics is essential in order to optimise outcome from TKR.

Using the LCS system, there is a small but insignificant increase in the quadriceps moment arm. We have not found that this has any bearing on functional outcome in these patients.

Introduction: Synchronous severe arthrosis of the ankle and subtalar joints is a debilitating problem that can be difficult to treat. Tibiotalocalcaneal arthrodesis remains the treatment of choice for this disabling condition. There are many techniques described for ankle arthrodesis, some of which are not applicable to patients with severe rheumatoid arthritis due to osteopenia and/or deformity. Minimally invasive procedures are preferable in this population, whose wound-healing ability is often compromised. This study aims to show the reliability and success of intra-medullary nailing for ankle arthrodesis. We also wished to assess postoperative pain relief and quality of life.

Methods: We reviewed 15 patients who had undergone tibiotalocalcaneal fusion with a retrograde intramedullary nail. Patients were assessed clinically and radiologically. Outcome measures included radiological union, ankle and foot function and quality of life, pre and postoperatively. The “ankle and foot function score” was used to assess function. Quality of life scores were obtained using the Short Form 36 (v2) pre and postoperatively. Statistical analysis was performed using the paired Student t-test.

Results: Indications for ankle arthrodesis were rheumatoid arthritis (n=11) and posttraumatic arthritis (n=4). Mean follow up was 11.2 months. Mean time to fusion was 2.9 months +/− 0.85. Solid fusion was achieved in 14 out of 15 patients (93%), one patient having a failed fusion due to persistent wound complications. There was an improvement in both the ankle and foot function scores and in the physical parameters of the SF-36 postoperatively. The mean preoperative ankle and foot function score was 26.7 +/− 13.5 versus 37 +/− 16 postoperatively (p=0.25). In assessing quality of life, the mean physical functioning score was 20.9 +/− 4 versus 29.1 +/− 10.4 postoperatively (p=0.08). Role limitations due to physical problems scored 26.3 +/− 5.3 preoperatively versus 32.7 +/− 10.9 postoperatively (p=0.09). Overall, there was a significant difference in pre and post-op mean summary physical component score: 27.5 +/− 4.9 versus 35 +/− 8.9, p=0.049.

Conclusion: This well tolerated, minimally invasive technique provides a surgical solution for a challenging clinical problem. Overall, this procedure improved both physical function and quality of life in our series and achieved a fusion rate equivalent to published series. We would advocate this procedure as a highly effective technique in the treatment of advanced rheumatoid hindfoot arthritis.

Nosocomial infection with methicillin-resistant Staphylococcus aureus (MRSA) is on the increase and is expensive to treat. MRSA surgical wound infection may have disastrous consequences, particularly in an orthopaedic setting. We studied the rate of MRSA colonization in an important subgroup of orthopaedic patients. 50 nursing home residents were retrospectively reviewed with regard to their MRSA status on admission to an orthopaedic ward with fractured neck of femur. As is policy in our institution, all patients from nursing homes or other institutions are screened for MRSA on admission.

Of the 50 nursing home patients requiring a hemi-arthroplasty, 16%(8) were MRSA positive. 2%(1/50) acquired MRSA infection while I hospital, while the remaining 14%(7/50) were carriers on admission. 4%(2/50) developed sepsis postoperatively, followed by multiorgan failure and death. 4% had their MRSA cleared prior to discharge, while 8% remained positive on discharge. All patients undergoing hemiarthroplasty received cefuroxime, unless allergic, as prophylaxis at induction. These findings of considerable MRSA carriage in nursing home patients is particularly relevant today, as the number of patients in nursing homes continues to grow as the population ages. The patient population in nursing homes is susceptible to infection because of the physiological changes that occur with ageing, the underlying chronic diseases of the patients and the institutional environment within which residents socialize and live.

Nursing home residents presenting to orthopaedic units for surgery are a unique group in repairing careful consideration.