The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial. Children aged seven to 15 years old inclusive, who have sustained a displaced fracture of the medial epicondyle, are eligible to take part. Baseline function using the Patient-Reported Outcomes Measurement Information System (PROMIS) upper limb score, pain measured using the Wong Baker FACES pain scale, and quality of life (QoL) assessed with the EuroQol five-dimension questionnaire for younger patients (EQ-5D-Y) will be collected. Each patient will be randomly allocated (1:1, stratified using a minimization algorithm by centre and initial elbow dislocation status (i.e. dislocated or not-dislocated at presentation to the emergency department)) to either a regimen of the operative fixation or non-surgical treatment.Aims
Methods
The Tour de France, commonly recognised and the hardest physical endurance event on the planet, is an iconic cycling competition with a history of ever impressive performances and increasingly notable injuries. This study aims to methodologically catalogue and analyse injuries sustained by professional riders over a span of six years and understand the operative workload created by this prestigious race. (2018–2023). Data was gathered from multiple publicly available sources, including pro-cycling stats, news articles, team press releases and independent medical reports. Each injury was categorized by year, rider, and injury type.Introduction
Methods
Retention and removal of children's orthopaedic metalwork is a contentious issue that has implications for current resource allocation, health economics, complication risks and can impact on future treatments. Understanding how to guide families make informed choices requires an overview of all the relevant evidence to date, and knowledge of where the evidence is lacking. Our aim was to systematically review the literature and provide a meta-analysis where possible, recommending either retention or removal. A search of the literature yielded 2420 articles, of which 22 papers were selected for the study analysis. Inclusion criteria: Any paper (evidence level I-IV) assessing the risks or benefits of retaining or removing orthopaedic metalwork in children. Exclusion criteria: Spinal implants; implant number < 40; < 75% recorded follow up; papers including implants in their analysis that always require removal; patients aged >18 years.Introduction
Materials and Methods
There remains a paucity of clinical studies on the effects of coronavirus on perioperative outcomes, with no existing trials reporting on risk factors associated with increased risk of postoperative mortality in these patients. The objectives of this study were to assess perioperative complications and identify risk factors for increased mortality in patients with coronavirus undergoing surgery. This multicentre cohort study included 340 coronavirus negative patients versus 82 coronavirus positive patients undergoing surgical treatment for neck of femur fractures across nine NHS hospitals within Greater London, United Kingdom. Predefined study outcomes relating to patient demographics, fracture configuration, operative treatment, perioperative complications and mortality were recorded by observers using a standardised data collection proforma. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality.Background
Methods
To investigate whether the duration of pain has an influence on the clinical outcomes of patients with low back pain (LBP) managed through the North East of England Regional Back Pain and Radicular Pain Pathway (NERBPP). The NERBPP is a clinical pathway based upon NICE guidelines (2009) for LBP. Patients with LBP referred onto the NERBPP by their General Practitioner (GP) between May 2015 and January 2017 were included in this evaluation. Data from 635 patients, who provided pre and post data for pain (Numerical rating scale [NRS]), function (Oswestry Disability Index [ODI]) and quality-of-life (EuroQol [EQ5D]), were analysed using a series of covariate adjusted models in SPSS. Patients were categorised into four groups based upon pain duration: <3months, ≥3 to <6months, ≥6months to <12months, ≥12months.Aims
Patients and Methods
Platelet rich plasma has been advocated for the treatment of plantar fasciitis but there are few good quality clinical trials to support its use. We report a pilot double blind randomised controlled trial of platelet rich plasma versus normal saline. Patients with more than 6 months of MRI proven plantar fasciitis who had failed conservative management were invited to participate in this study. Patients were block randomised to either platelet rich plasma injection (intervention) or equivalent volume of normal saline (control). The techniques used for the injection and rehabilitation were standardised for both groups. The patient and independent assessor were blinded. Visual analogue scale for pain (VAS) and painDETECT were recorded pre-op and at 6 months. Twenty-eight patients (19 females, mean age 50 years) were recruited, with 14 randomised to each arm. At 6 month follow-up, 8 patients (28.6%) were lost to follow-up. There was a significant change in VAS score from baseline to follow-up in both intervention (mean change 37.2, p = 0.008) and control (mean change 42.2, p = 0.003) groups. However there was no difference between the arms in terms of the change in VAS score from baseline to follow-up (p = 0.183). There was no correlation between pre-op PainDETECT score and change in VAS.Methods
Results
Surgical simulation and ‘virtual’ surgical tools are becoming recognised as essential aids for speciality training in Trauma & Orthopaedics, as evidenced by the BOA T&O Simulation Curriculum 20131,2. The current generation of hip arthroplasty simulators, including cadaveric workshops, offers the trainee limited exposure to reproducible real life bony pathology. We developed and implemented a novel training course using pathological dry bone models generated from real patient cases to support senior orthopaedic trainees and new consultants in developing knowledge and hands on skills in complex total hip arthroplasty. A two-day programme for 20 delegates was held at a specialist centre for hip arthroplasty. Three complex femoral and three complex acetabular cases were identified from patients seen at our centre. 3D models were printed from CT scans and dry bone models produced (using a mold-casting process), enabling each delegate to have a copy of each case at a cost of around £30 per case per delegate (Figure 1). The faculty was led by 4 senior Consultant revision hip surgeons. A computerised digitising arm was used to measure cup positioning and femoral stem version giving candidates immediate objective feedback (Figure 2). Candidate experience and satisfaction with the course and models was evaluated with a standardised post-course questionnaire.Introduction
Patient/Materials & Methods
To review the outcome of deep prosthetic infection in patients following hip hemiarthroplasty surgery. A retrospective case-note analysis was performed of deep infection coded hip hemiarthroplasty patients between 2004–2009. Patients were selected when there was proven microbiology from deep wound swabs or tissue specimens.Aim
Method
Anterior cruciate ligament (ACL) injuries are being seen with increasing frequency in children. Treatment of the ACL deficient knee in skeletally immature patients is controversial. To determine the outcome of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years after surgery. Between 2007–2008, 16 prepubescent skeletally immature patients underwent anatomic transphyseal ACL reconstruction using soft tissue grafts. All patients were tanner stage 1 and 2 and all had open growth plates. Outcomes were assessed at a minimum of 2 years after surgery and included: limb alignment, limb length, instrumented testing with KT-1000 and International Knee Documentation Committee (IKDC) score. Mean age at the time of surgery was 12 years (8–14). Graft choices included: living-related donor hamstring tendon allograft (n=14), hamstring tendon autograft (n=1) and fresh frozen allograft (n=1). Mean IKDC subjective score was 96 (84–100). Sixty-two percent of patients had <3mm side-to-side difference on instrumented KT-1000 testing and 88% had a negative pivot shift. At 2 years after surgery, all patients had returned to strenuous activities and normal or nearly normal overall IKDC score was documented in 94% of patients. There were no cases of limb malalignment or growth arrest. We present a large series of anatomic transphyseal ACL reconstruction in tanner stage 1 and 2 patients with open growth plates at a minimum of 2 years following surgery. Excellent clinical outcomes were obtained with high levels of return to desired activities. Importantly, no growth disturbances were seen in this series of patients.
Computer navigation has been shown to improve the accuracy of total knee replacement (TKR) when compared to intra or extra osseous referencing. Currently the surgical transepicondylar axis (TEA) is used to help determine femoral component rotation. This relies on the surgeon identifying medial and lateral epicondyles intra-operatively. This process has been shown to have a high variability and operator dependency. The functional flexion axis (FFA) of the femur is a kinematically derived reference axis which has previously been shown in a cadaveric model to correspond well with the transepicondylar axis. This study was therefore designed to evaluate its accuracy in vivo. 50 patients undergoing total knee replacement under the care of the three senior authors were prospectively recruited. A preoperative CT scan was obtained and the TEA evaluated by 2 independent clinicians. TKR was undertaken in the standard fashion using Stryker navigation. The FFA was derived at 3 time points during the procedure: pre-incision, post osseous registration and following component implantation. The deviations of the FFA and surgical TEA (surTEA) to the CT-derived TEA (ctTEA) was calculated and comparisons drawn between the 2 methods with respect to validity, as well as within and between-patient reproducibility. While the FFA results were highly correlated between pre and post-arthrotomy (r = 0.89), the post-incision FFA (−1.60+/−3.7) was significantly internally rotated (p<0.01) relative to the pre-incision FFA (−2.50+/−3.4). In addition the surgical TEA (−0.40+/−3.6) was significantly internally rotated (p = 0.02) relative to the post-incision FFA (1.80+/−3.7) for the combined data from all 2 surgeons. However, when examined individually, 1 of the 2 surgeons showed no significant difference between the FFA and TEA. In addition, the two methods demonstrated comparable between-patient variability in the knee axis, although surgeon-dependent patterns remained. The FFA has been shown to be of equivalent accuracy to the surgical TEA but surprisingly does not avoid its operator-dependency. Further evaluation of the FFA method with possible adjustments to the algorithm is warranted.
In order to address high failure rates following rotator cuff repairs, a greater understanding is required of the underlying structural changes so that treatments can be appropriately targeted and biomarkers of failure can be identified. As collagen is the primary constituent of tendon and determines force transmission, collagen structural changes may affect responses to loading. For example changes in collagen 1 and 5 are associated with the hyperelastic Ehlers-Danlos syndrome, which is diagnosed by looking for pathopneumonic altered collagen fibres or ‘collagen flowers’ in skin using transmission electron microscopy (TEM). To date no study has been performed on the microstructure of torn human rotator cuff tendons using TEM. It was hypothesized that normal, small and massive human rotator cuff tendons tears will have altered microscopic structures. The unique study aimed to use TEM to compare the ultrastructure of small and massive rotator cuff tears, to normal rotator cuff tendons. Samples from 7 human rotator cuff tendons repairs were obtained, including 4 massive (>5 cm) and 3 small (< 1 cm) tears, and 3 matched normal controls with no history of connective tissue disorders. Specimens were fixed in 4% glutaraldehyde in 0.1M phosphate buffer, processed and examined blind using routine TEM examination. To assess whether changes in the relative expression of collagen 1 and 5 (COL1A1, COL5A1 and COL5A2) occurred in all tears, qPCR was performed on another 6 phenotypically matched patients.INTRODUCTION
METHODS
The purpose of the current study was to compare the results of the P.F.C. Rotating Platform Knee System and the P.F.C. Knee System in a randomised prospective study. 151 patients were enrolled in the study, totalling 172 knees, with 84 receiving fixed bearing and 88 receiving rotating platform knees. Patients were enrolled prospectively with preoperative assessment of the defined outcome measures including Knee society score, Oxford Knee Score, SF-36 score, WOMAC score, VAS pain score and ROM. These outcome measures were repeated at 6 months, 1 year and 2 years At the two year follow up patients were assessed and results analyzed to see if there were any significant differences with regard to outcome measures. There was no statistically significant difference for the SF12, Oxford knee score or the VAS pain score. In the Knee Society Score a trend effect at the one year follow up (almost significant at p = 0.07) was seen with the rotating group scoring better in overall function than the fixed group. At the two year follow-up this difference between groups became significant (p = 0.05) and the rotating group had significantly better overall function than the fixed group. The early results show a better functional score with comparable subjective outcome measures with regard to pain and ROM. The long term purported benefits of the rotating platform versus fixed will be watched with interest in the medium to long term follow up.
