Introduction

Deltoid ligament reconstruction (DLR) is an important factor in the consideration of pes planus deformity. There is little evidence in the literature determining whether DLR could mitigate the risk of patients acquiring flat foot postoperatively following deltoid ligament injury.

The objectives of our study were to compare patient reported outcome measures between manual and robotic-assisted total hip arthroplasty.

Between 1st May 2021 and 31st August 2022, 539 consecutive patients who underwent 564 primary total hip arthroplasties were identified from the local registry database. Data were prospectively collected, and included patient demographics, American Society of Anaesthesiologists (ASA) grade, surgical approach, robotic-assistance, Oxford Hip Score (OHS), EQ-5D-3L and EQ-VAS pre-operatively and at twelve months.

Robotic-assistance, compared against manual total hip arthroplasty, was associated with an enhanced median (interquartile range) OHS (46 [42 – 48] vs 43 [36 – 47], p-value < 0.001), EQ-5D-3L (5 [5 – 7] vs 6 [5 – 8], p-value 0.002), and EQVAS (90 [75 – 95] vs 80 [70 – 90], p-value 0.003) at twelve months after surgery. Robotic-assistance was confirmed to be an independent predictor of a greater OHS at twelve months on a multivariate linear regression analysis (p-value 0.001).

Robotic assistance was superior to manual total hip arthroplasty in enhancing patient reported outcomes at twelve months after surgery.

Aims

Hydroxyapatite (HA)-coated collars have been shown to reduce aseptic loosening of massive endoprostheses following primary surgery. Limited information exists about their effectiveness in revision surgery. The aim of this study was to radiologically assess osteointegration to HA-coated collars of cemented massive endoprostheses following revision surgery.

Reduced length of stay (LOS) is logistically, economically and physiologically beneficial. Although a high proportion of total joint arthroplasty (TJA) patients are suitable for same day admission (SDA), removable barriers persist in many centres. This study aimed to determine factors limiting SDA and quantify the impact of implementing both SDA and a targeted enhanced recovery programme on length of stay.

This single-centre retrospective cohort study collected data on elective TJA patients aged <60. Qualitative service reviews identified opportunities for optimisation. Improvements were implemented in 2017, including: obtaining consent at the pre-assessment clinic and robustly assessing suitability for SDA. A targeted rapid recovery program was implemented in June 2018. Data was collected prior to changes in 2017, and following changes in 2018.

106 of 108 screened patients were eligible for inclusion. There were no significant between-year differences in baseline health characteristics. Significantly greater proportions of 2018 patients were consented at their pre-assessment clinic (56% vs 8.9%, p<0.001) and assessed as suitable for SDA (94% vs 57.1%, p<0.001). Pre-operative LOS was significantly reduced in 2018 for both total hip replacements (median [IQR]: 0[0,0] vs 1[1,1], p<0.001) and total knee replacements (median [IQR]: 0[0,0] vs 0[0,1], p=0.002). The departmental mean LOS improved from 4.7 days to 3.7 days following SDA. This was further shortened to 3.2 days after introduction of the rapid recovery program.

When a larger proportion of patients were deemed suitable for SDA, this correlated with reduction of LOS. The department now performs above national standards in both of these parameters.

Acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Conservative management is reserved for those unfit for extensive reconstruction, or those who achieve ‘secondary congruence' of a complex fracture. We present demographic data and the results of conservative management in patients over 65 years of age. The Fracture Outcome Research Database (FORD) at our unit was interrogated for all patients over 65 years, who had sustained an acetabular fracture between June 2008 and June 2016. 410 patients were identified. Following exclusions, thirty-two patients were included for analysis. They had a mean age of 80 (66–91), and a mean ASA equivalent score of 3.1 (2–4). Mean follow up was five (1–9) years. Twenty-five patients lived in their own home and seven in a nursing home. Thirty had low energy injures, two high energy. Twenty-four (75%) had anterior column posterior hemitransverse fractures, seven (22%) had associated both column and one (3%) had a T-type fracture. The mean length of inpatient stay was 43 days (4–140). Maximum post-operative mobility was limited to a hoist in eight (25%), a frame with or without assistance in 15 (47%), a stick in five (16%) and independence in four (13%). Thirty-day mortality was 6%- and one-year mortality 22%. The data demonstrates that conservative treatment in this cohort leads to long inpatient stays, poor mobility and significant levels of mortality. Complex reconstruction remains demanding on both surgeon and patient. Innovative ways of managing these patients are needed to improve outcomes.

Background

Anterior Cruciate Ligament Reconstruction is a commonly performed orthopaedic operation. The use of a four-strand semitendinosus and gracilis hamstring graft (STG) is a well established method of reconstruction to restore knee stability.

The royal victoria hospital is a tertiary trauma centre receiving pelvic injury referrals for a population of 1.7 million. The use of ilio-sacral screw fixation with low anterior frame stabilisation has been adopted as the principle treatment for unstable pelvic ring injuries in our institution. We aim to describe our practice and outcomes following the use of percutaneous screw fixation of the pelvis.

The review included standardised assessment of health-related quality of life (SF-36) as well as the Iowa pelvic score and Majeed pelvic injury outcome scores. Data was also collected on associated injuries, post-operative complications, nerve injury and pain scores.

A total case series of 45 patients undergoing percutaneous ilio-sacral screw fixation following traumatic pelvic injury were identified over a 5 year period. Of these 23 were contactable to follow-up or responded to questionnaire review.

The mean follow up was 680 days (range 151–1962). The mean age was 33 (range 18–57).

The mean SF-36 physical and mental scores were 38 and 46 respectively. The mean Majeed score was 69 and Iowa pelvic score was 65. The mean pain score was 3.5 (range 0–7). There were no incidences of deep infection, post-operative PE or nerve injury related to screw insertion.

Patients with isolated pelvic injuries performed better on outcome scoring however the low SF-36 scores highlight the severity of pelvic injuries

Anterior cruciate ligament (ACL) reconstruction is a commonly performed operation. A variety of graft options are used with the most popular being bone-patellar-tendon-bone and hamstring autograft. There has been an increase in the popularity of hamstring autograft over the past decade.

The aim of the study was to assess the ten year subjective knee function and activity level following four-strand semitendinosis and gracilis (STG) anterior cruciate ligament reconstruction.

86 patients underwent anterior cruciate reconstruction by two knee surgeons over a 12 month period (January 1999 to December 1999). 80 patients meet the inclusion criteria of arthroscopic ACL reconstruction. The same surgical technique was used by both surgeons involving four-strand STG autograft, single femoral and tibial tunnels and aperture graft fixation with the Round headed Cannulated Interference (RCI) screw. Patient evaluation was by completion of a Lysholm Knee Score and Tegner Activity Level Scale at a minimum of ten years from reconstructive surgery. This was by initial postal questionnaire and subsequent telephone follow-up.

80 patients underwent anterior cruciate reconstruction with average age 30.9 years (15 to 58 years). There was a 77.5% (62 patients) response at ten years to the questionnaire.

The median Lysholm Knee Score at ten years was 94 (52 to 100). The median activity level had decreased from 9 to 5 at ten years according to the Tegner Activity Scale. 73% of patients reported a good or excellent outcome on the Lysholm score. The group of patients was further divided into those that required meniscal surgery and those that did not. The patients that did not require meniscal surgery had a median Lysholm score of 94 and those that required meniscal surgery had a similar median Lysholm score of 92.5. However it was noted that 8 patients required medial and lateral partial menisectomies at the time of original reconstruction. This group of patients had a median Lysholm Knee Score of 83.5 and Tegner Activity Scale of 4 at ten years following reconstruction. 17 of the 62 patients (27.4%) required re-operation because of further knee symptoms, with 4 patients requiring revision of the anterior cruciate following re-rupture.

In conclusion anterior cruciate ligament reconstruction with four-strand STG hamstring autograft provides a reliable method of restoring knee function, with a 6% revision rate for re-rupture at ten years. Combined partial medial and lateral menisectomy at the time of the initial reconstruction is a poor prognostic indicator of function at ten years.

Acetabular bone loss is a problem in primary and revision Total Hip Joint Replacement (THJR). Impaction bone grafting is one method of dealing with this problem. We looked at the results of two surgeons who use this method at North Shore Hospital, Auckland.

A retrospective study was carried out on all patients who had acetabular impaction bone grafting carried out as part of THJR, whether primary or revision. All operations were performed by two surgeons, Mr Rob Sharp and Mr Bill Farrington. Patients were assessed in clinic at varying time intervals post grafting, and were functionally scored.

33 patients underwent impaction grafting, a total of 35 acetabular grafts. Of these the male to female ratio was 16:17, and the mean age range was 46–82 years. Average Harris hip score was 79 (Min 54 Max 95), and the average Oxford score was 39 (min 13 Max 48). There was one failure, 3 dislocations, and1 sciatic nerve palsy.

Impaction bone grafting is one method, which can be utilised to reconstruct acetabular bone loss, with the additional advantage of restoring bone stock. We found high rates of patient satisfaction, and a low failure rate.

Correct sizing of knee arthroplasty implants avoids problems such as stiffness from too large an implant, or periprosthetic fractures from undersizing. Currently most implants are based on a generic unisex population. Femoral component sizing is therefore based solely on the AP measurement after the distal femoral cut. In order to investigate the differences between the New Zealand population and other populations with reported anthropometrics we studied the anthropometrics of the male and female distal femur.

The distal femur of 26 cadaveric knees was resected using standard cutting guides. Using a sizing guide the AP dimension was measured from the posterior condyle to the anterior cortex just proximal to the trochlea (posterior referencing). The ML dimension was measured at the cut surface in the coronal plane of the epicondylar axis.

Overall AP measurement had a mean(standard deviation) of 62(±6.7) mm, the ML measurements had a mean (sd.) of 72(±6.6)mm yielding an ML/AP(100) ratio of 117(±11). The male AP mean was 67(±4.5) mm and female AP 57 (±4.4)mm. The male ML was 77 (±4.7)mm and female ML 68 (±4.5)mm. The ML/AP ratio for male was 111(±12) and female was 120 (±10).

This pilot study has shown differences between genders in the NZ population even with this small sample size. As this data is important for designers of total knee implants, planning is currently underway to perform measurements intraoperatively from approximately 400 patients undergoing total knee replacement.

Limb lengthening is described by means of external fixator in limb length discrepancy. Intramedullary distraction is a relatively new procedure undertaken infrequently. We present our initial results following the use of the ISKD for lower limb lengthening.

Methods: A retrospective review, over a three year period, revealed six patients (five femurs and one tibia) underwent lengthening by ISKD. Four of the femoral cases were secondary to trauma. The other femoral case and tibial case were secondary to congenital shortening.

All cases were male with mean age of 35 years (20 – 54 years). The mean total distraction was 42mm (10 – 65mm) and a mean daily distraction of 0.96mm/day (0.78 – 1.75mm). Mean time to full weight bearing was 12.5 weeks. The planned length of distraction was achieved in all patients undergoing femoral lengthening. Four of these patients regained full movement of the knee at 6 months and the other regained an arc of 5 – 105 degrees.

The tibial lengthening only achieved 28.5% of the desired length as a result of premature consolidation and poor patient compliance. There were no cases of infection, DVT, non-union or hardware failure. Three patients experienced no complications. One patient experienced premature consolidation and required repeat corticotomy. Two patients experienced inappropriate lengthening. One experienced distraction at the previous fracture site and as a result required 5 further operations and application Ilizarov frame. The other was as a result of a runaway nail achieving 56mm distraction in 32 days (1.75mm/day).

This review, although with small numbers, highlights that the ISKD is a satisfactory treatment for femoral lengthening although we experienced difficulties with tibial lengthening. Following our experience all patients require a CT scan preoperatively to confirm union at the fracture site. ISKD has been considered an option for femoral lengthening only.

Aim: The use of volar plates in the management of distal radius fractures has increased dramatically over the last decade. Our aim was to ascertain if long term outcome could be predicted at clinical review four months following operation.

Patients and Methods: Between January 2003 and January 2005, all patients presenting with unilateral distal radius fractures and treated with volar locking plate fixation (Synthes) were invited to participate in long-term follow up. The decision to use a volar plate and the operative procedure itself was undertaken by the on-call consultant and his team. Patients who agreed to enter the study were evaluated at 4, 6 and 12 months following operation. Patient demographics, hand dominance and fracture type were recorded. Assessment of grip strength and wrist movements were undertaken and expressed as a percentage of the contralateral, uninjured side.

Results: A total of 76 out of 100 eligible patients agreed to participate in the study. Of those patients, 23 (30%) failed to attend all their follow-up appointments, leaving a dataset of 53 patients (70%) available for analysis. There were 28 females (53%) and the mean patient age was 55 years (range 28–83).

Grip strength, pinch grip, wrist flexion, wrist extension, radial deviation, ulnar deviation, pronation and supination all showed graded improvement in the year following fracture, achieving a mean range of 73% to 95% of function compared to the contralateral side at 12 months. Wrist flexion and ulnar deviation showed near maximum improvement by 6 months, whereas the other variables continued to show significant improvement between 6 and 12 months.

Logistic regression analysis suggested that improvement in wrist extension at four months was the best predictor of a good outcome at one year.

Discussion: Use of volar plate fixation is an increasingly common method of managing distal radius fractures. Our study suggests that good functional results can be achieved by this method of treatment. Failure to regain reasonable wrist extension by four months appears to predict higher risk of poor outcome and therefore patients in this group should be followed up more closely.

Percutaneous fluoroscopically asseisted iliosacral screw insertion has become one of the most popular methods of stabilisation of the posterior aspect of the vertically unstable pelvis. Screw malpositioning rates range from 0 to 10%. Screw misplacement can cause injury to the iliac and gluteal vessels, L4 to s1 nerve roots and sympathetic chain.

We performed two radiographic studies on dry human bones to seek safe radiographic landmarks for insertion of iliosacral screws.

Part 1: Two parallel linear densities are always present on lateral plain radiographs of the lumbosacral spine and pelvis. Using wire markers on pelvic bones, we accurtely define the origins of these “pelvic lines”. Steel wires of different lengths were placed along the iliopectineal and arcuate lines of the pelvis. The shorter wire stopped at the anterior limit of the sacroiliac joint. The longer wire extended further along the entire course of the medial border of the ilium to the iliac crest posteriorly. We demonstrate that each “pelvic line” represents the sharp bony ridge that forms the anterosuperior limit for insertion of the iliosacral screws.

Part 2: In a second experiment on dry pelvis, we inserted balloons filled with radio-opaque contrast medium into the spinal canal of the sacrum and exiting through the anterior and posterior sacral foramina on either side. Plain lateral radiographs and CT scan with reformatted images were obtained. We present a previously undescribed radiological sign on plain lateral radiographs of the lumbosacral spine. The inferior and posterior boundaries of the “acorn sign” are delineated. Together, the “pelvic lines” and “acorn sign” provide accurate landmarks for the safe insertion of iliosacral screws. Iliosacral screws should be contained within this “acorn sign” to avoid injury to the nerve roots and below the “pelvic lines” to safeguard the iliac vessels and lumbosacral trunk.

Percutaneous fluoroscopically assisted iliosacral screw insertion has become one of the most popular methods of stabilisation of the posterior aspect of the vertically unstable pelvis. Screw malpositioning rates range from 0 to 10 per cent. Screw malplacement can cause injury to the iliac and gluteal vessels, L4 to S1 nerve roots and sympathetic chain.

We performed two radiographic studies on dry human bones to seek safe radiographic landmarks for insertion of iliosacral screws.

Part 1. Two parallel linear densities are always present on lateral plain radiographs of the lumbosacral spine and pelvis. Using wire markers on pelvic bones, we accurately define the origin of these pelvic lines. Steel wires of different lengths were placed along the iliopectineal and arcuate lines of the pelvis. The shorter wire stopped at the anterior limit of the sacro-iliac joint. The longer wire extended further along the entire course of the medial border of the ilium to the iliac crest posteriorly. We demonstrate that each ‘ pelvic line ‘ represents the sharp bony ridge that forms the anterosuperior limit for insertion of iliosacral screws.

Part 2. In a second experimenton dry pelvis, we inserted balloons filled with radio-opaque contrast medium into the spinal canal of the sacrum and exiting through the anterior and posterior sacral foramina on either side. Plain lateral radiographs and CT scan with reformatted images were obtained. We present a previously undescribed radiological sign on plain lateral radiographs of the lumbosacral spine. The inferior and posterior boundaries of the acorn sign are delineated.