Osteonecrosis of the knee encompasses three conditions; spontaneous osteonecrosis of the knee, secondary osteonecrosis (ON) and post-arthroscopic ON. Early stage lesions can be managed by non-operative measures that include protected weight-bearing and analgesia. The aim of this study was to report the experience of the authors in managing early stages of knee ON by analysing the functional outcome and need for surgical intervention. All patients treated for osteonecrosis of the knee between 1st August 2001 and 1st April 2014 were prospectively collected. Treatment consisted of touch-down weight bearing for four to six weeks. The cases were retrospectively reviewed. MR imaging was evaluated for the stage of disease according to Koshino's Classification system, the condyles involved and the time taken for resolution. Tegner Activity Scale, VAS pain, Lysholm, WOMAC and IKDC scores were recorded at presentation and final follow up.Introduction
Methods
The highest incidence of recurrent shoulder instability is in young patients, surgical repair can reduce recurrent instability and improve shoulder function. This has led to an increasing rate of stabilisation and use of MRI to identify associated injuries in first time dislocations. MRA has the benefit of distending the joint and is becoming increasingly used. The aim of this study is to establish the sensitivity and specificity of MRA in the investigation of patients with traumatic anterior shoulder dislocations. A retrospective analysis of patients undergoing both magnetic resonance arthrography and arthroscopy after a traumatic anterior shoulder dislocation between January 2011 and 2014. Images were interpreted by eight musculoskeletal radiologists and arthroscopic findings were obtained from surgical notes and used as a reference. The sensitivity, specificity and positive predictive value for the different injuries were calculated.Introduction
Methods
The stability of the elbow joint following an acute elbow dislocation is dependent on associated injuries. The ability to identify these concomitant injuries correctly directs management and improves the chances of a successful outcome. Interpretation of plain radiographs in the presence of either a dislocation or post-reduction films with plaster in-situ is difficult. This study aimed to assess the ability of orthopaedic registrars to accurately identify associated bony injuries on initial plain radiographs using CT as the gold standard for comparison. Patients over the age of 16 years undergoing an elbow CT scan within one week of a documented elbow dislocation between 1st June 2010 and 1st June 2014 were included in the study. Three orthopaedic registrars independently reviewed both the initial dislocation and immediate post reduction plain radiographs to identify any associated bony injuries. This radiograph review was repeated by each registrar after two weeks. The incidence of associated injuries as well as the inter- and intra-observer variability was calculated.Introduction
Methods
Patients suffering a distal femoral fracture are at a high risk of morbidity and mortality. Currently this cohort is not afforded the same resources as those with hip fractures. This study aims to compare their mortality rates and assess whether surgical intervention improves either outcome or mortality following distal femoral fractures. Patients over sixty-five admitted with a distal femoral fracture between June 2007 and 2012 were retrospectively identified. Patients mobility was categorised as unaided, walking aid, zimmer frame, or immobile. The 30-day, six-month, and one-year mortality rates were recorded for this group as well as for hip fractures during the same period.Background
Methods
Despite arthroscopy being the gold standard for long head of biceps pathology, the literature is seemingly lacking in any critical appraisal or validation to support its use. The aim of this study was to evaluate its appropriateness as a benchmark for diagnosis. The objectives were to evaluate whether the length of the tendon examined at arthroscopy allows visualisation of areas of predilection of pathology and also to determine the rates of missed diagnoses when compared to an open approach. A systematic review of cadaveric and clinical studies was performed. The search strategy was applied to Medline, PubMed and Google Scholar databases. All relevant articles were included. Critical appraisal of clinical studies was performed using a validated quality assessment scale.Background
Methods
Distal radius fractures are common injuries but no clear consensus regarding optimal management of unstable fractures exists. Open reduction and internal fixation with volar plates is an increasingly popular but the associated complication rate can be 10%. Intramedullary nails are an alternative offering the potential advantages of reduced risk of tendon injury and intra-articular screw penetration. This article systematically reviews the published literature evaluating the biomechanics, outcomes and complications of intramedullary nails in the management of distal radius fractures. A systematic review of Medline and EMBASE databases was performed for studies reporting the biomechanics, functional outcome or complications following intramedullary nailing of distal radius fractures. Critical appraisal was performed with respect to validated quality assessment scales.Background
Methods
Applying the concept of a regional trauma network to the UK paediatric trauma population has unique difficulties in terms of low patient volume and variation in paediatric service provision. In addition, no consensus exists as to which radiological investigations should be employed and an increasing trend towards computerised tomography raises concerns over radiation exposure. We carried out a retrospective review of all paediatric trauma calls from April 2010 and March 2013 around becoming a Major Trauma Centre. We aim to analyse the impact this has on trauma calls and assess the radiological investigations currently used in this population. The number of yearly paediatric trauma calls doubled during our study and totalled 132. The commonest mechanisms of injury were road traffic collisions, fall from a height or fall off a horse. 91.7% of children had some form of radiological investigation; 67% plain radiograph, 37.1% trauma CT, 21.2% focused CT and 5.3% abdominal ultrasound scan. Of the 77 CT scans performed 57.1% were reported as normal and 54.5% of these patients were discharged home the same day. Five children re-attended the emergency department within 30 days with two positive findings; a subdural haematoma and a tibial plateau fracture. The current use of harmful radiological investigations in paediatric trauma patients is not uniform. We propose implementation of radiology protocols and clinical guidance to imaging in paediatric trauma to limited radiation exposure.
Informed consent is vital for good patient-surgeon communication. It allows the patient to be given an unbiased and accurate view of the procedure as well giving an opportunity for patients to gain trust in their surgical team. The consent form is written evidence of this discussion and a poor consent form implies a sub-standard consenting process. The General Medical Council (GMC) have issued guidelines for consent in surgical procedures. These state that all common risks and rare but serious risks should be disclosed as well as all information being given in clear simple and consistent language. Currently, the consent form for a hip fracture operation is hand written. Our hypothesis was that the quality of consenting is variable and that many important complications may not be identified. The British Orthopaedic Association (BOA) blue book, ‘The care of patients with fragility fractures,’ has given guidance of common and serious complications associated with operative management of hip fractures. In addition to these procedure specific complications, we have identified general complications from standardised joint arthroplasty consent forms in our trust, such as deep vein thrombosis. Our standards based on GMC guidance are that the consent form should be legible, free from jargon, without abbreviations and should include the specific and general complications. We retrospectively identified and analysed 30 consecutive consent forms of patients that underwent operative management for hip fractures between March and April 2011. Of all consent forms, 59% were completely or partly illegible, 77% had used abbreviations and medical jargon. Inclusion of general complications on the consent form varied; infection 100%, bleeding 100%, deep vein thrombosis 82%, MI 18%, pneumonia 12%, death 12% and haematoma 0%. Specific operative complications were poorly included, with no patients undergoing hemiarthroplasty being advised of the risk of prosthetic loosening, acetabular wear or periprosthetic fractures. For consent of patients undergoing fracture fixation, 67% had been informed of re-operation and 40% had been told of non-union. This data shows that consent forms are generally poorly written and subject to great variation in complications for the same surgical procedure. This data is likely to apply to some extent to all hospitals that use blank consent forms. This has implications for patient care and safety, as well as medicolegal implications for medical professionals. In our hospital, consent forms have been standardised for joint arthroplasty, with all complication pre-printed with plain English explanations below. Our proposal is that all common operations should have pre-printed consent forms. This would standardise consenting and provide a much improved documentary evidence of the consenting process. This data has a number of lessons that can be applied to other hospitals. Firstly, we suggest that other hospitals consider standardised consent forms. Secondly, individual trainees should be clear that consent forms remain the documentary evidence of the consenting process, long after you forget the verbal details and you should ensure that you include all complications, write clearly and without jargon or abbreviations.
