The recruitment drive, investment and collaboration within Betsi Cadwaladr University Health Board (BCUHB) sites providing specialist lower limb arthroplasty and trauma service has evolved over last few years with aims to improve patient care and reduce reliance on tertiary referral centres. Through our service-evaluation project, we reviewed the results of treatment provided for periprosthetic femur fractures (PPFFs) presenting to BCUHB sites over last 4 years.

We retrospectively reviewed consecutive PPFFs admitted at three BCUHB sites from January’20 to June’23 with mean follow-up of 20.8 ± 13.2 (8–49) months [n=161; Mean age: 82.2 ± 8.5 (59–101) years, Females:107]. Over the review period we noted a 23% increase in service demand for care of PPFFs. Majority were managed surgically [132/161] [38 revision arthroplasties; 94 ORIFs] at BCUHB sites and two patients were referred to tertiary centre. Average time to surgery was 3.5 days. 90% of the PPFFs were managed successfully with 10% (16/159) having orthopaedic complications needing further intervention. 6.3 (10/159) had medical complications and did not need orthopaedic re-intervention. In our series, 12-month re-operation rate was 6.1% (8/132) and 1-month, 3-month and 1-year mortality rate was 6.3%, 11.3% and 21.4% respectively. These results are comparable to the published results of PPFF management at tertiary centres. Potential cost savings compared to transfer to tertiary centre for PPFF management was £2.31 million. Thus, it is possible to successfully provide adequate care for PPFFs at DGHs and efforts should be made to appropriately equip and adequately staff DGHs, to provide service for local PPFF care.

Periprosthetic joint infections (PJIs) and osteosynthesis-associated infections (OSIs) present significant challenges in trauma and orthopaedic surgery, substantially impacting patient morbidity, mortality, and economic burden. This concern is heightened in patients with pre-existing comorbidities, such as diabetes mellitus, which are not always modifiable at presentation. A novel intraoperative strategy to prevent these infections is the use of Defensive Antibacterial Coating (DAC), a bio-absorbable antibiotic-containing hydrogel applied to implant surfaces at implantation, acting as a physical barrier to prevent infection.

The purpose of this study is to assess the use of a commercially available hydrogel (DAC), highlighting its characteristics that make it suitable for managing PJIs and OSIs in orthopaedics and traumatology. Twenty-five patients who underwent complex orthopaedic procedures with intraoperative application of DAC between March 2022 and April 2023 at a single hospital site were included. Post-operative assessment encompassed clinical, laboratory, and radiographic examinations.

In this study, 25 patients were included, with a mean age of 70 ± 14.77 years and an average ASA grade of 2.46 ± 0.78. The cohort presented an average Charleston Comorbidity score of 5.45 ± 2.24. The procedures included 8 periprosthetic fractures, 8 foot and ankle surgeries, 5 upper limb surgeries, and 4 elective hip and knee surgeries. Follow-up assessments at 6 weeks and 6 months revealed no evidence of PJI or OSI in any patients, nor were any treatments for PJI or OSI required during the interim period.

DAC demonstrated efficacy in preventing infections in high-risk patients undergoing complex orthopaedic procedures. Our findings warrant further investigation into the use of DAC in complex hosts with randomized control trials.

Aims

Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for the purpose of guiding clinicians’ management of PFI. There are also concerns about the validity of the Dejour Classification (DJC), which is the most widely used classification for TD, having only a fair reliability score. The Oswestry-Bristol Classification (OBC) is a recently proposed system of classification of TD, and the authors report a fair-to-good interobserver agreement and good-to-excellent intraobserver agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications.

Classifying trochlear dysplasia (TD) is useful to determine the treatment options for patients suffering from patellofemoral instability (PFI). There is no consensus on which classification system is more reliable and reproducible for this purpose to guide clinicians in order to treat PFI. There are also concerns about validity of the Dejour classification (DJC), which is the most widely used classification for TD, having only a fair reliability score.

The Oswestry-Bristol classification (OBC) is a recently proposed system of classification of TD and the authors report a fair-to-good interobserver agreement and good-to-excellent intra-observer agreement in the assessment of TD. The aim of this study was to compare the reliability and reproducibility of these two classifications.

6 assessors (4 consultants and 2 registrars) independently evaluated 100 magnetic resonance axial images of the patella-femoral joint for TD and classified them according to OBC and DJC. These assessments were again repeated by all raters after 4 weeks. The inter and intra-observer reliability scores were calculated using Cohen's kappa and Cronbach's alpha.

Both classifications showed good to excellent interobserver reliability with high alpha scores. The OBC classification showed a substantial intra-observer agreement (mean kappa 0.628)[p<0.005] whereas the DJC showed a moderate agreement (mean kappa 0.572) [p<0.005]. There was no significant difference in the kappa values when comparing the assessments by consultants to those by registrars, in either classification systems.

This large study from a non-founding institute shows both classification systems to be reliable for classifying TD based on magnetic resonance axial images of the patella-femoral joint, with the simple to use OBC having a higher intra-observer reliability score compared to the DJC.

Background

Positioning of the acetabular component in total hip arthroplasty has profound effects on the biomechanics, stability and wear of the prosthesis. Normal anatomical position in females is 57 degrees (50 – 67 degrees) inclination with 19 degrees (9 – 32 degrees) of anteversion, whilst in males 56 degrees of inclination (48 – 66 degrees) with 19 degrees (9 – 32 degrees) is normal. In total hip arthroplasty, inclination recommendation ranges from 30 – 50 degrees. The aim of this study was to radiographically measure acetabular component position in total hip arthroplasty and compare to normal values.

Introduction

The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol.

Infection after knee arthroplasty is a devastating complication. Our aim is to present our outcomes of treating infected knee replacements at a tertiary referral centre.

We performed a consecutive, retrospective case series of all revision knee arthroplasty for infection between January 2006 and December 2008. Case notes were reviewed and data collated on the date and institution of primary arthroplasty, procedures undertaken at our institution, microbiology and bone loss post first stage, serological markers (C-reactive protein, ESR) prior to second stage and outcome.

During this three year period we performed 430 knee revision operations. 51 were in the presence of deep chronic infection. 90% were referred from other hospitals. Overall infection was successfully eradicated in 69%.

Nineteen patients underwent repeat two-stage and overall eleven (58%) patients had successful eradication of infection with multiple two-stages. Of these 47% had F3/T3, the highest grading of Anderson Orthopaedic Research Institute bone loss indicating no metaphyseal bone. A further 12% had bicondylar deficiency on the tibia and no femoral metaphyseal bone (F3/T2b).

Multidrug resistance present in 69% and 47% were infected with multiple organisms. All members of the unsuccessful outcome group had at least one multidrug resistant organism compared to 43% in the successful cohort (P=0.0002). Multiple organisms are associated with an unsuccessful outcome (P=0.056).

Serological markers were not significantly different between the successful and unsuccessful outcome groups.

Where the referring hospital had attempted revision and failed, the chance of eradicating infection dropped from 75% to 58% and the rate of above knee amputation was twelve times higher (3% vs. 36%).

Custom constrained, rotating hinge prostheses enable aggressive soft tissue debridement including ligaments. Successful two-stage requires a multidisciplinary approach including tissue viability nurses, microbiologists and plastic surgeons. Where units lack revision expertise this series suggests early referral increases the chance of limb salvage.

Purpose

Late stage medial unicompartmental osteoarthritic disease of the knee can be treated by either Total Knee Replacement (TKR) or Unicompartmental Replacement (UKR). As a precursor to the TOPKAT study this work tested the postulate that individual surgeons show high variation in the choice of treatment for individual patients.

Aims

To evaluate the results of Elastic Stable Intramedullary Nailing (ESIN) for displaced, unstable paediatric forearm diaphyseal fractures.

Introduction: A Rose calcaneal osteotomy and Cobb procedure for treatment of acquired pes planus is gaining in popularity as a result of the advantages of anatomical reconstruction and reduced graft site morbidity. Although, its ability to provide long term dynamic function and effect on patient’s symptoms remains to be seen.

Materials and Methods: Twenty-two patients with stage two and three Posterior tibialis tendon dysfunction underwent surgical reconstruction with a Cobb procedure and Rose calcaneal osteotomy between 2003 and 2008. The average age was 59 years (range: 20–80 years). There were 18 females and four males.

Results: We evaluated the dynamic function of the Tibialis posterior muscle tendon function by ultra-sonograms postoperatively at mean follow-up time of 36 months. Eighty three per cent of patients achieved a single heel raise. Seventy-three percent of the patients showed an intact and mobile tibialis posterior tendon on supination and pronation movements. There was no difference in the satisfaction of patients with a tenodesis or non tenodesis.

Conclusion: Our results suggest that Cobb procedure does provide dynamic Tibialis posterior function in majority of patients.

The surgical correction of hammertoe deformity of the lesser toes is one of the most commonly performed forefoot procedures. In general, percutaneous Kirschner wires are used to provide fixation to the resected proximal interphalangeal joint. Although these wires are effective, issues such as pin tract infection as well as difficult postoperative management by patients make alternative fixation methods desirable.

The biomechanical studies suggested that the bioabsorbable implant would be a suitable fixation device for the hammer toe procedure. These wire are made of a copolymer of 82% poly-L-lactic acid and 18% polyglycolic acid.

The aim of our study was to assess the clinical outcome of these two implants. We compared 100 consecutive proximal interphalangeal joint fusions performed with each implant. There was no statistically significant difference in the fusion rate at six months using either implant. However, there was significant statistical difference in cost, rate of infection, implant migration, recurrence of deformity, patient’s return to driving, walking with routine foot wear and satisfaction. There was 11% rate of reactive inflammation in the absorbable wire group but no infection.

The study shows the absorbable wires are safe for fusion of proximal inter phalangeal joints.

We aimed to audit the results of one stop fragility fracture risk assessment service at fracture clinic for non-hip fractures in 50–75 years old patients at Newcastle General Hospital. Currently, fewer than 30% of patients with fragility fractures benefit from secondary prevention in the form of comprehensive risk assessment and bone protection because of multifactorial reasons. We have a fragility fracture risk assessment service staffed by an Osteoporosis Specialist Nurse equipped with a DEXA scanner located at the fracture clinic itself.

We carried out a retrospective audit of 349 patients of 50–75 years with suspected non-hip fractures referred from A& E Department from October 2006 to September 2007. Patients over 75 years were excluded because as per NICE guidelines, they should receive bone protection without need of a DEXA scan.

Out of these 349 patients with suspected fractures, 171 had fragility fractures. Median age was 64 years. 69 patients had humerus fracture, 65 had forearm fracture and 23 patients had ankle fracture and 14 had metatarsal fractures. Fracture risk assessment was carried out in 120 (70%) patients. Thirty Seven (31%) patients had osteoporosis and bone protection was recommended to GP. 38 (32%) had osteopenia and lifestyle advice was provided. 45 (37%) had normal axial bone densitometry. 90% patients had DEXA scan at the same time of fracture clinic appointment. Patients with male gender, undisplaced fracture and fewer fracture clinic appointments were more likely to miss fracture risk assessment.

Our experience suggests that locating fragility fracture risk assessment service co-ordinated by an Osteoporosis Specialist Nurse at fracture clinic is an efficient way of providing secondary prevention for patients with fragility fractures. This can improve team communication, eliminate delay and improve patient compliance because of ‘One Stop Shop’ service at the time of fracture clinic appointment.

Introduction: Large numbers of studies have been conducted to help the decision making of appropriate management of an ankle fracture.

Aim: To assess intra-observer and inter-observer agreement of treatment for ankle fracture based on plain radiographs.

Materials and Methods: Fifty patients with ankle fracture were randomly selected. Antero-posterior and lateral view ankle radiographs were blinded by the first author and then reviewed by five orthopaedic surgeons with varying clinical experience. The observers were asked for their opinion about how they would like to treat the fracture? They were provided with additional basic information of patient age, sex, mechanism of injury and associated comorbidities. This exercise was repeated again after four weeks. The kappa coefficient and observed agreement values were used for statistical analysis.

Results: The kappa values on both occasions were 0.41(SE: 0.084, 95% Confidence interval: 0.248–0.576, P< 0.00001) and 0.29(SE: 0.099, 95% confidence interval: 0.098 TO 0.487, P< 0.00001). These results show only fair inter-observer agreement.

The kappa values for intra-observer agreement were from 0.34 to 0.69 (P< 0.001) for different observers. The observed agreement for these observers was from 70% to 94%. Only two most senior observers had good agreement.

Conclusion: These results show that there is only fair inter-observer agreement of the treatment for ankle fracture based on plain radiographs and only senior clinicians were consistent about their preferred mode of treatment on both occasions. There is a need of clear guidelines and better understanding of biomechanics of Ankle Fractures to minimize the ‘grey’ zone of when to intervene.

Background: The exact incidence of cancer (primary/metastatic) leading to pathological fracture in femoral neck is not clear. Bone specimen is often sent for histology in suspicious cases. This retrospective study was aimed to answer the above question and to review our hospital practice in managing these patients.

Materials & Methods: All patients with fracture neck of femur undergoing surgery and had bone specimen taken for histo-pathological examination between 01.01.2002 and 31.12.2003 were included. Case notes and histology reports were reviewed.

Results: Out of total 533 patients with femoral neck fracture, 32 (6%) patients had bone specimen taken for histology. 9 male & 23 female patients with mean age of 82 years. 58% had past history of cancer (commonest being breast) with/without suspicious lesion on x-rays where as the remaining had no history of cancer but suspicious lesion on x-rays. 4 (12.5%) had positive histology results. All four had metastatic disease (2 from breast, 1 from renal and 1from multiple myeloma). Only 19% had results documented in case notes but 81% had reports filed in notes. Appropriate referral was made to oncology team for three patients. The fourth patient with multiple myeloma died in hospital before the referral. Four of 28 (14%) patients with negative results died within 3 years following the surgery compared to only 1 (multiple myeloma) out of 4 patients with positive results.

Conclusion: The incidence of suspicious pathological femoral neck fracture was 6% but incidence of cancer was 0.7%. All positive cases were metastatic. Commonest primary was from breast – adenocarcinoma). Mortality in negative cases was 16% at average of 3 years compared to 25% in metastatic fracture patients.

Introduction: It was noted that INR levels transiently increased before dropping after stopping warfarin pre-operatively in warfarinised patients with femoral neck fractures. Surgery was more likely to be delayed in these patients. The aim of this retrospective study was to determine the trend of INR level after stopping warfarin and to determine the morbidity and mortality in these patients.

Material and Methods: All patients with femoral neck fracture who were on warfarin between 01.01.2002 and 31.12.2003 were included. Case notes and haematology reports were reviewed.

Results: 22 (4.2%) out of 533 patients with femoral neck fractures were found to be on warfarin on admission. 21 case notes were obtained. 7 male and 14 females with mean age of 81 years. In 11 (52%) cases, INR level increased before coming down after stopping warfarin. 60% of them had morphine as analgesic compared to 40% in the other group. Average rise in INR was 0.4. Average delay in surgery due to high INR was 3.5 (range 1–8) days. It took average of 4 days to achieve desirable INR after restarting warfarin. 6 (28%) needed blood transfusion. Nine (43%) patients developed complications including: intra-operative bleeding-1, postoperative DVT-1, fast AF-2, post-operative anaemia-1, other medical-3. One patient (5%) died from large CVA 12 days after surgery. No further mortality was found within 30 days of surgery.

Conclusion: Incidence of femoral neck fractures on warfarin was 4.2%. In over half of the cases, the INR level went up before going down after stopping warfarin. Morphine may be responsible for this trend. Delay in surgery does not seem to increase mortality or morbidity compared to published studies.

The correct positioning of implant components in total knee replacement (TKR) is important for a successful long-term outcome. In order to address the problems inherent with conventional alignment methods, several computer-assisted navigation systems (CAS) have been developed. Despite numerous reports of clinical outcomes and system reliability, there is a lack of studies independently evaluating the precision and accuracy of such systems. We report on the design and development of a method and device to evaluate the accuracy of such a computer-assisted navigation system in two situations; 1) Normal or near-normal lower limb mechanical axis, and 2)Simulated femoral and/or tibial extra-articular deformity in either varus/valgus (x), internal/external rotation (y) or flexion/extension (z) planes.

The system assessed was the Ci Knee-CAS navigation system (BrainLab/De Puy). This image-free system requires the registration of specific anatomical points to identify the mechanical axis of the lower limb and therefore provide information on resection level and alignment. In order to precisely measure and accurately reproduce these points we constructed a phantom device along anatomical guidelines, with lockable joints located at the mid-shaft of both femur and tibia. We then identified geometric CAS data; 1) Tibial resection height, and 2) Tibial resection plane, and using specially written software compared this against validated co-ordinate measurements independently obtained by a FaroArm co-ordinate measurement system (FARO Technologies, USA). This enabled data from the navigation system to be directly compared against highly accurate reference measurements.

Accuracy of the system was then assessed with both normal mechanical alignment of the lower limbs and simulated extra-articular deformity.

To determine the effect of experience of the operator and the effect of type of anaesthesia used on re-manipulation rates of fracture distal radius manipulated in A& E, a retrospective review of distal radius fractures manipulated in A& E between January 2000 and January 2001. Operators were divided into two categories: junior (SHO grade) and senior (higher grade) doctor.

54 patients with fracture distal radius had manipulation in A& E. 15 male and 39 female patients with mean age of 61 years (52 for males and 63 for females) were included.

42 (78%) fractures were manipulated under haematoma block (18 by junior, 23 by senior doctor) and 12 (22%) fractures were manipulated under Bier block (1 by junior, 11 by senior doctor). Operator’s grade was not clearly mentioned in one case. 13 out of 54 patients (24%) needed fracture re-manipulation under general anaesthesia. 12 out of 42 fractures manipulated under haematoma block (30%) needed re-manipulation compared to only one out of 12 fractures (8%) manipulated under Bier block (p=0.25). 9 out of 19 fractures manipulated by junior doctors needed re-manipulation compared to only 4 out of 34 fractures manipulated by senior doctors (p=0.007). Haematoma block was used for 18 out of 19 cases by junior doctors and for 23 out of 34 cases by senior doctors (p=0.038). Average number of fracture clinic follow-ups was 4 (range 2 to 8).

Junior doctors had significantly higher preference for haematoma block and significantly higher re-manipulation rate. Re-manipulation rates were higher with fractures manipulated under haematoma block compared to Bier block.

Adequate training and supervision should be provided for SHOs while performing such procedures in A& E. Use of Bier block as a regional anaesthesia for manipulation of distal radius fractures in A& E should be encouraged.

The Phantom based Computer assisted orthopaedic surgical system (CAOSS) has been developed collaboratively by the University of Hull and the Hull Royal Infirmary, to assist in operations like dynamic hip screw fixation. Here we present summary of our system.

CAOSS comprises a personal computer based computer system, a frame grabber with video feed from a C-arm image intensifier, an optical tracking system and a radiolucent registration phantom which consists of an H arrangement of 21 metal balls. The phantom is held in position by the optically tracked end-effector. Knowing the optical position of the phantom, a registration algorithm calculates the position of C-arm in coordinate space of the optical tracking system.

Computer based planning uses an anteroposterior (AP) and lateral image of the fracture. Marks are placed on the 2D projections of femoral shaft, neck and head on the computer screen, which are then used to create 3D surgical plan. The computer then plans a trajectory for the guide wire of DHS. The depth of the drill hole is also calculated. The trajectory is then shown on both AP and lateral images on the screen.

CAOSS meets all the requisite of electrical and electromagnetic radiation standards for medical equipment. There has been extensive validation using software simulation, performance evaluation of system components, extensive laboratory trials on plastic bones. The positional accuracy was shown to be within 0.7mm and angular accuracy to be within 0.2°. The system was also validated using Coordinate Measurement Machine.

Our system has the unique feature of the registration phantom which provides accurate registration of the fluoroscopic image.

Introduction and Aims Back pain patients usually demand more time in clinic. A significant proportion of this time is spent in performing clinical examination. It has been recognised that detailed history of symptoms is the backbone in reaching the diagnosis and deciding the management plan for patients with lower back pain and/or radiculopathy. The aim of the study was to look at 1) Contributions from History and Examination. 2) Does Clinical Examination add any further information not identified from history?

Method A prospective, blinded study was carried out to determine the usefulness of history and clinical examination, individually to reach the diagnosis and plan the management. 75 consecutive lower back pain and/or radiculopathy patients were included in the study. Two orthopaedic registrars saw all the patients. One took detailed history and the other registrar performed clinical examination. Both registrars based on their information arrived at a provisional diagnosis. A consultant also took history and examined these patients. MRI scan was done as per clinical indication.

Results The data was analysed using standard statistics software. In all patients history suggested the possible diagnosis. Clinical examination did not add any further information to alter the course of management, which was planned for the patient. Clinical examination did not show any further information that was not identified in the MRI scan.

Conclusion Clinical examination does not add to the body of information available from history. Clinical examination does not add any further information not available on the scan. Clinical examination should be performed for patients considered for surgery to document the findings; here both subjective and objective assessment should be performed. Examination is not a useful screening tool.

Introduction and Aims: Lower back and/or leg pain is a symptom of a number of pathological conditions involving lumbosacral nerve roots. Disc herniation is one of the most common causes of LBP (after mechanical back pain). There is controversy regarding the progression of disc degeneration and/or lower back pain to symptomatic disc prolapse over time.

Method: The aim of the study was to determine the natural progression of patients with lower back pain/disc degeneration established clinically and on MRI to symptomatic disc herniation over three to six years. Total of 970 patients who had an MRI scan between January 1998 and September 2000 were included in the study. Information about disc pathology, level and number of discs involved were recorded from MRI scan reports. A short questionnaire was sent to all patients. It contained 10 questions regarding current status of pain and neurology, any treatment in form of back injection and operation, current occupation and smoking status.

Results: The collected data was analysed using standard statistics software (SPSS). The results will be discussed.

Conclusion: The information provided by this study will be useful in judging the natural progression of lower back pain and/or disc degeneration to a symptomatic prolapse intervertebral disc. It will also be useful in medico-legal cases where patients had pre-existing disc degeneration and subsequently developed disc herniation over time.