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Bone & Joint 360
Vol. 4, Issue 4 | Pages 2 - 7
1 Aug 2015
Nicol S Jackson M Monsell F

This review explores recent advances in fixator design and used in contemporary orthopaedic practice including the management of bone loss, complex deformity and severe isolated limb injury.


Bone & Joint 360
Vol. 4, Issue 4 | Pages 8 - 11
1 Aug 2015
McBride A Nicol S Monsell F


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_8 | Pages 15 - 15
1 Jun 2015
Poole W Guthrie H Wilson D Freeman R Bellringer S Guryel E Nicol S
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Distal femoral fracture fixation has historically been associated with high rates of reoperation because of mal-union, non-union and implant failure. We hypothesised that recent advances in distal femoral locking plate design and material along with an improved understanding of biomechanical principles would improve outcome. In a 5-year retrospective study utilising electronic patient records and serial radiographs (including recall by letter where there was no radiological evidence of union) we identified a series of 129 distal femoral fractures treated with modern locking plates in 123 patients. The majority were female (80%), elderly (mean 73 years) and infirm (72/123 ASA 3 or more). A consultant performed the operation in 67% of cases. 49% were followed to radiological union, while 25% died within the follow up period. Reoperation rate for implant failure was 4%, with all failures occurring early (within 5 months). Our follow up correlates with the infirm elderly population concerned. Our cohort shares many similarities with hip fracture patients and we propose that this group should receive equal surgical priority and optimum management also be rewarded by enhanced tariffs. Modern locking plates used in combination with the correct biomechanical principles are performing well in our centre.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_2 | Pages 7 - 7
1 Jan 2013
Khan I Nicol S Jackson M Monsell F Livingstone J Atkins R
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Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the majority of deformities, however distal femoral deformity is difficult to assess because of the difference between anatomic and mechanical axes. We found the described technique involving constructing a line perpendicular to a line from the tip of the greater trochanter to the centre of the femoral head inaccurate, particularly if the trochanter is abnormal. We devised a novel technique which accurately determines the CORA and extent of distal femoral deformity, allowing accurate correction.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylized as a block. A line bisecting the axis of the proximal femur is then extended distally to intersect the joint. The angle (θ) between the joint and the proximal femoral axis and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of the deformity, permitting accurate correction.

We examined the utility and reproducibility of the new method using 100 normal femora. θ = 81 ± sd 2.5°. As expected, θ correlated with femoral length (r=0.74). P (expressed as the percentage of the distance from the lateral edge of the joint block to the intersection) = 61% ± sd 8%. P was not correlated with θ.

Intra-and inter-observer errors for these measurements are within acceptable limits and observations of 30-paired normal femora demonstrate similar values for θ and p on the two sides.

We have found this technique to be universally applicable and reliable in a variety of distal femoral deformities.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 481 - 481
1 Sep 2012
Smith H Manjaly J Yousri T Upadhyay N Nicol S Taylor H Livingstone J
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Informed consent is vital to good surgical practice. Pain, sedative medication and psychological distress resulting from trauma are likely to adversely affect a patient's ability to understand and retain information thus impairing the quality of the consent process. This study aims to assess whether provision of written information improves trauma patient's recall of the risks associated with their surgery.

121 consecutive trauma patients were randomised to receive structured verbal information or structured verbal information with the addition of supplementary written information at the time of obtaining consent for their surgery. Patients were followed up post-operatively (mean 3.2 days) with a questionnaire to assess recall of risks discussed during the consent interview and satisfaction with the consent process.

Recall of risks discussed in the consent interview was found to be significantly improved in the group receiving written and verbal information compared to verbal information alone (mean questionnaire score 41% vs. 64%), p=0.0014 using the Mann-Whitney U test. Patient satisfaction with the consent process was significantly improved in the group receiving written and verbal information, 97.9% of patients reported that they understood the risks of surgery when they signed the consent form compared to 83.2% who received verbal information alone (p=0.01). The majority of patients who received written information reported finding it helpful (93.8%) and most of the patients who did not receive written information reported they would have found it useful had it been offered (66%).

Patients awaiting surgery following trauma can pose a challenge to adequately inform about benefits conferred, the likely post operative course and potential risks. Written information is a simple and cost-effective means to improve the consent process and was popular with patients.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XVIII | Pages 66 - 66
1 May 2012
Khan IH Nicol S Jackson M Monsell F Livingstone JA Atkins RM
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Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the majority of deformities, however distal femoral deformity is difficult to assess because of the difference between anatomic and mechanical axes. We found the described technique involving constructing a line perpendicular to a line from the tip of the greater trochanter to the centre of the femoral head inaccurate, particularly if the trochanter is abnormal. We devised a novel technique which accurately determines the CORA and extent of distal femoral deformity, allowing accurate correction.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylized as a block. A line bisecting the axis of the proximal femur is then extended distally to intersect the joint. The angle (Θ) between the joint and the proximal femoral axis and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of the deformity, permitting accurate correction.

We examined the utility and reproducibility of the new method using 100 normal femora. Θ = 81 ± sd 2.5. As expected, Θ correlated with femoral length (r=0.74). P (expressed as the percentage of the distance from the lateral edge of the joint block to the intersection) = 61% ± sd 8%. P was not correlated with Θ.

Intra-and inter-observer errors for these measurements are within acceptable limits and observations of 30-paired normal femora demonstrate similar values for Θ and p on the two sides.

We have found this technique to be universally applicable and reliable in a variety of distal femoral deformities.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XII | Pages 15 - 15
1 Apr 2012
Khan I Nicol S Jackson M Monsell F Livingstone J Atkins R
Full Access

Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the deformities. However, distal femoral deformity is difficult to assess because of the difference between anatomic and mechanical axes. We describe a novel technique which accurately determines the CORA and extent of distal femoral deformity.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylised as a block. A line bisecting the anatomical axis of the proximal femur is then extended distally to intersect the joint. The angle (?) between the joint and the proximal femoral axis, and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of deformity, permitting accurate correction.

We examined the utility and reproducibility of the new method using 100 normal femora. We found this technique to be universally robust in a variety of distal femoral deformities.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_III | Pages 388 - 388
1 Jul 2011
Khan IH Nicol S Jackson M Monsell F Livingstone JA Atkins RM
Full Access

Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and limb dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the majority of deformities, however distal femoral deformity is difficult to assess because of the difference between the anatomic and mechanical axes. We have found the described technique involving constructing a line perpendicular to a line from the tip of the greater trochanter to the centre of the femoral head inaccurate, particularly if the trochanter is abnormal. We have devised a novel technique which accurately determines the CORA and extent of distal femoral deformity, allowing accurate correction.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylised as a block. A line bisecting the axis of the proximal femur is then extended distally to intersect the joint. The angle (𝛉) between the joint and the proximal femoral axis and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of the deformity, permitting accurate correction.

We have examined the utility and reproducibility of the new method using one hundred normal femurs. Θ=81+/− sd 2.5°. As expected, 𝛉 correlated with femoral length (r=0.74). P (expressed as the percentage of the distal from the medial edge of the joint block to the intersection) = 61% +/− sd 8%. P was not correlated with 𝛉.

Intra-and inter-observer errors for these measurements are within acceptable limits and observations of twenty paired normal femora demonstrate similar values for 𝛉 and p on the two sides.

We have employed this technique in a variety of distal femoral deformities, including vitamin D resistant rickets, growth arrest, fibula hemimelia, post-traumatic deformity and Ellis-van Creveld syndrome. We find the system universally applicable and reliable.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 494 - 494
1 Aug 2008
McGowan J Nicol S Kumar CS
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Purpose: The purpose of the study was to compare the maximum compression force of three different 6.5 mm cancellous screws commonly used in hindfoot fusions.

Materials and methods: Screw 1 was a solid core standard fragment partially threaded cancellous screw (Smith and Nephew).

Screw 2 was a titanium cannulated screw with a medium thread pitch (Asnis III, Stryker).

Screw 3 was also a titanium cannulated screw with a large core diameter but with a small thread pitch (Ace, DePuy).

Four different densities of polyurethane foams were used simulating cancellous bone and the compression

Results: Screw 3 had the highest compression force in tests with the low density foams (p< 0.05) and screw 1 performed better in higher density foams (p< 0.05). In medium density foams, both screws 1 and 3 showed significantly more compression than screw 2 (p< 0.05).

Clinical relevance: The results indicate that the 6.5 mm standard fragment non-cannulated cancellous screw may provide more compression in a normal density bone whereas in an osteoporotic bone a cannulated titanium screw may be preferred for producing better compression during arthrodesis.


Orthopaedic Proceedings
Vol. 88-B, Issue SUPP_II | Pages 251 - 251
1 May 2006
Nicol S Howard M Newman J
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Introduction: Progressive symptomatic tibiofemoral arthritis following PFJR is an important cause of failure. This study is designed to quantify radiologically the degree of tibiofemoral disease progression in patients who have undergone PFJR in our institution.

Patients and Methods: A prospective series of 102 consecutive Avon PFJRs in 78 patients with a minimum follow-up of five years was analysed.

Available AP weight bearing radiographs of the knee taken at 8 months and 5 years postoperatively were examined in a random order twice by each of two surgeons who were blinded to the patient details and length of follow up. The severity of arthritis was graded using the classifications of Ahlback and Altman, giving a measure of arthritis progression.

Results and Discussion: Arthritis was seen to progress in 8.5–17% of medial and 11–17% of lateral compartments after PFJR. Statistically significant progression was demonstrated using the Altman but not the less sensitive Ahlback scoring system, suggesting that the former should be used in scoring the tibiofemoral joint prior to PFJR. Of those patients who had a preoperative tibiofemoral Altman score of zero, 87% showed no radiological evidence of disease progression at minimum 5 year follow up, suggesting that these are the ideal candidates for PFJR.