Extracapsular Hip Fractures (EHF's) are a significant health burden on healthcare services. Optimal treatment is controversial with conflicting evidence being reported. Currently treatment is undertaken with Intramedullary Nail (IMN) or Dynamic Hip Screw (DHS) constructs with a recent increase in IMN use (1). This study aims to conduct a systematic review of Randomised Control Trials published between 2020 and 2023 with particular focus on patient demographics and holistic patient outcomes.

Using a unified search-protocol, RCT's published between 2020 and 2023 were collected from CENTRAL, PubMed, MEDLINE and EMBASE. Rayyan software screened duplicates. Using the CASP and Cochrane Risk of Bias Tool papers were critically examined twice, and Blood Loss, Infection and Mobility described the patient journey. Patient demographics were recorded and were contrasted with geographically diverse cohort studies to compare population differences. Parametric tests were used to determine significance levels between population demographics, namely Age and Sex.

Eleven papers were included, representing 908 patients (436 Male). The mean age for patients was 64.39. There was considerable risk of bias in 7/11 studies owing to the randomization process and the recording of data. Four Cohort studies were selected for comparison representing 14314 patients. Mean age was significantly different between Cohort Studies and RCT's (Independent T-Test, df 13, t=7.8, p = <0.001, mean difference = 19.251, 95% CI = 13.888, 24.613). This was also true for sex ratios included in the studies (df 13, t = -2.268, p = 0.024, Mean Difference = -0.4884, 95% CI = -0.9702, -0.0066).

To conclude, RCT's published in the post COVID-19 era are not representative of patient demographics. This has the potential to provide inaccurate information for implant selection. Additionally further research must be conducted in how to better improve RCT patient inclusion so as to be more representative of patients whilst balancing the risks of operations.

Despite multiple published reviews, the optimum method of correction and stabilisation of Blount's disease remains controversial. The purpose of this study is to evaluate the clinical and radiological outcomes of acute correction of late-onset tibial vara by percutaneous proximal tibial osteotomy with circular external fixation using two simple rings. This technique was developed to minimise cost in a context of limited resources.

This study was conducted between 2016 and 2020. We retrospectively reviewed the clinical notes and radiographs of 30 patients (32tibiae) who had correction of late-onset tibia by proximal tibial osteotomy and Ilizarov external fixator. All cases were followed up to 2 years.

The mean proximal tibial angle was 65.7° (±7.8) preoperatively and 89.8° (±1.7) postoperatively. The mean mechanical axis deviation improved from 56.2 (±8.3) preoperatively to 2.8 (±1.6) mm postoperatively. The mean femoral-tibial shaft angle was changed from – 34.3° (±6.7) preoperatively to 5.7° (±2.8) after correction. Complications included overcorrection (9%) and pin tract infection (25%). At final follow up, all patients had full knee range of motion and normal function. All cases progressed to union and there were no cases of recurrence of deformity.

This simple procedure provides secure fixation allowing early weight bearing and early return to function. It can be used in the context of health care systems with limited resources. It has a relatively low complication rate. Our results suggest that acute correction and simple circular frame fixation is an excellent treatment choice for cases of late-onset tibia vara, especially in severe deformities.

Greater trochanteric pain syndrome is a painful condition characterised by pain around the greater trochanter usually affecting middle-aged women. The majority of patients will improve with conservative management such as physiotherapy and non-steroidal anti-inflammatory drugs (NSAIDs); however, if this fails then more invasive treatments including corticosteroids and surgery may be required. Platelet-rich plasma (PRP) is an autologous blood product, which has a higher concentration of growth factors postulated to provide enhanced healing and anti-inflammatory properties. The Hip Injections PRP Vs Placebo (HIPPO) trial aims to assess the ability of ultrasound-guided PRP injections to improve symptoms and function in patients with GTPS.

64 patients were enrolled and randomised to either the PRP or placebo (normal saline) treatment arm. Two patients decided to drop out of the trial. Clinical outcomes in both groups were evaluated and compared using the International Hip Outcome Tool-12 (iHOT12), Visual Analogue Scale (VAS) of pain, the modified Harris Hip Score (mHHS) and the presence or absence of complications at 3 and six months. The level of significance was set at p<0.05. Both groups received physiotherapy after the injections.

The mean age was 57.5. There were 6 males and 56 females with M:F ratio of 1:9.3. Both groups were similar in terms of demography and preoperative scores. The iHOT12 score improved from 28.23 to 45.42 at three-months and decreased slightly to 42.44 at six-months in the Placebo group. The iHOT12 in the PRP group improved from 35.51 to 44.47 at three-months and decreased to 39.78 at six-months. Both groups showed improved VAS and mHHS at three-months compared to the baseline with no statistically significant difference between the two groups (p >0.05). The scores decreased at six-months however remained above the baseline. No complications were reported. Gender and age had no effect on outcomes.

Both groups similarly improved from baseline. Physiotherapy can be considered as an important factor in patients' treatment. Further research should be conducted to investigate the role of physiotherapy in the treatment of GTPS.

Anesthetic peripheral nerve blocks (PNB) have been shown to be more advantageous than general anesthesia in a variety of surgical operations. In comparison to conventional methods of general anesthesia, the choice of regional localized infiltration has been shown to shorten hospital stays, decrease hospital readmissions, allow early mobilization, and reduce narcotic use. Perioperative complications of PNBs have been reported at varying rates in literature. Thus, the purpose of this study was to provide a review on the clinical evidence of PNB complications associated with foot and ankle surgeries.

A systematic review of the literature was completed using PubMed search terms: “lower extremity”, “foot and ankle”, “nerve block”, and “complications”. All studies reporting minor and major complications were considered along with their acute management, treatments, and postoperative follow up timelines. The range of complications was reported for Sensory Abnormalities, Motor Deficits, Skin and systemic complications (local anesthetic systemic toxicity & intravascular injections). A designation of the scientific quality (Level I-IV) of all papers was assigned then a summary evidence grade was determined.

The search strategy extracted 378 studies of which 38 studies were included after criteria review. Block complications were reported in 20 studies while 18 studies had no complications to report. The quality of evidence reviewed ranged from Level I to Level IV studies with follow up ranging from twenty four hours to one-three year timelines. The range of complications for all studies reporting sensory abnormalities was 0.53 to 45.00%, motor deficits 0.05 to 16.22% and skin and systemic complications 0.05 to 6.67%. Sensory abnormalities that persisted at last follow up occurred in six studies with incidence ranging from 0.23 to 1.57%. Two studies reported motor complications of a foot drop with an incidence of 0.05% and 0.12%. When considering only the highest quality studies (Level 1) that had complications to report, the complications rate was 10.00% to 45.00% for sensory abnormalities, 7.81 to 16.22% for motor deficits, 6.67% for skin complications and 2.50% for systemic complications.

High quality studies (Level I providing Summary Grade A Evidence) reporting all complications with a range of incidence from 0 to 45%. While most of these complications were not serious and permanent, some were significant including sensory abnormalities, foot drop and CRPS. Based on this systematic review of the current literature, the authors emphasize a significant rate of complications with PNB and recommend that patients are appropriately informed prior to consenting to these procedures.

Introduction and Aims

There are many surgical, implant design and patient factors that should be considered in preclinical testing of hip replacement which are not being considered in current standards. The aim of this study was to develop a preclinical testing method that consider surgical positioning, implant design and patient factors and predict the occurrence and severity of edge loading under the combination of such conditions. Then, assess the safety and reliability of the implant by predicting the wear, deformation and damage of the implant bearings under worst case conditions.

Aim

A two-stage surgical strategy (debridement-negative pressure therapy (NPT) and flap coverage) with prolonged antimicrobial therapy is usually proposed in pressure ulcer-related pelvic osteomyelitis but has not been widely evaluated.

Introduction

Variations in component position can lead to dynamic separation and edge loading conditions. In vitro methods have been developed to simulate edge loading conditions and replicate stripe wear, increased wear rate, and bimodal wear debris size distribution, as observed clinically [1, 2]. The aim of this study was to determine the effects of translational and rotational positioning on the occurrence of dynamic separation and severity of edge loading, and then investigate the wear rates under the most severe separation and edge loading conditions on an electromechanical hip joint simulator.

Introduction

Edge loading of hip replacements may result in plastic deformation, creep and wear at the rim of the cup and potentially fatigue failure. Variations in component positioning can lead to dynamic separation and edge loading [1]. The aim of this study was firstly to investigate the effects of translational and rotational positioning on the dynamic separation and severity of edge loading, and secondly to determine the wear rates of metal-on-polyethylene bearings under the more severe separation and edge loading conditions.

Edge loading due to dynamic separation can occur due to variations in component positioning such as a steep cup inclination angle (rotational) or mismatch between the centres of rotation of the head and the cup (translational). The aim of this study was to determine the effect of variations in rotational and translational positioning of the cup on the magnitude of dynamic separation, wear and deformation of metal-on-polyethylene bearings.

Eighteen 36mm diameter metal-on-polyethylene hip replacements were tested on an electromechanical hip simulator. Standard gait with concentric head and cup centres were applied for cups inclined at 45° (n=3) and 65° (n=3) for two million cycles. A further two tests with translational mismatch of 4mm applied between the head and cup bearing centres for cups inclined at 45° (n=6) and 65° (n=6) were run for three million cycles. Wear was determined using a microbalance and deformation by geometric analysis. Confidence intervals of 95% were calculated for mean values, and t-tests and ANOVA were used for statistical analysis (p<0.05).

Under 4mm mismatch conditions, a steeper cup inclination angle of 65° resulted in larger dynamic separation (2.1±0.5mm) compared with cups inclined at 45° (0.9±0.2mm). This resulted in larger penetration at the rim under 65° (0.28±0.04mm) compared to 45° (0.10±0.09mm) cup inclination conditions (p<0.01). Wear rates under standard concentric conditions were 12.8±3.8 mm³/million cycles and 15.4±5.0 mm³/million cycles for cups inclined at 45° and 65° respectively. Higher wear rates were observed under 4mm of translational mismatch compared with standard concentric conditions at 45° (21.5±5.5 mm³/million cycles, p<0.01) and 65° (23.0±5.7 mm³/million cycles, p<0.01) cup inclination.

Edge loading under dynamic separation conditions due to translational mismatch resulted in increased wear and deformation of the polyethylene liner. Minimising the occurrence and severity of edge loading through optimal component positioning may reduce the clinical failure rates of polyethylene.

Edge loading due to dynamic separation can occur due to variations in component positioning such as a steep cup inclination angle (rotational) or mismatch between the centres of rotation of the head and the cup (translational). The aim of this study was to determine the effect of variations in rotational and translational positioning of the cup on the magnitude of dynamic separation, wear and deformation of metal-on-polyethylene bearings.

Eighteen 36mm diameter metal-on-polyethylene hip replacements were tested on an electromechanical hip simulator. Standard gait with concentric head and cup centres were applied for cups inclined at 45° (n=3) and 65° (n=3) for two million cycles. A further two tests with translational mismatch of 4mm applied between the head and cup bearing centres for cups inclined at 45° (n=6) and 65° (n=6) were run for three million cycles. Wear was determined using a microbalance and deformation by geometric analysis. Confidence intervals of 95% were calculated for mean values, and t-tests and ANOVA were used for statistical analysis (p<0.05).

Under 4mm mismatch conditions, a steeper cup inclination angle of 65° resulted in larger dynamic separation (2.1±0.5mm) compared with cups inclined at 45° (0.9±0.2mm). This resulted in larger penetration at the rim under 65° (0.28±0.04mm) compared to 45° (0.10±0.05mm) cup inclination conditions (p<0.01). Wear rates under standard concentric conditions were 12.8±3.8 mm³/million cycles and 15.4±5.0 mm³/million cycles for cups inclined at 45° and 65° respectively. Higher wear rates were observed under 4mm of translational mismatch compared with standard concentric conditions at 45° (21.5±5.5 mm³/million cycles, p<0.01) and 65° (23.0±5.7 mm³/million cycles, p<0.01) cup inclination.

Edge loading under dynamic separation conditions due to translational mismatch resulted in increased wear and deformation of the polyethylene liner. Minimising the occurrence and severity of edge loading through optimal component positioning may reduce the clinical failure rates of polyethylene.

Introduction

Translational surgical mismatch in the centres of rotation of the femoral head and acetabular cup in hip joint replacements can lead to dynamic microseparation resulting in edge loading contact [1]. Increased wear in retrieved ceramic-on-ceramic bearings has been associated with edge loading [2]. Hip joint simulators were used to replicate increased wear rate, stripe wear and bimodal wear debris size distribution, as seen clinically [3,4]. Recently developed electromechanical simulators are able to comply with the latest international standards, which include three axes of rotation conditions [5]. Previous simulators had applied two axes of rotation under microseparation conditions [6]. Therefore, the aim of this study was to compare the wear of ceramic-on-ceramic bearings obtained under edge loading due to microseparation conditions during gait using the same electromechanical hip joint simulator with two axes of rotation and three axes of rotation conditions.

Introduction

We conducted a study of 312 patients undergoing primary hip and knee arthroplasty in 2005. The aim was to identify the correlation between length of stay, ASA (American society of Anaesthesiologist) grade and BMI (Body Mass Index).

Purpose of the study: Fracture dislocations are complex injuries compromising elbow stability and functional potential. The treatment of these injuries should restore the exact anatomy of the joint, the only guarantee for a good functional outcome. The purpose of our work was to analyse our results and review the literature in order to establish an evidence-based therapeutic algorithm essentially based on the type of associated fracture.

Material and methods: This was a retrospective analysis of 15 cases (12 men, 3 women) reviewed at mean 18 months. The causal event was a fall in most patients, followed by traffic and sports accidents. This was a first-intention treatment for 12 patients and a second-intention intervention for three. Initially, none of the patients presented vessel or nerve injury. There were three open fractures. The most common fracture was: radial head (n=12), coronoid process (n=9). One or two approaches were used, depending on the type of associated fracture. Treatment consisted in fixation of the radial head (n=8) and arthroplasty (n=4).. The coronoid process was fixed in six cases. All ligament tears were repaired. An articulated external fixator was used in four cases.

Results: All patients had a stable elbow. Mean flexion was 125, extension -16, pronation 72 and supination 63. Wrist force was 80% compared with the controlateral side. The Mayo Clinic function score was 84 points.

Discussion: Reconstruction of the lateral osteoligament column, associated with fixation of the coronoid, restores stability in the majority of elbows. For very high energy injuries with complex bone and ligament damage, addition of an articulated external fixator is indispensable to enable early mobilization. Stiffness and instability are the most common complications after traumatic injury.

Conclusion: Fracture dislocations of the elbow are complex injuries requiring adequate emergency care, with surgery as needed, for all lesions at the same time via one or two approaches followed by early rehabilitation. The function outcome depends on the intraoperative stability achieved and early mobilization.

Purpose of the study: Few data are available concerning the proper management of patients with a periprosthetic fracture of the hip who presents biological signs of inflammation (increased WBC, sedimentation rate, or C-reactive protein). The purpose of this work was to determine the prevalence of elevated biological markers in this type of patient and to determine the reliability of such markers for the diagnosis of periprosthetic infection.

Material and methods: A periprosthetic hip fracture was diagnosed in 204 patients from 2000 to 2006. The WBC count, the sedimentation rate and the serum CRP level were noted at admission to the emergency ward. The diagnosis of infection was confirmed by at least two positive bacteriological samples of tissue biopsy and/or joint fluid collected at surgery. A statistical analysis was conducted to determine the prevalence of elevated biological markers of inflammation, the sensitivity, their specificity and their positive predictive value for deep infection.

Results: Twenty-one patients (11.6%) developed a periprosthetic infection. Among the 204 patients, the WBC count increased in 16.2%, sedimentation rate in 33.3% and CRP in 50.5%. The sensitivity was 24% (WBC), 50% (sedimentation rate) and 83% (CRP). The specificity was 85% (WBC), 69% (sedimentation rate) and 56% (CRP). The positive predictive value was low (18, 21 and 29% respectively).

Discussion: Markers of inflammation are frequently ordered before surgery to search for infection but can be elevated for various reasons. Most often, these markers are elevated because of the patient’s general status and are thus related to other co-morbid conditions and/or reaction to the new fracture. In this population, the WBC count did not contribute to the diagnosis of infection as only 24% of the infected patients had a high count. CRP and sedimentation rate and the WBC count had low positive predictive values.

Conclusion: This study shows that an isolated elevation of biological markers of inflammation in a patient with a periprosthetic fracture is not a good indicator of infection.

Purpose of the study: To analyse 300 supracondylar fractures with major displacement presenting with acute vascular comprimise and to propose an effective therapeutic strategy in a tertiary referral centre.

Material and Methods: Three hundred patients aged 18 months to 14 years were treated for Larange stage IV supracondylar fracture of the humerus in the same centre. Acute vascular compromise was noted in 46 cases (15%). The radial pulse was absent in all patients with two different contexts: ‘pink hand’ with good distal perfusion in 41 cases (13.5%) and ‘white hand’ with ischemia in five cases (1.5%). Nerve injury was associated in half of the cases, predominantly involving the medial nerve (87%). Emergency management included repeated assessment of the vascular and nervous status using a departmental protocol and Doppler control together with oxygen saturation. Emergency anatomical reduction and stable percutaneous fixation, with lateral and medial wires via a minimal medial exposure to control the ulnar nerve, was performed in all cases. Post-operative immobilisation with a posterior splint at 90° of elbow flexion. Repeated postoperative clinical surveillance: distal perfusion, O2 saturation and Doppler assessment.

Results: 90% of the cases with vascular compromise had posterolateral displacement. Post reduction, the radial pulse was restored immediately in 28 cases and secondarily in 10. The three remaining cases with an absent radial pulse but with a pink hand developed ischemia necessitating surgical exploration revealing incarceration of the brachial artery and medial nerve within the fracture site. Release of the brachial artery restored the radial pulse.

The five cases of primary ischemia with absent pulse and a white hand were managed by emergency reduction followed by exploratory surgery and vascular repair which restored the radial pulse, excepting one case which required anterior fasciotomy.

Conclusion: Early vascular complications after stage IV supracondylar humerus fractures are common in children. This study identified the following points: priority is required for reduction of these fracture and emergency stabilisation; posterolateral displacement is associated with a higher risk of vascular complications; these injuries should be treated in a specialised centre; the absence of a radial pulse with a pink hand warrants repeated observation during the postoperative period; it is not an absolute indication for invasive investigation and surgical exploration; the absence of a pulse with a white hand requires surgical vascular exploration.

We present the functional and radiological results after implantation of thirty four uncemented Buechel Pappas total ankle replacements. The average follow-up period was 5 years. All consecutive uncemented Buechel Pappas total ankle replacements were performed by the senior author (MSA) between 1990 and 2005, at Corbett District General Hospital, Dudley. Thirty four ankle replacements were performed. One patient died before follow-up. All ankle replacements were performed for osteoarthritis. The patients were assessed clinically and radiologically.

Thirty four ankle replacements were performed on thirty three patients. There were eight female and twenty five male patients. One patient had died 2 years after her ankle replacement. The average age of the patients was 69(58–84). All ankle replacements were performed for osteo-arthritis. 59% had post traumatic osteoarthritis.

The average body mass index was 30 (22–37). One hundred percent of patients were happy with their ankle replacement. Fifty nine percent of patients were completely pain-free, or had occasional twinges. All patients were mobile, forty seven percent of patients required no walking aids and only six percent required 2 walking aids. One patient complained of occasional instability. One patient sustained a medial malleolar fracture intra-operatively which was fixed with two partially threaded cancellous screws. The patients were placed in a back-slab post-operatively and were non-weight bearing for a period of 6 weeks. No revision operations were performed to date.

Clinical examination revealed forty two (5–57) degrees of movement in the ankle replacement at follow-up. Radiological examination revealed forty five (0–57) degrees of movement in the ankle joint. Pearson Correlation coefficient was 0.956, p< 0.001. There was excellant correlation between clinical and radiological assessment of range of movement.

Examination of the radiographs demonstrated no evidence of gross subsidence, or lucency. One implant had a poorly positioned talar component, but so far this has been assymptomatic.

The American Foot and Ankle Society Scores were 34.6(20–56) pre-operatively compared with 76(54–100) at follow-up. This was significant improvement p< 0.001. Average scores for pain, function and alignment were 30(20–40),40(29–50) and 9(5–10).

There was one intra-operative fractured medial malleolus and two superficial wound infections (with negative swabs) treated with antibiotics.

We compare our results with others published and feel the Buechel Pappas Uncemented Total Ankle replacement performs well and is a good alternative to ankle arthrodesis preserving ankle movement and biomechanics. The results are comparable to other uncemented total ankle replacements.

We report the case of an 80-year-old woman treated by palliative knee arthrodesis for metastases of the proximal left tibia secondary to bladder carcinoma, using percutaneous femortibial intramedullary arthrodesis nailing.

The technique provided a simple alternative to massive allografting, total joint prosthesis or amputation, with advantages of low morbidity, short operating time, minimal blood loss, immediate ambulation and weight bearing, relief of pain, restoration of independence, and ease of nursing care.

We are satisfied with the procedure of percutaneous femorotibial intramedullary nailing as a palliative treatment of proximal tibial metastases in an elderly patient.

Introduction: Dynamic Hip Screw (DHS) fixation is one of the most common orthopaedic surgical procedures. Tip Apex Distance (TAD) is a well recognised method of evaluating the screw position of the DHS. We studied the adequacy of fixation of DHS by assessing TAD and type of reduction.

Materials and Methods: We selected a random cohort of 102 patients who had DHS fixation and had the requisite clinico-radiologic data. TAD is defined as sum of the distance, in millimeteres, from the tip of the lag screw to the apex of femoral head, as measured on AP radiograph and Lateral radiograph, after correction has been made for radiological magnification. Tip apex distance of 25 mm or less is considered as good, 26–30mm as acceptable, 31–35mm as poor and more than 35mm as unacceptable.

Quality of reduction was assessed as per Sernbo. Good, if alignment was normal on AP and maximum 20 degrees angulation on lateral radiograph and less than 4mm of displacment of any fragment. To be labelled acceptable, a reduction had to meed the criteria of a good reduction with respect to either alignement or displacement, but not both. A poor reduction met neither.

Results: Mean TAD in our series was 24mm. (9.84 – 37.6). Our of this 58.82% were 25mm or less indicating good, 25.49% of them were 26–30mm indicating acceptable, 8.82% were 30–35mm indicating poor and 6.8% were more than 35mm indicating unacceptable. 39.21% patients had good reduction. 43.13% had acceptable reduction and 17.64% had poor reduction.

Conclusion: This study shows that only 58.82% of all patients having DHS fixation had good placement of the fixation device and only 39.21% had a good reduction. We conclude that complacency must not set in on DHS fixation and that we must endeavour for good reduction and placement in as many cases as possible.

Back pain screening clinics are established to clinically screen patients with back pain for organic lumbar pathology. The aim of this study is to assess the relationship between clinical signs of organic pathology and the level of disability as measured by functional outcome scores. Methods: Notes from 581 consecutive patients who were seen in the back screening clinic was analyzed. Sixty-nine patients who were found to have clinical signs of organic pathology and 69 age and sex-matched patients from 512 patients who were found to have no signs of organic pathology in the same time period in the back pain screening clinic were selected. The Oswestry disability, Short form-36 and visual analogue (pain) scores between the two groups were statistically analyzed.

The correlation between the level of psychological morbidity, length of symptoms and presence of past history of symptoms against the level of disability was statistically assessed. Results: Although there was a signiþcant increase in the level of disability in the referred group with each score (Oswestry Disability Score P< 0.001, SF-36 physical component score P=0.014, Visual analogue pain score P< 0.001). We also found a strong relationship between psychological disability and the duration of back symptoms. Conclusions: High level of disability is associated with organic pathology. Acute back pain should be treated promptly to reduce it impact on the psychological disability.