There are concerns regarding the rates and significance of DVT and PE following ankle fracture with published rates of VTEs varying widely. This study aimed to identify the incidence of VTEs in patients with ankle fractures and to compare this to the background risk of VTEs in these patients and the population.

1,283 consecutive patients with ankle fractures presenting to our trauma centre over a twenty-month period were studied prospectively. Patients with conservatively-managed ankle fractures were encouraged to mobilise weight-bearing but not provided with chemical thromboprophylaxis, whilst operatively-managed fractures were only prescribed chemical thromboprophylaxis during their inpatient stay. Both hospital and national episode data were searched to identify VTEs between 1981 and 2014.

Over this 33-year period there were 17 PEs and 5 DVTs. Of these, 50percnt; occurred prior to the ankle fracture, 23percnt; greater than one year after the fracture and only 27percnt; in the 90 days following injury, with no fatal PEs in this cohort. The incidence of VTEs among conservatively-managed ankle fractures within 30 and 90 days was 1.1 and 3.3 per thousand patients respectively. Operatively-managed fractures were at greater risk, with 5.2 per thousand patients at 30 days and 7.8 at 90 days.

We have found that the incidence of VTEs is very low after ankle fracture: approximately five times lower than after major joint arthroplasty. The efficacy of chemical thromboprophylaxis remains controversial, and given that the rate of major haemorrhagic complications is 2percnt;, it remains to be determined whether this is appropriate after ankle fracture.

Kirschner wires are commonly used in paediatric fractures, however, the requirement for removal and the possibility of pin site infection provides opportunity for the development of new techniques that eliminate these drawbacks. Bioabsorbable pins that remain in situ and allow definitive closure of skin at the time of insertion could provide such advantages.

Three concurrent studies were performed to assess the viability of bioabsorbable pins across the growth plate. (1) An epidemiological study to identify Kirschner wire infection rates. (2) A mechanical assessment of a bioabsorbable pin compared to Kirschner wires in a simulated supracondylar fracture. (3) The insertion of the implants across the physis of sheep to assess effects of the bioabsorbable implant on the growth plate via macroscopic, pathohistological and micro-CT analysis.

An infection rate of 8.4% was found, with a deep infection rate of 0.4%. Mechanically the pins demonstrated comparable resistance to extension forces (p=) but slightly inferior resistance to rotation (p=). The in vivo component showed that at 6 months: there was no leg length discrepancy (p=0.6), with micro-CT evidence of normal physeal growth without tethering, and comparable physeal width (p=0.3).

These studies combine to suggest that bioabsorbable pins do not represent a threat to the growth plate and may be considered for physeal fracture fixation.

Soft tissue Intravenous drug abuse is known to be associated with significant health problems including soft tissue infections. Our department observed a concerning increase in the level of admissions of drug users presenting with severe soft tissue infections after injecting “Legal Highs”. These findings contributed to the body of evidence which led to the introduction of a Temporary Banning Order on these agents in Scotland in April 2015. The aim of this study was to investigate the effectiveness of banning orders on reducing patients presenting with soft tissue infections associated with intravenous drug abuse.

All admissions to the Orthopaedic trauma unit with soft tissue infections over three six-month periods in 2013, 2014 and 2015 were investigated. Those associated with intravenous drug usage were identified. Cases were reviewed to assess patient demographics, co-morbidities, infection characteristics and management.

There was a three-fold increase in hospital admissions for soft tissue infections resulting from intravenous drug use between 2013 and 2014. In 2013, 9.1% of admissions were related to use of “Legal Highs”, whilst in 2014 this had increased to 68.8%. After April 2015 there was a 28% reduction in admissions of intravenous drug use related soft tissue infections with “Legal High” associated admissions reduced to 39%.

“Legal Highs” were responsible for the dramatic increase in admissions associated with soft tissue infections resulting from intravenous drug abuse seen between 2013 and 2014. Introduction of Temporary Banning Orders for “Legal Highs” in April 2015 has been instrumental in reducing these admissions.

We have previously reported that fibular nailing in the elderly is associated with a significantly reduced complication rate and greater cost-effectiveness when compared to ORIF. The aim of this study was to compare the outcomes of fibular nailing to ORIF in patients under the age of 65.

100 patients aged 18 to 64 were randomly allocated between groups. Outcomes assessed over two years post-operatively included: development of wound complications or radiographic arthritis, the accuracy of reduction and patient satisfaction. The mean age was 44, 25% of patients were smokers and 35% had some form of comorbidity of whom three were diabetic. 27 injuries occurred after sport and two after assault the remainder occurred after a simple fall from a standing height.

Superficial wound infections occurred in two patients in each group. Six patients requested removal of the nail, and six patients requested plate and screw removal. Patient reported outcome scores were comparable for the two groups. Two failures of fixation occurred in the fibular nail group; one in a patient with neuropathy. One failure of fixation occurred in the ORIF group. All other patients went on to an anatomical union without complication. Patient satisfaction with the surgical scar was higher after fibular nailing (visual analogue scale mean 0.75, range 0–5) than for ORIF (mean 1.5, range 0–7).

The fibular nail allows accurate reduction and secure fixation of ankle fractures with comparable radiographic and patient-reported outcomes to ORIF at two years and a greater patient satisfaction with the appearance of the surgical scars.

Early weight-bearing of patients with ankle fractures is associated with good outcomes. There are a number of potential advantages to early mobilisation including reduced hospital stay and earlier return to work and regular daily activities. However, many surgeons have not incorporated this into their routine ankle fracture protocol, particularly for patients managed operatively; potentially due to concerns regarding loss of reduction. We hypothesised that ankle fractures managed fully weight-bearing would have good outcomes and a low rate of loss of reduction.

All ankle fractures presenting to our department over a 15-month period were studied prospectively. Patients were instructed to mobilise fully weight-bearing as able, either immediately postoperatively (for those fractures considered unstable that underwent operative intervention), or at the first fracture clinic review (if stable and managed conservatively). Only patients with syndesmotic injuries and those with neuropathy or psychiatric illness were excluded. The effectiveness of this management protocol was assessed by clinical and radiographic review following fracture union.

847 patients were included, of whom 25% were over the age of 65. 33% of fractures were unstable and therefore managed operatively, 66% were stable and therefore managed in casts or with functional bracing. In every case the radiographs showed maintenance of anatomical mortise and fracture reduction at the time of union, good patient reported outcomes were also recorded.

Early weight-bearing of patients with ankle fractures, whether managed conservatively or operatively, results in very low rates of loss of reduction and should be considered routine management for the majority of patients.

Articular cartilage has very poor repair potential, however it has an extraordinary capacity to withstand physiological mechanical loads in an intact joint. The nature and extent of chondrocyte death in articular cartilage following many forms of injury (trephine, scalpel, osteotome, sutures and drilling) has been characterised, but the ability to bear mechanical injury from iatrogenic surgical interventions is still unknown.

A standard arthroscopic probe was moved at varying physiological pressures along the articular cartilage of joint before staining with fluorescent dyes to allow live/dead cell imaging using laser confocal scanning microscopy and imaging software, Image J. Bovine metatarsal phalangeal joints and fresh human cadaveric femoral condyles were used.

The probe caused statistically significant chondrocyte death in bovine cartilage (p=0.02). Mild pressure 5% cell death, moderate (standard arthroscopic technique pressure) 22% and severe pressure 38%. A similar result was seen in human tissue with 24% cell death at moderate pressure compared to a control (p=0.0699).

The widely assumed benign arthroscopic probe produces significant cell death in articular cartilage when used at standard operating pressures.

The aim of this study was to document the outcome following either early or delayed fixation for complex (AO-OTA type 43.C) fractures of the tibial plafond. From our trauma database we identified all patients who sustained a complex intra-articular fracture of the distal tibia over an 11-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary outcome measure was the development of early complications following surgery. The secondary outcome measure was the long-term patient reported outcome.

There were 102 type C pilon fractures in 99 patients with a mean age of 42yrs (16–86) and 75.5% (n=77) were male. 73 (71.6%) patients underwent primary open reduction internal fixation (ORIF), with 20 (19.6%) undergoing primary external fixation with delayed ORIF. 34 complications were recorded in 28 (27.5%) patients. There were 18 (17.6%) infections, with a deep wound infection in 9 (8.8%) patients and a superficial wound infection in 9 (8.8%). Risk factors for developing infection were multiple co-morbidities (p=0.008), an open fracture (p=0.008), and primary external fixation with delayed ORIF (p=0.023). At a mean of 6 years (0.3–13; n=53) post injury the mean FAOS score was 76.2 (0–100), the mean FADI score was 75.7 (0–100), and 72% (n=38) of patients were satisfied.

This is the largest series in the literature documenting the outcome following fixation for type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated a satisfactory outcome using primary early fixation in the vast majority of cases.

Assessment of stability in ankle fractures is key in deciding the most appropriate mode of treatment. Stress radiographs have been suggested as a potential method for assessing ankle stability in patients with apparently isolated lateral malleolar fractures. Whilst stress radiographs have been found to be both sensitive and specific in cadaveric experiments, recent clinical studies have suggested that a widened medial clear space (MCS) on stress radiographs may not equate to a functionally unstable ankle. We aimed to assess whether patients with an apparently isolated lateral malleolar fracture on presentation but with a positive gravity stress radiograph (GSR) could be successfully managed non-operatively.

A prospective study of all patients with lateral malleolar fractures presenting to our orthopaedic trauma department was undertaken. Patients with an oblique distal fibular fracture pattern and no obvious MCS widening on routine radiographs underwent a GSR. Measurements of the radiographic MCS and superior clear space (SCS) were made and compared with published criteria.

155 patients were included in the study and treated non-operatively fully weight bearing in either a cast or removable boot. Following fracture union all patients had both anatomical alignment of the ankle mortise and good or excellent function. The MCS of 79% of these patients was found to be greater than 4 mm with 19% greater than 6 mm. All of these patients were successfully managed non-operatively.

The currently used criteria for measurements on stress radiographs result in high numbers of false positive cases. This may be leading to unnecessary surgery. Further investigation is required in order to identify other clinical or radiographic criteria that may be of use in the assessment of functional ankle stability after fracture.

Tibial plateau fractures are common intraarticular fractures. The principal long-term complication is post-traumatic osteoarthritis (PTOA) with the usual salvage procedure being total knee arthroplasty (TKA). Our aim was to define the incidence of PTOA requiring TKA following tibial plateau fractures and identify the risk factors.

We looked at all tibial plateau fractures between 1995 and 2008. There were 888 tibial plateau fractures. 23% were Schatzker I, 25% II, 14% III, 22% IV, 8% V and 8% VI. To date 25 have undergone TKA (2.8%). The mean age of patients at time of fracture was 56 in the overall cohort and 65 in those requiring TKA; this was statistically significant (p=0.04). 4% of females with tibial plateau fractures required TKA in comparison to 2% of males. The Schatzker I fractures were the least likely to require TKA at 1% with the most likely requiring arthroplasty surgery being type III at 6%. Only 1% of the patients treated non-operatively later underwent TKA

The overall incidence of TKA after tibial plateau fractures was 3%. For displaced fractures requiring internal fixation this rose to 4%. Risk factors were increasing age, split depression fractures and female gender. Although tibial plateau fractures are commonly associated with degenerative radiographic changes, we concluded that the incidence of symptomatic OA severe enough to require TKA is low.

Open reduction and internal fixation (ORIF) of ankle fractures is associated with well known complications including wound dehiscence and infection, construct failure and symptomatic metalwork. A technique of intramedullary fibular nailing has been developed that requires only minimal incisions, is biomechanically stronger than ORIF and has low-profile hardware. We hypothesized that fibular nailing would result in a rate of reduction and union comparable to ORIF, with a reduced rate of wound and hardware problems.

100 patients over the age of 65 years with unstable ankle fractures requiring fixation were randomised to undergo fibular nailing or ORIF. Outcome measures assessed over the 12 postoperative months were wound complications, accuracy of reduction, Olerud and Molander score (OMS), and total cost of treatment.

The mean age was 74 years (range 65–93) and 75 patients were women, all had some form of comorbidity. Significantly fewer wound infections occurred in the fibular nail group (p=0.002). Eight patients (16%) in the ORIF group developed lateral-sided wound infections, two of these developed a wound dehiscence requiring further surgical intervention. No infections or wound problems occurred in the fibular nail group and at 1 year patients were significantly happier with the condition of their scar (p=0.02), and had slightly better OMS scores (p=ns). The overall cost of treatment in the fibular nail group was less despite the higher initial cost of the implant.

The fibular nail allows accurate reduction and secure fixation of ankle fractures with a significantly reduced rate of soft-tissue complications when compared with ORIF.

Lateral malleolar plating is associated with complication rates of up to 30%. The fibular nail is an alternative fixation technique, requiring a minimal incision and tissue dissection, with the potential to reduce the incidence of complications. We reviewed our results of 105 unstable ankle fractures fixed with the Acumed fibular nail between 2002 and 2010. The mean age was 65 years and 72% of patients had significant systemic medical comorbidities.

A number of different locking screw configurations were assessed over the study period. A proximal blocking screw resulted in satisfactory stability in 93%, single locking screws in 86%, but nailing without locking in only 66%, leading to the development of our current technique. Of the twenty-one patients treated with this technique there have been no significant complications, and only two superficial wound infections. Good fracture reduction was achieved in all of these patients. The mean physical component SF12, Olerud and Molander and Foot and Ankle Outcome scores were 46, 65 and 83 respectively.

The outcomes of unstable ankle fractures managed with the fibular nail are encouraging, with good radiographic and functional outcomes and minimal complications. This technique should be considered in the management of debilitated patients with unstable ankle fractures.

The aim of this study was to document our experience of acute forearm compartment syndrome, and to determine the risk factors for requiring split skin grafting (SSG) and developing complications post fasciotomy. We identified from our trauma database all patients who underwent fasciotomy for an acute forearm compartment syndrome over a 22-year period. Diagnosis was made using clinical signs and/or compartment pressure monitoring. Demographic data, aetiology, management, wound closure, complications and subsequent surgeries were recorded. Outcome measures were the use of SSG and the development of complications following forearm fasciotomy.

90 patients were identified with a mean age of 33 yrs (range, 13–81 yrs) and a significant male predominance (n=82, p<0.001). A fracture of one or both of the forearm bones was seen in 62 (69%) patients, with soft tissue injuries causative in 28 (31%). The median time to fasciotomy was 12hrs (2–72). Delayed wound closure was achieved in 38 (42%) patients, with 52 (58%) undergoing SSG. Risk factors for requiring a SSG were younger age and a crush injury (both p<0.05). Complications occurred in 29 (32%) patients at mean follow-up of 11 (3–60) months. Risk factors for developing complications were a delay in fasciotomy of >6 hrs (p=0.018), with pre-operative motor symptoms approaching significance (p=0.068).

Forearm compartment syndrome requiring fasciotomy predominantly affects males and can occur following either a fracture or soft tissue injury. Age is an important predictor of undergoing SSG for wound closure. Complications occur in a third of patients and are associated with an increasing delay in the time to fasciotomy.

Background

Morton's neuroma (MN) is a common cause of metatarsalgia. Whilst there are a many treatment modalities available, studies looking at the long term effectiveness of most forms of treatment are scarce. The injection of MN with alcohol has gained popularity over the past ten years with widespread media coverage. Many surgeons have anecdotally questioned the long-term effectiveness. Sixty patients underwent alcohol injection for the treatment of MN by Radiologists at our institution. These results were originally published showing 92% (92/100) success rates and only 3% (3/100) requiring surgical excision at a mean follow up of 10.5 mths. The authors concluded that alcohol injection was comparable to results for surgical excision.

Techniques for fixation of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities.

Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and AAOS Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Introduction

The optimal treatment of elderly patients with unstable ankle fractures is a widely contested and as yet unresolved issue. Whereas the AO technique of anatomical reduction and plate fixation has been shown to give good functional results it is associated with a wound complication rate of up to 40%. This has led some surgeons to believe the risks of operative intervention are too great.

The fibula nail is an intra-medullary device with the benefit of requiring minimal soft-tissue dissection. It provides lateral column support over a greater area than the standard plate.

The study aims were to assess the clinical and radiographic outcome of a cohort of patients managed with the Fibula Nail (Acumed).

Intra-articular screw fixation is indicated for internal fixation of large osteochondral fragments secondary to trauma or osteochondritis dissecans. During surgery, orthopaedic drills are used to prepare a hole through which the screw can pass. Previous work has shown that mechanical injury to articular cartilage results in a zone of cell death adjacent to the traumatised articular cartilage (1). Here, we characterise and quantify the margin of in situ chondrocyte death surrounding drill holes and screws (standard cortical and headless compression designs) placed in mature bovine articular cartilage to model the orthopaedic procedure.

Drill holes (1mm) were made through the articular cartilage and bone of intact bovine metacarpophalangeal joints obtained from 3-yr old cows within 12hrs of slaughter. Osteochondral explants (∼1cm square and 2-3mm thick) encompassing the drilled holes in articular cartilage and subchondral bone were harvested using a chisel. Explants were then incubated in Dulbecco's modified Eagle's medium for 45mins with CMFDA (5-chloromethylfluorescein diacetate) and PI (propidium iodide; both at 10micromolar) to identify/quantify living and dead in situ chondrocytes respectively in a consecutive series of axial optical sections using confocal scanning laser microscopy (CLSM).

The drill holes through cartilage appeared to have clearly defined edges with no macroscopic evidence of cartilage splitting. However visualisation of fluorescently-labelled in situ chondrocytes by CLSM demonstrated clear cell death around the periphery of the drilled hole which was 166±19 micrometers in width. This increased with a larger diameter (1.5mm) drill to 450±151 micrometers (all data are means±s.e.m.; n=3). Preliminary experiments indicated that the margin of chondrocyte death around a 1.5mm hole was dramatically increased further by the insertion of screws into pre-drilled holes.

These results suggest that the mechanical trauma associated with cartilage drilling and the insertion of intra-articular screws occurs with marked death of in situ chondrocytes extending into normal cartilage beyond the area occupied by the screw. As chondrocytes are not replaced in mature cartilage, their loss around the hole/screw will mean that the extracellular matrix is not maintained, inevitably leading to cartilage failure.

Damage Control techniques involve primary external fracture fixation to reduce the ‘second hit’ of surgery. This study used a large animal (ovine) trauma model to compare pathophysiological responses of primary external femoral fixation and intramedullary stabilisation.

Under terminal anaesthesia bilateral femoral fractures and hypovolaemia were produced using a pneumatic ram. 24 sheep were randomised into 4 groups and monitored for 24 hours. Group 1 – Control; Group 2 – Trauma only; Group 3 – Trauma and external fixation; Group 4 – Trauma and reamed intramedullary stabilisation. Outcome measures: pulmonary embolic load (transoesophageal echocardiography); plasma coagulation markers; bronchoalveolar lavage differential cell counts (neutrophils, lymphocytes and macrophages).

Total embolic load was significantly higher (p<0.001) in the intramedullary fixation group (median score 42 versus 20). All trauma groups had a significant increase (p < 0.05) in prothrombin time with a fall in antithrombin III and fibrinogen levels. No significant differences occurred between trauma groups with any coagulation or alveolar lavage marker.

Intramedullary femoral fracture fixation produced a relatively higher pulmonary embolic load. However, the initial fracture fixation method did not affect any of the changes seen in the measured coagulation or inflammatory markers during the first 24 hours of injury.

Background

The optimal treatment for pilon fractures remains controversial. We have used early single-stage open reduction and internal fixation to treat these injuries and the purpose of this study was to determine the safety and efficacy of this strategy.

Purpose: This study was performed to assess the incidence of generalized ligament laxity in patients undergoing revision ACL reconstruction.

Methods and Results: Prospective data was collected for 40 patients undergoing revision ACL reconstruction, between 2004 and 2009 under the care of a single orthopaedic consultant including demographic details, graft used during primary and revision ACL reconstruction and causes of graft failure.

Clinical examination was used to assess the ligament laxity using the Beighton score. Laxity is scored on a 0–9 scale. Scores of 4 or above are indicative of generalized ligament laxity. Brighton criteria is used to diagnose Benign Joint Hypermobility Syndrome (BJHS) and use signs and symptoms along with Beighton score.

The most common graft used was a quadruple hamstring in 23 patients (57%). The causes of graft failure were trauma in 22 patients (55%), biological in 17 patients (42%) and infection in 1 patient (2.5%).

The revision ACL graft was patella tendon in 23 patients (57%), allograft tendon was used in 11 patients (28%) and quadruple hamstring was used in 4 patients (10%).

The average Beighton score for these patients was 3 with a range from 0–9. 20 patients (50%) in this group had a Beighton score of 4 or more. Only 6 patients (15%) fulfilled the Brighton criteria for BJHS.

Conclusion: We found that there is a high incidence (50%) of generalized ligament laxity in patients undergoing revision ACL reconstruction. Biological failure is common (42%) in these patients after using autogenous tendons. We recommend the use of allograft for primary ACL reconstruction in patients with generalized ligament laxity.

Introduction: Despite advances in surgical and anaesthetic techniques the mortality after hip fracture has not significantly changed in the last 40 years. Pre-operative anaemia is a risk factor for peri-operative death.

We speculate that a significant proportion of the blood loss related to hip fracture has occurred prior to surgery. Identifying patients at risk of pre-operative anaemia can facilitate appropriate medical optimisation. This study is unique in its attempt to quantify the blood loss associated with the initial hip injury.

Methods: In a retrospective study over 12 months all patients with both a diagnosis of hip fracture and an operative delay of > 48 hours were assessed. The information collected included: fracture classification, serial haemoglobins and patient comorbidities. The exclusion criteria included a pre-injury diagnosis of anaemia and gastrointestinal bleeds.

Results: 68 intracapsular and 50 extracapsular hip fracture patients had serial haemoglobins and operative delays of > 48hrs (mean 75hrs, range 48–270hrs).

The mean lowest recorded haemoglobin prior to surgery for both extracapsular and intracapsular fractures were 95.0 g/L (+/−SEM 2.2) and 108.5 g/L (+/−SEM 2.2) respectively. The difference was statistically significant (Students t-test p< 0.05).

The mean haemoglobin drop for male and female patients with extracapsular hip fractures were 15.0 g/l (range 0–40 g/l) and 19.3 g/l (range 0–49 g/l) respectively and the mean haemoglobin drop for male and female intracapsular fracture patients were 10.2 (range 0–59 g/l) and 10.5 g/l (range 0–41 g/l) respectively.

Conclusions:

Hip fracture patients have a large drop in haemoglobin that is likely to be associated with the initial trauma. Patients with extracapsular fractures demonstrate a greater haemoglobin loss than those with intracapsular fractures. This highlights the need for anaesthetic and orthopaedic staff to be vigilant to the risk of pre-operative anaemia in this cohort of frail patients.