Hip fracture care is complex multi-disciplinary. We hypothesise that quality of care is affected by variance in resources between ‘in-hours’ (Monday-Friday, 0800–1700) and ‘out-of-hours’ services.

This prospective multicentre national cohort study assessed quality of care by evaluating adherence to the evidence-based Scottish Standards of Care for Hip Fracture Patients. Data was collected by the Scottish Hip Fracture Audit for 15174 patients admitted to any of 22 Scottish hospitals from January 2014-April 2018.

11197/15174 (73.8%) patients were admitted out-of-hours. They were significantly less likely to meet the following Standards: ED Big-6-Bundle (OR 0.85, p= 0.002); Time in ED <4 hours (OR 0.76, p< 0.001); avoidance of repeated fasting (OR 0.80, p< 0.001), and avoidance of prolonged fluid fasting (OR 0.83, p< 0.001). Out-of-hours admissions were more likely to receive: geriatric assessment <3 days (OR 1.16, p< 0.001); OT input <3 days (OR 1.10, p= 0.013), and PT input <2 days (OR 1.44, p< 0.001). There were no significant differences for: Time to Theatre <36 hours; Inpatient Care Bundle <24 hours, and Post-op Day 1 Mobilisation.

Quality of hip fracture care is affected by time of admission. ED care is poorer out-of-hours, which may reflect limited resources, and out-of-hours admissions are more likely to be excessive fasted excessively. Weekday in-hours admissions are less likely to receive geriatric and allied health professional input in the days following admission, which may reflect the reduced weekend services. Examination of out-of-hours service organisation is required for the pursuit of consistent, equitable care for hip fracture patients.

There is currently no information regarding long-term outcomes following total hip replacement (THR) for hip fracture in patients selected in accordance with national guidelines. We define the long-term outcomes and compare these to short-term outcomes in the same previously reported cohort.

We prospectively identified patients who underwent THR for a displaced hip fracture over a 3-year period from 2007–2010. These patients were followed up at 10 years using the Oxford hip score(OHS), the Short-form 12(SF-12) questionnaire and satisfaction questionnaire. These outcomes were compared to the short-term outcomes previously assessed at 2 years. We identified 128 patients. Mean follow up was 10.4 years. 60 patients(48%) died by the time of review and 5 patients(4%) developed dementia and were unable to respond. 3 patients were untraceable. This left a study group of 60 patients with a mean age of 81.2.

Patients reported excellent outcomes at 10 year follow up and, when compared with short-term outcomes, there was no statistically significant change in levels of satisfaction, OHS, or SF-12. The rates of dislocation(2%), deep infection(2%) and revision(3%) were comparable to those in the literature for elective THR. Mortality in the hip fracture group at 10 years is lower than that of elective registry data.

Long-term outcomes for THR after hip fracture in selected patients are excellent and the early proven benefits are sustained. Our data validates the selection process of national guidelines and confirms low complication rates. THR is a safe and highly effective treatment for fit elderly patients with displaced hip fractures.

Anterior knee pain (AKP) is the commonest complication of total knee arthroplasty (TKA). This study aims to assess whether sagittal femoral component position is an independent predictor of AKP after cruciate retaining single radius TKA without primary patellofemoral resurfacing.

From a prospective cohort of 297 consecutive TKAs, 73 (25%) patients reported AKP and 89 (30%) reported no pain at 10 years. Patients were assessed pre-operatively and at 1, 5 and 10 years using the short form 12 and Oxford Knee Score (OKS). Variables assessed included demographic data, indication, reoperation, patella resurfacing, and radiographic criteria.

Patients with AKP (mean age 67.0 (38–82), 48 (66%) female) had mean Visual Analogue Scale (VAS) Pain scores of 34.3 (range 5–100). VAS scores were 0 in patients with no pain (mean age 66.5 (41–82), 60 (67%) female). Femoral component flexion (FCF), anterior femoral offset ratio, and medial proximal tibial angle all differed significantly between patients with AKP and no pain (p<0.001), p=0.007, p=0.009, respectively). All PROMs were worse in the AKP group at 10 years (p<0.05). OKSs were worse from 1 year (p<0.05). Multivariate analysis confirmed FCF and Insall ratio <0.8 as independent predictors of AKP (R² = 0.263). Extension of ≥0.5° predicted AKP with 87% sensitivity.

AKP affects 25% of patients following single radius cruciate retaining TKA, resulting in inferior patient-reported outcome measures at 10 years. Sagittal plane positioning and alignment of the femoral component are important determinants of long-term AKP with femoral component extension being a major risk factor.

The evidence for treatment of acute complex radial head fractures with radial head replacement (RHR) predominantly comprises short to mid-term follow-up. This study describes the complications and long-term patient reported outcomes following RHR.

From a single-centre trauma database we retrospectively identified 119 patients over a 16-year period who underwent primary RHR for an acute complex radial head fracture. We reviewed electronic records to document post-operative complications, including prosthesis revision and removal. Patients were contacted to confirm complications and long-term patient reported outcomes. The primary outcome measure was the QuickDash (QD).

The mean age at injury was 50 years (16–94) and 63 (53%) were female. Most implants were uncemented ‘loose-fit’ monopolar prostheses; 86% (n=102) were metallic and 14% (n=17) silastic. Thirty patients (25%) required revision surgery (n=3) or prosthesis removal (n=27). Five patients underwent arthrolysis and there were four cases of infection. In the long-term, 80% (80/100; 19 deceased) were contacted at a mean of 12 years (7.5–23.5). The median QD was 6.8 (IQR, 16.8), the median EQ-5D was 0.8 (IQR, 0.6) and the median Oxford Elbow Score was 46 (IQR, 7). Overall satisfaction was high with a mean of 9.4/10 (2–10). There was no significant difference in any outcome measure for those patients requiring revision or removal surgery (all p>0.05).

This is the largest series in the literature documenting the long-term patient reported outcome after RHR. Despite a quarter of patients requiring further surgery, RHR is supported by positive long-term results for the treatment of complex radial head fractures.

Revision hip arthroplasty presents a challenge in the setting of femoral bone loss. Tapered stems are susceptible to subsidence which leads to leg length inequality, hip instability and may necessitate repeat femoral revision surgery.

The purpose of this study was to compare radiographic outcomes in two modular tapered revision systems with different distal stem geometries. We sought to establish the minimum postoperative stem bi-cortical contact length that predicts subsidence for tapered stems.

This study examined revision total hip arthroplasties between 2009 and 2016 in a European university affiliated major trauma center. Modular stem A has a taper of 3 degrees whereas modular stem B has a taper of 2 degrees. Radiologic assessment compared x-rays at two time points: immediately post-surgery and most recent x-ray available at a minimum follow up of two years. Leg length discrepancy, subsidence and postoperative bi cortical contact was assessed. Descriptive summary statistics calculated clinical factors (i.e. age, gender, Paprosky classification).

122 arthroplasties were completed. Complete data was available for 112. Revisions were carried out for Paprovski grade 3a/ 3b femoral deficits. Post-operative bi-cortical contact of the proximal stem < 20mm was associated with higher subsidence rates (P = 0.047). Subsidence rates for implant A and B system were 4.27mm (0.12–25.62mm) and 3.43 mm (0.3–11.1 mm) respectively. Significant subsidence was noted in 9.8% (n=8) in implant A and 5.2%(n=2) in implant B.

We conclude that immediate postoperative bi-cortical stem contact of <20mm was associated with significantly higher subsidence rates in this study.

International literature reports a 30% lifetime prevalence of intimate partner violence (IPV, domestic abuse). Many of those affected have little interaction with healthcare. Since a third of abused patients sustain musculoskeletal injuries, the fracture clinic has potential for identifying victims of abuse. The aim was to identify the proportion of fracture clinic patients who had suffered IPV within the past year.

A prospective questionnaire study of patients in three UK adult fracture clinics was conducted. There were no gender/age exclusions and the target sample size was 278. This study had ethics approval and the questionnaire used is validated in this population.

Of 336 respondents, 46% were females with 63% aged over 40 (212/336). The total prevalence of IPV within the preceding 12 months was 9% (29/336). The lifetime prevalence of IPV amongst respondents was 20% (68/336). 38% of patients suffering from IPV had been physically abused by their partner (11/29 vs. 7% in controls, p<0.001). None of the patients were being seen for an injury related to abuse. Two thirds of respondents thought that staff should ask routinely about IPV (64% 216/336) but only 5% had been asked about abuse (18/336).

This is the first study in the UK investigating prevalence of IPV in orthopaedics. There is a high lifetime prevalence of abuse in fracture clinic patients. Patients are willing to disclose abuse within the fracture clinic setting and are supportive of staff asking about abuse. This presents an opportunity to identify those at risk in this vulnerable population.

To investigate predictors of periprosthetic fracture level (around stem (Vancouver B) or distal to stem (Vancouver C/D) in cemented polished tapered femoral stems.

Retrospective cohort study of 188 patients (mean age 79 (range 30–91); 99 (53%) male) with unilateral periprosthetic femoral fractures associated with CPT stems. Medical notes were reviewed and the following recorded: patient demographics, past medical history, drug history, date of prosthesis insertion, and date of injury. Radiographs analysis included Vancouver classification, cement restrictor type, cement mantle to implant tip distance, cortical thickness, femoral diameter and DORR classification. Univariate, multivariate and ROC curve analysis was performed.

Fractures occurred at mean 7.5 years following primary procedure: 152 (83%) were B fractures; and 36 (19%) C/D. On univariate analysis female gender, lower BMI, osteoporosis, NSAID use, Bisphosphonate therapy, cortical thickness, distal cement mantle length and distal cement mantle length:femoral diameter ratio were significantly associated with C level fractures (p<0.05). Distal cement mantle lengths of >19.6mm (AUC 0.688, p<0.001) were associate with C level fractures. Multivariate analysis demonstrated female gender and distal cement mantle length:femoral diameter ratio to be independent predictors of C level periprosthetic fractures.

Though female sex is the largest independent predictor of periprosthetic fractures distal to a CPT femoral stem, the relationship between cortical thickness and distal cement mantle length appears significant. As fractures distal to the stem are invariably managed by ORIF, whereas fractures around the stem frequently require revision arthroplasty, this has relevance at primary surgery in osteoporotic females to reduce the need for complex revisions.

Antimicrobial resistance (AMR) is projected to result in 10 million deaths every year globally by 2050. Without urgent action, routine orthopaedic operations could become high risk and musculoskeletal infections incurable in a “post-antibiotic era.” However, current methods of studying AMR processes including bacterial biofilm formation are 2D in nature, and therefore unable to recapitulate the 3D processes within in vivo infection.

Within this study, 3D printing was applied for the first time alongside a custom-developed bioink to bioprint 3D bacterial biofilm constructs from clinically relevant species including Staphylococcus aureus (MSSA), Methicillin-resistant staphylococcus aureus (MRSA), Escherichia coli and Pseudomonas aeruginosa. Bacterial viability and biofilm formation in bioprinted constructs was excellent, with confocal laser scanning microscopy (CSLM) used to demonstrate biofilm production and maturation over 28 days. Bioprinted 3D MRSA and MSSA biofilm constructs had greater resistance to antimicrobials than corresponding two-dimensional (2D) cultures. Thicker 3D E.coli biofilms had greater resistance to tetracycline than thinner constructs over 7 days of treatment. Raman spectroscopy was also adapted in a novel approach to non-invasively diagnose 3D bioprinted biofilm constructs located within a joint replacement model.

In conclusion, mature bacterial biofilm constructs were reproducibly 3D bioprinted for the first time using clinically relevant bacteria. This methodology allows the study of antimicrobial biofilm penetration in 3D, and potentially aids future antimicrobial research, replicating joint infection more closely than current 2D culture models. Furthermore, by deploying Raman spectroscopy in a novel fashion, it was possible to diagnose 3D bioprinted biofilm infections within a joint replacement model.

Atypical femoral fractures (AFFs) are reported in patients taking bisphosphonates (BPs). This study aims to describe demographics, potential risk factors and outcome of fixation in AFFs.

Forty-three patients with AFF were identified retrospectivity from all identified patients with subtrochanteric or diaphyseal fractures within NHS Grampian between 2008–2018. Patients were identified via hospital coding and electronic search of patients undergoing femoral fixation. AFFs were diagnosed by the 2014 American Society of Mineral and Bone Research diagnostic criteria by electronic patient record review by two investigators.

Within this cohort, the incidence of AFF was 8.25% with male to female ratio of 10:1 and a mean of presentation age 73.3 years. 27.9% of AFFs occurred in the diaphysis. 22% of AFFs were bilateral. Mean follow-up was 11.5 months. 87.5% of patients had documented prodromal symptoms. 35% had proven radiological changes before fracture. All patients identified were on BPs. Duration of BPs before fracture was 5 months- 13.2 years (mean 6.3 years). Concurrent use of BPs with steroid and proton pump inhibitors was seen in 58.5%. All patients had intramedullary fixation with 8 (18.6%) requiring revision for non-union. For those that united radiologically it took on average 304 days (220–513). BPs were only stopped in 45% of patients after fixation.

AFFs in this cohort appear to be associated with BP use, female sex, clinical and radiological prodrome. AFF remain a difficult clinical problem with a high revision rate. Further work is required to identify the temporal relationships and to raise awareness to improve surveillance/management.

Aims

Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called ’combined hip procedure’ (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone.

Aims

The aim of this study was to evaluate the clinical and radiological outcomes of locking plate fixation, with and without an associated fibular strut allograft, for the treatment of displaced proximal humeral fractures in elderly osteoporotic patients.

Aims

Many authors have reported a shorter treatment time when using trifocal bone transport (TFT) rather than bifocal bone transport (BFT) in the management of long segmental tibial bone defects. However, the difference in the incidence of additional procedures, the true complications, and the final results have not been investigated.

The primary aim of this study was to compare the knee specific functional outcome of partial compared with total knee replacement (TKR) for the management of patellofemoral osteoarthritis.

Fifty-four consecutive Avon patellofemoral replacements were identified and propensity score matched to a group of 54 patients undergoing a TKR with patella resurfacing for patellofemoral osteoarthritis. The Oxford knee score (OKS), the Short Form (SF-) 12 and patient satisfaction were collected (mean follow up 9.2 years). Survival was defined by revision or intention to revise.

There was no significant difference in the OKS (p>0.60) or SF-12 (p>0.28) between the groups. The TKR group was significantly less likely to be satisfied with their knee (95.1% versus 78.3%, OR 0.18, p=0.03). Length of stay was significantly (p=0.008) shorter for the Avon group (difference 1.8 days, 95% CI 0.4 to 3.2). The 10 year survival for the Avon group was 92.3% (95% CI 87.1 to 97.5) and for the TKR group was 100% (95% CI 93.8 to 100). There was no statistical difference in the survival rate (Log Rank p=0.10).

The Avon patellofemoral replacement have a shorter length of stay with a functional outcome and satisfaction rate that is equal to that of TKR. The benefits of the Avon need to be balanced against the increased rate of revision when compared with TKR.

An increased prevalence of osteoarthritis (OA) in post-menopausal women has led to the suggestion that hormonal factors may play a role in the pathogenesis. This study aims to examine if undergoing a hysterectomy, both with retention and removal of ovaries, predisposes women to OA and secondly if the development is influenced by hormone replacement therapy (HRT).

Statistical shape modelling (SSM) is a method of image analysis allowing for detection of subtle shape variation described by landmark points. Through the generation of linearly independent modes of variation, each image can be described in terms of numerical scores. 149 radiographs from female participants of the Osteoarthritis Initiative (OAI) were examined to compare hip morphology in those who had undergone hysterectomies compared to controls.

No differences were observed in BMI, age, height or weight between groups. ANOVA and Games-Howell post-hoc analysis showed that modes 3 and 5 were statistically significant. Lower mode 3 scores were associated with hysterectomy (p=0.019), with narrowing of the femoral neck and increased acetabular coverage. Lower mode 5 scores were associated with hysterectomy and oophorectomy (p=0.049), displaying reduced coverage of the femoral head, superolateral migration of the femoral head and larger greater trochanter. No associations were observed between HRT use and OA.

The subtle morphologic features of hip OA present in only hysterectomised women suggests undergoing a hysterectomy may be a predisposing factor and a clinical consideration. The use of HRT was not observed to influence the development of OA and thus cannot be suggested as a protective measure.

Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce peri-operative bleeding. Increasingly, topical administration as an intra-articular injection or peri-operative wash is being administered at concentrations between 10–100mg/ml. This study investigated effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations.

Tendon, synovium and cartilage obtained from routine orthopaedic surgeries were used ex vivo or cultured for in vitro studies using various concentrations of TXA. They were stained with 5-chloromethylfluorescein diacetate and propidium iodide and imaged using confocal microscopy to identify the proportion of live and dead cells. The in vitro effect of TXA on primary cultured tenocytes, synovial like fibroblast (FLS) cells and chondrocytes was investigated using cell viability assays (MTT), fluorescent microscopy and multi-protein apoptotic arrays for cell death.

There was significant (p<0.01) increase in cell death in all tissue treated with 100mg/ml TXA, ex vivo. MTT assays revealed significant (p<0.05) decrease in cell viability following treatment with 50 or 100mg/ml of TXA within 4 hours of all cell types cultured in vitro. Additionally, there was significant (p<0.05) increase in cell apoptosis detected by fluorescent microscopy within 1 hour of exposure to TXA. Furthermore, multi-protein apoptotic arrays detected increased apoptotic proteins within 1 hour of TXA treatment in tenocytes and FLS cells.

Our study provides evidence of TXA cytotoxicity to human peri-articular tissues ex vivo and in vitro at concentrations and durations of treatment routinely used in clinical environments. Clinicians should therefore show caution when considering use of topical TXA administration.

National guidelines recommend that trauma centres have a designated consultant for managing metastatic bone disease (MBD). No such system exists in Scotland. We compared MBD cases in a trauma hospital to a national bone tumour centre to characterise differences in management and outcome.

Consecutive patients with metastatic proximal femoral lesions referred to a trauma unit and a national sarcoma centre were compared over a seven-year period (minimum follow-up one year).

From Jan 2010-Dec 2016, 195 patients were referred to the trauma unit and 68 to the tumour centre. The trauma unit tended to see older patients (mean 72 vs. 65 years, p<0001) with cancers of poorer prognosis (e.g. 31% 61/195 vs. 13% 9/68 lung primary, p<0.001).

Both units had similar operative rates but patients referred to the tumour centre were more likely to have endoprosthetic reconstruction (EPR 44% tumour vs. 3% trauma centre, p<0.001). Patients with an EPR survived longer than those with other types of fixation (81% 17/21 vs. 31% 35/112 one-year survival, p<0.001). Patients undergoing EPR were more likely to have an isolated metastasis (62% 13/21 vs. 17% 4/24, p<0.001). One patient from each centre had a revision for failed metalwork.

There was a difference in caseload referred to both units, with the tumour centre seeing younger patients with a better prognosis. Patients suitable for endoprostheses were more likely to have isolated metastatic disease and a longer survival after surgery. An MBD pathway is required to ensure such patients are identified and referred for specialist management where appropriate.

Hip fractures in young adults are rare but represent an important cohort of patients, of which relatively limited data exists. The aim of this study was to evaluate this distinct subgroup of hip fractures from an epidemiological perspective and assess their subsequent outcomes.

Patients aged 18–50 were identified across an 8 year period from a total of 5326 hip fractures. 46 hip fractures met the inclusion criteria and a retrospective case series analysis was conducted.

25/46 (54%) of fractures were intracapsular and 21/46 (46%) were extracapsular. Only 15/46 (33%) of fractures were sustained from a high energy mechanism and 31/46 (67%) low energy. The low energy cohort was significantly more comorbid with a mean Elixhauser comorbidity score of 1.5 compared to the high energy cohort 0.3 (p<0.0005, unpaired t-test). Alcohol excess was the most prevalent comorbidity present in 24% of patients and was a positive predictor in complication (p=0.006, binary regression). Failure of fixation (non-union/avascular necrosis) in displaced intracapsular fractures sustained following low energy trauma managed by internal fixation 5/11 (45%) was markedly higher than the high energy cohort 0/6 (0%). 5 year mortality was 9% for all hip fractures, six times higher than an aged matched cohort of non-hip fractures (p=0.007, Wilcoxon test).

Representing only 0.86% of all hip fractures in the study period, hip fractures in young adults are rare. A clear sub-division of patients is observed between patients with a low and high energy mechanism, both in terms of level of comorbidity and surgical outcome.

Arthritis of the mid-foot is a common presentation to the foot and ankle clinic, resulting from primary (idiopathic), post-traumatic, or inflammatory joint degeneration. Treatment in the initial stages is conservative, with midfoot fusion regarded as the operative treatment of choice; however there is a paucity of comparative and patient reported data regarding outcomes.

Patient reported outcome measures (PROMS), were prospectively collected from October-2015 to March-2018. Diagnoses were confirmed with image guided injection and initial management was conservative. In total, 66 patients were managed conservatively and 40 treated with mid-foot fusion. MOxFQ (Manchester Oxford Foot Questionnaire) and EQ-5D-3L (Euroqual) PROMS were collected pre-operatively, at 26 weeks and at 52 weeks.

In the operatively managed group, the female:male ratio was 5.7:1, with a mean age of 61 (range 24–80), while in the conservatively managed group, the ratio was 2.1:1 with mean age 63 (range 29–86).

In the surgically managed group, 88.2% of patients reported improvement in symptoms at 26 weeks and 88.9% at 52 weeks. This was greater than the conservatively managed group, in which 40.6% reported improvement at 26 weeks and 33.3% at 52 weeks. Mean MOxFQ improvement in the surgically managed group was +30.7 and +33.9 at 26 and 52 weeks respectively, and in the conservative group, +9.4 and +4.3, at 26 and 52 weeks. Similarly, favourable surgical outcomes were reported across all domains of EQ-5D-3L.

This study has highlighted excellent early outcomes after surgical treatment and may represent promise for those patients for whom conservative management fails.

The Pronator Quadratus (PQ) is commonly damaged in the surgical approach to the distal radius during volar plating. This study explored the functional strength of the PQ muscle, 12 months after volar plating of a distal radial fracture.

Testing of treated and contralateral forearms was carried out using a custom-made Torque Measuring Device (TMD) and surface Electromyography (sEMG). To assess both the direct and indirect function of PQ in participants treated with volar plating and compared to the contralateral non-injured forearms. The angle of elbow flexion was varied from 45o, 90o and 135o when measuring forearm pronation. Mean peak torque of the major pronating muscles, PQ and Pronator Teres (PT) was directly measured with the TMD and the indirect activation of the PQ and PT was measured with sEMG.

In total 27 participants were studied. A statistically significant reduction in mean peak pronation torque was observed in the volar plated forearms (P<0.05 SE 0.015, CI 95%). This is unlikely to be of clinical significance as the mean reduction was small (13.43Nm treated v 13.48Nm none treated). Pairwise comparison found no statistically significant reduction in peak torque between 45o, 90o and 135o of elbow flexion. There was an increase in PQ muscle activation at 135o compared to 45o elbow flexion. The converse was identified in PT.

The small but statistically significant difference in mean peak torque in treated and uninjured forearms is unlikely to be of clinical significance and results suggest adequate functional recovery of the PQ after volar plating.

The optimal approach for total hip arthroplasty (THA) remains controversial. We present the results of the Direct Superior Approach (DSA), an improved variation of the posterior approach with high levels of stability, patient-reported functional outcomes, and satisfaction.

This is a single-surgeon prospective series. All patients undergoing THA between 2010 and 2015 via the DSA were included. Complication data was collected by interrogation of the Scottish Arthroplasty Project national joint registry. Pre and one-year post-operative Oxford Hip Score (OHS), Euroqol-5D (EQ-5D), and patient satisfaction questionnaires were collected.

659 patients received a THA via the DSA during the study period. Average age was 61.8 years (range 16.4–93.3). Analysis of registry data revealed no cases of dislocation, 5 cases of venous thromboembolism (0.75%), and 5 cases of deep infection (0.75%). 586 patients (88.9%) underwent their surgery in the National Health Service, and post-operative outcomes were available for 337 of these patients (57.5% follow-up) at one year. Average improvement in OHS and EQ-5D was 20 (range −14 – 48) and 0.39 (−0.697–1.2) respectively. 311 patients (92.3%) were satisfied.

This description of the DSA is accessible to all surgeons, confers excellent stability with no dislocations, and is associated with excellent post-operative functional outcomes and patient satisfaction.

MHRA guidance for patients with metal on metal hip replacements (MOM) was provided in 2012 and updated in 2017 to assist in the early detection of soft tissue reactions due to metal wear debris. A large number of metal on metal hip replacements were undertaken at our trust. A program of recall for all patients with metal on metal hip replacements was undertaken and MHRA guidelines implemented.

Identification and recall of all patients from 2001 with MOM hip replacements using theatre logs, patient records and consultant log books. Two consultant review of X-rays and patient records. Postal questionnaires and GP requests for cobalt & chromium blood tests. Two consultant led MOM review clinics undertaken with metal artefact reduction scans (MARS) performed following consultation in 2017.

674 patients, 297 available for review. 59 refused follow up. 87 moved out of area, 36 untraceable, 26 not MOM, 147 RIP, 22 already revised. From 297 patients 126 female, 171 male, age range 39 – 95 yrs. 126 resurfacing, 171 MOM THR. 26 patients with elevated metal ions, MARS performed of which 17 positive, 9 negative. Of 17 positive scans 10 patients asymptomatic, 7 waiting revision.

A time consuming effort and additional resource was needed and supported by the trust. From 297 hips 17 positive MARs were identified (5.7%). A new database registry has been developed to track MOM patients, clinics set up for ongoing follow up with radiological protocols for imaging. An arthroplasty advanced nurse practitioner (ANP) is now trained reviewing patients independently.

Deficiency in the gluteus medius and minimus abductor muscles is a well-recognised cause of hip pain and considerable disability. These patients present a management challenge, with no established consensus for surgical intervention. Whiteside in 2012 described a surgical technique for gluteus maximus tendon transfer, with successful outcomes reported. This study is the largest known case series to date of patients undergoing gluteus maximus tendon transfer with clinical and patient reported outcomes measured.

13 consecutive patients were included in the study. All patients had clinical evidence of abductor dysfunction together with MRI evidence of gluteal atrophy and fat infiltration. All patients underwent gluteus maximus transfer with surgery performed according to the procedure described by Whiteside. Patients were followed up with both clinical assessment and patient questionnaires conducted.

Mean age was 69 (range 54–82) with 9 patients (69%) having previous Hardinge approach to the affected hip. 6 patients (46%) reported they were satisfied overall with the procedure and 5 patients (38%) were unsatisfied. 7 patients (54%) had improvements in visual analogue scale of pain and 5 patients (54%) reported overall improvements in function. Mean Oxford Hip Score on follow up was 20/48 (range 5–48) and trendelenberg test was positive in 11 patients (85%). No differentiating variable could be identified between patients with positive and negative outcomes (Assessed Variables: Age, sex, BMI, aetiology and gluteus maximus muscle thickness).

Clinical outcomes were varied following gluteus maximus tendon transfer for chronic hip abductor dysfunction. Results are considerably less promising than pre-existing studies would suggest.

The primary aim was to assess survival of the opening wedge high tibial osteotomy (HTO) for medial compartment osteoarthritis. The secondary aim was to identify independent predictors of early (before 12 years) conversion to total knee arthroplasty (TKA).

During the 18-year period (1994–2011) 111 opening wedge HTO were performed at the study centre. Mean patient age was 45 years (range 18–68) and the majority were male (84%). Mean follow-up was 12 (range 6–21) years. Failure was defined as conversion to TKA. Kaplan-Meier, Cox regression and receiver operating curve (ROC) analyses were performed.

Forty (36%) HTO failed at a mean follow-up of 6.3 (range 1–15) years. The five-year survival rate was 84% (95% confidence interval (CI) 82.6–85.4), 10-year rate 65% (95% CI 63.5–66.5) and 15-year rate 55% (95% CI 53.3–56.7). Cox regression analysis identified older age (p<0.001) and female gender (hazard ratio (HR) 2.37, 95% CI 1.06–5.33, p=0.04) as independent predictors of failure. ROC analysis identified a threshold age of 47 years above which the risk of failure increased significantly (area under curve 0.72, 95% CI 0.62–0.81, p<0.001). Cox regression analysis, adjusting for covariates, identified a significantly greater (HR 2.49, 95% CI 1.26–4.91, p=0.01) risk of failure in patients aged 47 years old or more.

The risk of early conversion to TKA after an opening wedge HTO is significantly increased in female patients and those older than 47 years old. These risk factors should be considered pre-operatively and discussed with patients when planning surgical intervention for isolated medial compartment osteoarthritis.

Aims

The aim of this study was to investigate the association between the type of operation used to treat a trochanteric fracture of the hip and 30-day mortality.

Staphylococcus aureus is responsible for 60–70% infections of surgical implants and prostheses in Orthopaedic surgery, costing the NHS £120–200 million per annum. Its ability to develop resistance or tolerance to a diverse range of antimicrobial compounds, threatens to halt routine elective implant surgery. One strategy to overcome this problem is to look beyond traditional antimicrobial drug therapies and investigate other treatment modalities. Biophysical modalities, such as ultrasound, are poorly explored, but preliminary work has shown potential benefit, especially when combined with existing antibiotics.

Using a methicillin-sensitive S. aureus reference strain and the dissolvable bead assay, biofilms were challenged by a low-intensity ultrasound (1.5MHz, 30mW/cm2, pulse duration 200µs/1KHz) for 20 minutes and gentamicin. The outcome measures were colony-forming units/mL (CFU/mL) and the minimum biofilm eradication concentration (MBEC) of gentamicin. The mean number of S. aureus within control biofilms was 1.04 × 109 CFU/mL. There was no clinically or statistically significant (p=0.531) reduction in viable S. aureus following ultrasound therapy alone. The MBEC of gentamicin for this S. aureus strain was 256 mg/L. The MBEC of gentamicin with the addition of ultrasound was 64mg/L. Further studies confirmed that the mechanism of action was due to incomplete disruption of the extracellular matrix with subsequent metabolic stimulation of the dormant biofilm-associated bacteria due to increased nutrient availability and oxygen tension.

Low intensity pulsed ultrasound was associated with a 4-fold reduction in the effective biofilm eradication concentration of gentamicin; bringing the MBEC of gentamicin to within clinically achievable concentrations.

Limited long term data exists comparing operatively and non-operatively treated Achilles tendon ruptures. A previous randomised controlled trial comparing early outcomes showed a short term advantage for surgery, but there are no long term prospective randomised comparisons. Our aim was to determine whether surgery conferred long term benefits in terms of patient reported outcomes or re-rupture.

64 patients (80%) were followed up with postal questionnaires. Patients were asked to complete the Short Musculoskeletal Function Assessment (SMFA), Achilles Tendon Total Rupture Score (ATRS) and EQ-5D questionnaires, and to report re-ruptures.

32 patients were treated non-operatively and 32 operatively; 59 completed the SMFA and 64 the ATRS and EQ-5D assessments. There was no significant difference in SMFA score (median 1.09, IQR 4.89 in the cast group versus 2.17 and 7.07 in the operative group; p=0.347), ATRS (median 96, IQR 18 versus 93 and 15; p=0.509), EQ-5D Index (median 1.0, IQR 0.163 versus 1.0 and 0.257; p=0.327) and EQ-5D Visual Analogue Score (median score 85, IQR 15 versus 85 and 24; p=0.650). There were 2 re-ruptures in the operative group and 4 in the non-operative group (p=0.067).

This is the first prospective, randomised, long term report comparing operative and non-operative management. At follow up between 13–17 years after injury, patients reported good function and health related quality of life. There was no significant difference in re-rupture rate between the treatment groups.

Due to changes in population demographics, the burden of hip fractures in Scotland is expected to rise dramatically over the coming decades. This study aims to establish the future incidence of hip fracture in Scotland in individuals aged 50 and over.

The number of patients admitted to hospital in Scotland with a hip fracture between 1999 and 2016 were ascertained from discharge coding across NHS Scotland. The annual number of hip fractures were categorised to enable gender and age specific hip fracture incidence rates to be calculated. Through static and variable projection methods, the annual hip fracture incidence up to 2035 was forecast and analysed with respect to specific demographics ascertained from population data provided by the National Records of Scotland.

Between 1999 and 2016 the total number of hip fractures in individuals aged 50 and over increased by 11%, from 7,131 to 7,930, equating to an average year-on-year increase of 0.6%. Patients aged over 75 consistently accounted for more than 85% of recorded hip fractures, with females having a higher incidence rate than males across all age groups. A decreasing incidence in females aged over 70 was observed. Using multiple projection methods, the annual number of hip fractures in Scotland is predicted to increase by 55% from 7,930 in 2016, to an average of 12,316 by 2035.

Projection modelling confirms the annual number of hip fractures in Scotland will rise substantially by 2035 with considerable implications for health and social care provision.

Trainees experience significant stress in the operating room, with potentially adverse effects on performance and learning. Psychological resilience explains why some individuals excel despite significant stress, meeting challenges with optimism and flexibility. The purpose of this study was to explore the relationships between trainee resilience, intraoperative stress, and desire to leave residency training.

Qualitative focus groups and a literature review were used to develop a new instrument to assess Surgical TRainee Experiences of StresS in the Operating Room (STRESSOR). STRESSOR was used in a survey of Canadian surgical residents to assess trainee stress. Resiliency was measured using the 10-item Connor-Davidson Resiliency Scale (CD-RISC-10).

The survey was distributed nationally and 171 responses were collected for a 36% response rate. The greatest sources of intraoperative stress were time pressure, attending temperament, and being interrupted by a pager. The STRESSOR instrument had strong reliability (Cronbach's α=0.92) and demonstrated good construct validity using confirmatory factor analysis. The mean CD-RISC-10 score was 28.8, which is similar to that of Canadian medical students. Resilience was protective against intraoperative stress (R2=0.16, p<0.001). Residents with higher stress or lower resilience were more likely to have seriously considered leaving their training program (Spearman's rho = 0.42, p<0.001).

Screening for resilience may assist in selecting trainees who are better able to manage stress during surgery and reduce resident attrition. Resiliency training may help learners manage the high stress environment of the operating room, potentially improving surgical performance and learning in the next generation of surgeons.

Historically rib fractures have been managed conservatively but over recent years evidence has continued to grow in support of fixation in select cases.

Rib fractures can affect patients’ ability to adequately ventilate and increase the morbidity and mortality of patients with multiple injuries. There is increasing evidence that rib fracture fixation in certain patients is of benefit, reducing length of stay both in the Intensive Care Unit (ICU) and overall hospital stay, as well as resulting in a decreased rate of tracheostomy and pneumonia.

We commenced rib fracture fixation two years ago as a combined procedure between Trauma Orthopaedics and Cardiothoracic surgery for carefully identified patients. We instituted a multi-disciplinary decision making process involving the Orthopaedic, Cardiothoracic and ICU teams. We present the initial results for these patients.

Fourteen patients with a total of 49 ribs were fixed between November 2015 and August 2017. Nine patients were acute and multiply injured, with five patients treated with delayed fixation for ventilation problems following non-union of existing fractures.

The average length of stay was 13 days. Follow up is ongoing with a mean follow up of 192 days. There have been no deep infections or acute complications and no incidence of peri-operative pneumothorax in this initial cohort. There have been no deaths, and all of these patients have since been discharged to their own home.

The initial outcomes following the introduction of this new procedure to our unit have been encouraging, although the long term results are awaited.

Acute Kidney Injury (AKI) is an increasingly prevalent complication of lower limb arthroplasty (LLA). Even a transient decrease in kidney function has been shown to be associated with increased mortality and development of subsequent Chronic Kidney Disease (CKD).

We set out to determine which perioperative factors are associated with AKI development at our institution through a retrospective cohort methodology. Patients who underwent primary elective LLA from 01/10/16 to 31/09/17 were included, with relevant perioperative data collected from electronic patient records. AKI was classified according to the Acute Kidney Injury Network (AKIN) criteria.

Overall 6.6% of 686 patients developed an AKI post-operatively. These individuals had a significantly longer length of stay (Median 7 days vs 5 days for no AKI [p<0.001]). Independent predictors of AKI on multivariate regression analysis included: Diabetes (OR 3.10, 95% CI 1.34 to 7.20; p=0.008) CKD (OR 5.07, 95% CI 2.60 to 9.86; p=<0.001) and male sex (OR female sex 0.33, 95% CI 0.17 to 0.63; p=0.001). A model including any of these three risk factors predicted 82.2% of patients with an AKI. The overall AKI rate for this model was 11.2% compared to 2.3% for those without any of the three criteria. Only 11% of patients had IV fluid continued beyond the recovery room.

AKI is a significant problem in LLA. Knowledge of associated risk factors will allow for targeted interventions to decrease AKI incidence. Continuation of IV fluids until the first post-operative morning for high risk individuals may be a simple method of reducing AKI.

This study aimed to ascertain whether stabilising only the AITFL is enough to prevent talar shift, and to test a simple, novel technique to reconstruct the AITFL.

Twelve cadavers were used. Talar shift was measured following: 1- no ligaments cut; 2- entire deltoid ligament division; 3- group A (5 specimens) PITFL cut whilst group B (7 specimens) AITFL cut; 4- group A had AITFL divided whilst group B had the PITFL cut. Reconstruction of the AITFL was performed using part of the superior extensor retinaculum as a local flap. Measurement of talar shift was then repeated.

With no ligaments divided, mean talar shift was 0.8mm for group A and 0.7mm for group B. When the deltoid ligament was divided, mean talar shift for group A was 4.8mm compared to 4.7mm in group B (P=1.00). The mean shift in group A after PITFL division was 6.0mm, increasing the talar shift by an average of 1.2mm. In group B after AITFL division mean talar shift was 8.3mm (P=0.06), increasing talar shift by an average of 3.6 mm. After division of the second tibiofibular ligament, mean talar shift in group A measured 10.0mm and in group B was 10.9mm(P=0.29).

Three times more talar shift occurred after the AIFTL was divided compared to the PITFL. Repairing just the PITFL (for example by fixation of the posterior malleolus avulsion fracture) may not adequately prevent talar shift while reconstruction of the AITFL potentially restores ankle stability.

The modified Glasgow Prognostic Score (mGPS) is a validated prognostic indicator in various carcinomas as demonstrated by several meta-analyses.

The mGPS includes pre-operative CRP and albumin values to calculate a score from 0–2 that correlates with overall outcome. Scores of 2 are associated with a poorer outcome.

Our aim was to assess if the mGPS is reliable as a prognostic indicator for soft tissue sarcoma (STS) patients.

All patients with a STS diagnosed during years 2010–2014 were identified using our prospectively collected MSK oncology database. We performed a retrospective case note review examining demographics, preoperative blood results and outcomes (no recurrence, local recurrence, metastatic disease and death).

94 patients were included. 56% were female and 53% were over 50 years. 91% of tumours were high grade (Trojani 2/3) and 73% were >5cm. 45 patients had an mGPS score of 0, 16 were mGPS 1 and 33 were mGPS 2. On univariate analysis, an mGPS of 0 or 2 was statically significant with regards to outcome (p=0.012 and p=0.005 respectively).

We have demonstrated that pre-treatment mGPS is an important factor in predicting oncological outcome. A score of 0 relates to an improved prognosis whilst a score of 2 relates to an increased risk of developing metastases and death. mGPS as a prognostic indicator was not affected by either the tumour size or grade.

We believe that a pre-operative mGPS should be calculated to help predict oncological outcome and in turn influence management. Further work is being undertaken with a larger cohort.

The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was developed in 2004 to risk-stratify patients with soft tissue infections using common blood tests when the clinical picture is equivocal. A score ≥ 6 conferred a positive predictive value (PPV) of 92% and negative predictive value of 96% for necrotising fasciitis.

We retrospectively calculated LRINEC scores for Orthopaedic patients admitted to ITU in our hospital with limb soft-tissue infection and confirmed Group-A Streptococcus or Staphylococcus in fluid, blood, tissue or swab culture between 2010–2017 (n=10). Mean age = 57.4 and 60% were female. Half of all patients died during admission. Mean LRINEC score of all patients was 5.3±3.1 (median = 6). Mean score in deceased patients was 4.8±2.8 (scores: 0,5,6,6,7; median = 6); in discharged patients mean = 5.8±3.7 (scores: 0,5,7,7,10; median = 7). 6 patients had a score ≥6, making our PPV 60%. 4 patients had necrotising fasciitis confirmed on histology (LRINEC scores = 0,5,7,10).

Our PPV of 60% is less than the figure obtained in the original paper. 2 patients with a LRINEC score <6 died during admission, including a patient with a score of 0. Furthermore, a patient with necrotising fasciitis confirmed on histology also had a LRINEC score of 0. We conclude that LRINEC scores should not delay surgery when clinical suspicion is high, and should be used as an adjunct to clinical decision-making, rather than a replacement, as patients with low LRINEC scores can also have confirmed necrotising fasciitis and poor outcomes.

Early mortality in patients with hip fractures due to bony metastases is unknown. The aim was to quantify 30 and 90-day mortality in patients with metastatic hip fractures and identify markers associated with early death.

Consecutive patients referred to orthopaedics with a metastatic proximal femoral fracture/impending fracture over a six-year period were compared to a matched control group of non-malignant hip fractures. Minimum follow-up was 1 year and data was analysed using the student´s t-test (significance p<0.05).

From Jan 2010-Dec 2015, 163 patients were referred with metastatic proximal femoral lesions. 90-day mortality was three times higher than controls (44% 71/163 vs. 12% 4/33, p<0.01). Mean time from referral to surgery was longer in impending versus completed fractures (11 and 4 days respectively, p<0.05).

Multiple biochemical markers were associated with early mortality in the metastatic group. Patients who died early were more likely to demonstrate low haemoglobin and albumin, and high c-reactive protein, platelets, urea, alkaline phosphatase and calcium (p<0.05).

Several biochemical markers associated with early mortality reached clinical and statistical significance. These markers were combined into a score out of 7 and indicated a higher early mortality in metastatic patients compared to controls. Patients with a score of 5–6/7 were 31 times more likely to die within 90 days versus controls.

This scoring system could be utilised to predict early mortality and guide management. The average delay to surgery of 4 days (completed) and 11 days (impending fractures) identifies a window to intervene and correct these abnormalities to improve survival.

Historically avoidance of avascular necrosis (AVN) has been the primary objective in the management of an acute unstable slipped upper femoral epiphysis (SUFE). When achieved through pinning in situ it was invariably associated with significant malunion. With increasing appreciation of the consequences of femoroacetabular impingement, modern techniques aim to correct deformity and avoid AVN.

Exactly what constitutes an acute unstable SUFE is a source of debate but should represent 5–10% of all cases.

This audit reviewed cases over the past 25 years treated in one region. Of 89 patients with 113 slips, 21 hips were recorded as unstable. During this period the management has evolved from closed reduction and stabilization through pinning in situ, to open reduction.

Radiographic outcomes following these three treatment methods were compared with record of any subsequent surgery in the form of osteotomy or total hip arthroplasty.

Currently the lowest reported incidence of AVN in patients with an acute unstable slip is associated with the Parsch technique which combines open arthrotomy, digital reduction and screw fixation. Early outcomes with this technique are in accordance with those reported in the literature and represents a significant improvement in outcome when compared to earlier techniques used in the management of the severe unstable SUFE.

Bone is the second most commonly transplanted tissue worldwide, with over four million operations using bone grafts or bone substitute materials annually to treat bone defects. However, significant limitations affect current treatment options and clinical demand for bone grafts continues to rise due to conditions such as trauma, cancer, infection and arthritis. The need for a novel, cost effective treatment option for osteochondral defects has therefore never been greater.

As an emerging technology, three-dimensional (3D) bioprinting has the capacity to deposit cells, extracellular matrices and other biological materials in user-defined patterns to build complex tissue constructs from the “bottom up”. Through use of extrusion bioprinting and fused deposition modelling (FDM) 3D printing, porous 3D scaffolds were successfully created in this study from hydrogels and synthetic polymers. Mesenchymal stem cells (MSCs) seeded onto polycaprolactone scaffolds with defined pore sizes and porosity maintained viability over a 7-day period, with addition of alginate hydrogel and scaffold surface treatment with NaOH increasing cell adhesion and viability. MSC-laden alginate constructs produced via extrusion bioprinting also maintained structural integrity and cell viability over 7 days in vitro culture. Growth within osteogenic media resulted in successful osteogenic differentiation of MSCs within scaffolds compared to controls (p<0.001). MSC spheroids were also successfully created and bioprinted within a novel, supramolecular hydrogel with tunable stiffness.

In conclusion, 3D constructs capable of supporting osteogenic differentiation of MSCs were biofabricated via FDM and extrusion bioprinting. Future work will look to increase osteochondral construct size and complexity, whilst maintaining cell viability.

The aim of this study was to identify psychosocial factors associated with pain intensity and disability following distal radius fracture (DRF).

We prospectively followed up 216 adult patients with DRF for 9 months. Demographics, injury and treatment details and psychological measures (Hospital Anxiety and Depression Score (HADS), Pain Catastrophising Scale (PCS), Post Traumatic Stress Disorder Checklist – Civilian (PCL-C), Tampa Scale for Kinesiophobia (TSK), Illness Perception Questionnaire Brief (IPQB), General Self-efficacy Scale (GSES) and Recovery Locus of Control (RLOC)) were collected at enrolment. Multivariable linear regression was used to identify factors associated with DASH and Likert pain score.

Ten week DASH was associated with age (β-coefficient (β)= 0.3, p < 0.001), deprivation score (β=0.2, p = 0.014), nerve injury (β=0.1, p = 0.014), HADS depression (β=0.2, p = 0.008), IPQB (β=0.2, p = 0.001) and RLOC (β= −0.1, p = 0.031). Nine month DASH was associated with age (β=0.1, p = 0.04), deprivation score (β=0.4, p = 0.014), number of medical comorbidities (β=0.1, p = 0.034), radial shortening (β=0.1, p = 0.035), HADS depression (β=0.2, p = 0.015) and RLOC (β= −0.1, p = 0.027). Ten week pain score was associated with deprivation score (β=0.1, p = 0.049) and IPQB (β=0.3, p < 0.001). Pain score at 9 months was associated with number of medical comorbidities (β=0.1, p = 0.047).

Psychosocial factors are more strongly associated with pain and disability than injury or treatment characteristics after DRF. Identifying and treating these factors could enhance recovery.

Aims

This study describes and compares the operative management and outcomes in a consecutive case series of patients with dislocated hemiarthroplasties of the hip, and compares outcomes with those of patients not sustaining a dislocation.

Aims

The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb.

Aims

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.

Aims

The aims of this study were to evaluate the incidence of postoperatively restricted weight-bearing and its association with outcome in patients who undergo surgery for a fracture of the hip.

Aims

Recent studies of nonoperatively treated displaced midshaft clavicular fractures have shown a high incidence of nonunion and unsatisfactory functional outcome. Some studies have shown superior functional results and higher rates of healing following operative treatment. The aim of this study was to compare the outcome in these patients after nonoperative management with those treated with fixation.

Aims

We aimed to determine the effect of dementia and Parkinson’s disease on one, three and 12-month mortality following surgery for fracture of the hip in elderly patients from an Asian population.

Aims

Little is known about the effect of haemorrhagic shock and resuscitation on fracture healing. This study used a rabbit model with a femoral osteotomy and fixation to examine this relationship.

Aims

This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent.

Aims

The aims of this study were to quantify health state utility values (HSUVs) after a tibial fracture, investigate the effect of complications, to determine the trajectory in HSUVs that result in these differences and to quantify the quality-adjusted life years (QALYs) experienced by patients.

Aims

The aims of this study were to establish whether composite fixation (rail-plate) decreases fixator time and related problems in the management of patients with infected nonunion of tibia with a segmental defect, without compromising the anatomical and functional outcomes achieved using the classical Ilizarov technique. We also wished to study the acceptability of this technique using patient-based objective criteria.

Aims

The aim of this study was to compare the functional and radiological outcomes in patients with a displaced fracture of the hip who were treated with a cemented or a cementless femoral stem.

Aims

The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization.

Aims

The Edinburgh Trauma Triage Clinic (TTC) streamlines outpatient care through consultant-led ‘virtual’ triage of referrals and the direct discharge of minor fractures from the Emergency Department. We compared the patient outcomes for simple fractures of the radial head, little finger metacarpal, and fifth metatarsal before and after the implementation of the TTC.

Aims

This study aimed to investigate the role of quantitative histological analysis in the diagnosis of fracture-related infection (FRI).

Aims

A high rate of suicide has been reported in patients who sustain fractures, but the association remains uncertain in the context of other factors. The aim of this study was to examine the association between fractures and the risk of suicide in this contextual setting.

Aims

Outcome measures quantifying aspects of health in a precise, efficient, and user-friendly manner are in demand. Computer adaptive tests (CATs) may overcome the limitations of established fixed scales and be more adept at measuring outcomes in trauma. The primary objective of this review was to gain a comprehensive understanding of the psychometric properties of CATs compared with fixed-length scales in the assessment of outcome in patients who have suffered trauma of the upper limb. Study designs, outcome measures and methodological quality are defined, along with trends in investigation.

Aims

The aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS).

Aim

The aim of this study was to determine whether the absence of periosteal reaction on plain radiographs was predictive of exchange nail failure in lower limb diaphyseal fracture non-unions.

Abstract

Distraction Osteogenesis (DO) for the management of bone defects in long bones is an established technique. Problems with bone regeneration are a common occurrence and literature is full of different modalities to enhance regenerate formation and quality. Strontium Ranelate (SR) has a dual mode of action and enhances bone formation in addition to decreasing osteoclastic activity. Due to this dual mode of action as well as ease of administration in a suspension form, it makes an ideal drug in scenarios where realignment of bone homeostasis towards positive bone balance is desirable. We studied the relationship of administration of SR with rate of regenerate progression, docking site union and complications associated with bone transport in 48 patients undergoing bone transport for management of bone defects. The findings of our retrospective observation study indicated that compliant use of SR was associated with good regenerate progression, decreased problems with docking site union and decreased the need for additional interventions.

Purpose

Pilon fracture is a severe injury which has a great impact on the patients' lives, but in what extend is not clear yet in the literature. The purpose of this study was to investigate the gait alternations after treatment of patients who had pilon fractures.

Introduction

Plate fixation for distal femoral fractures is a commonly used method of fracture stabilisation. Many orthopaedic surgeons traditionally do not allow their patients to weight bear for the first 6 weeks after surgery, fearing of loss of fracture reduction and metalwork failure. The aim of this study is to investigate whether the post-operative weight bearing status after plate fixation influences the outcome in terms of loss of reduction and metalwork failure.

Background

In a systematic review of 1125 distal tibia fractures treated with an intramedullary nail, the reported incidence of malalignment was 14%. The purpose of our study is to assess whether the addition of blocking screws during intramedullary nailing of a distal tibia fracture improved radiological outcomes. As a secondary outcome, the time to radiographic union was compared to see if a more rigid bone-implant construct had an effect on healing.

Background

Humerus fracture non-union is a challenge for which a wide range of treatments exist. We present our experience of managing these by hybrid Ilizarov frame fixation, without bone graft or debridement of the non-union site.

Introduction

Anatomical reduction of articular fragments in tibial plateau fractures often leads to a void and there is a need to fill dead space and support the articular fragment. MIIG X3 is marketed as high strength injectable graft, which resorbs and remodels fast. Efficacy and complications related to the use of this bone graft substitute were evaluated in this study

Aim

To quantify the micro-motion at the fracture gap in a tibial fracture model stabilised with an external fixator.

Aim

Previous studies of primary internal fixation of infected non-unions have reported high failure rates. Local antibiotic carriers and coatings have been advocated to reduce infection around implants and allow bone healing. We evaluated the effect of a calcium sulphate/hydroxyapatite antibiotic-loaded composite on bone healing and the eradication of infection in combination with internal fixation.

Aim

To investigate the biomechanical behaviours of the TL-Hex & Taylor Spatial Frame (TSF) Hexapod external fixators, with comparison to traditional ring-fixator constructs.

Background

The viability of any surgical practice relies on the income that practice generates for the parent NHS Trust. The OPCS codes are a key determinant of an NHS trust's tariff for an admission. These contribute to the HRG codes - the means the NHS uses to determine the value of a patient's treatment, including operations. The clinical knowledge of coders may not differentiate specialist practice, including circular frames.

Background

Patients requiring lower limb reconstruction have often undergone significant trauma. In some patients this is a consequence of self-harm, others develop depression as a result of the accidental trauma that caused their injury. Little is known of the extent of the problem and how it changes over the course of their treatment.

Aim

The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and ‘locking’ plate fixation in the treatment of extra-articular fractures of the distal tibia.

Aim

The aim was to investigate the value of quantitative histological analysis in the diagnosis of fracture-related infection (FRI).

Background

Disruption of the normal relationship between the proximal tibia and fibula is seen in a number of different conditions such as skeletal dysplasias and post-infective deformity, as well as the consequence of lengthening procedures. Radiographic indices for the tibio-fibular relationship at the ankle have been described, but no similar measures have been reported for the proximal articulation.

Introduction

Distraction histogenesis is utilised for cosmetic reasons in patients with constitutional short stature, achondroplasias, or height dysphoria. One of the considerations of patients and surgeons alike, is the preservation of aesthetically acceptable body proportions after the lengthening i.e which segment of the lower limb to lengthen and by how much, in order to preserve the patient's proportions within -or as close as possible to- the normal range of human body proportions. Sound anthropometric data on the normal range of the human body proportions is currently lacking. The aim of this study is to calculate the normal range of the ratio between the lengths of the lower limb, upper limb, femur, tibia, stature and trunk.

Background

Medical grade Calcium Sulphate can be used as a delivery vehicle for antibiotics. We use these for treating patients with established osteomyelitis, but also use it prophylactic for contaminated war injuries, to fill voids in bone with osteo conductve filler that delivers local antibiotics, and can integrate with bone. Although antibiotic loaded calcium sulphate is increasingly used, there is little data to demonstrate that systemic levels generated by local release of antibiotics are safe. For this reason, we routinely assay systemic levels of antibiotics.

Introduction

Aim of this study was to review a single surgeon series and analyse the results of hip reconstruction and compare them to an historical cohort.

Introduction

This study evaluates the need for limb reconstruction surgery in Syria and gives examples of how this service has been delivered by UK surgeons. The conflict in Syria has resulted in over 500,000 deaths and 1.2 million injured. There is not yet a centre for limb reconstruction surgery in the country. Injuries from gunshots and shrapnel were not common prior to the civil war resulting in a paucity of experience.

Introduction

This study reviews the orthopaedic care of the thirteen patients who were admitted and treated at Royal Manchester Children's' Hospital following the Manchester Arena Bomb blast

Introduction

Fractures of the distal tibia can be challenging to manage. Numerous surgical techniques have been utilised in managing these however there remains debate as to the optimum method of fixation. This study aims to assess the surgical outcomes and PROMs of patients with distal tibial fractures managed with intramedullary-nails or ring fixation.

Introduction

The case of Montgomery in 2015 considered standards of risk disclosure, whether alternative treatments had been discussed, standards of professional performance, and the importance of patient autonomy.

There is an ongoing revolution in the use of data within orthopaedics and medicine in general, with an imperative for surgeons to be involved from the bottom up and better define the data collection culture.

The use of registries plays a major role in the development of “big data” in orthopaedics. There are multiple examples that are already set up and running, both those inspired and set up by clinicians or those where the main stakeholders may lay people, with some input from clinicians. The British Limb Reconstruction society is no exception, with registries for lengthening nails and pilon fractures due to roll out imminently.

The BLRS has tasked this years BOA clinical leadership fellow to investigate the current state of registries among the specialist orthopaedic societies. In particular, comparison of the already well established registries and national audits with the development of registry projects in the smaller societies.

The issues of funding, consent, infrastructure and governance each infer particular challenges when translating the methods of the larger registries to the needs and resources of a smaller group. We have aimed to consider these challenges in relation to the set-up of the BLRS registries in order to better understand the potential future pitfalls and opportunities.

Background

Many patients undergo frame removal in the outpatient setting and nitrous oxide is frequently used, but has varying effects. The aim of the study was to ascertain whether pain levels during frame removal are improved with local infiltration of local anaesthetic (LA) and to assess the effect of LA and nitrous oxide compared to nitrous oxide alone.

Aims

The management of a significant bony defect following excision of a diaphyseal atrophic femoral nonunion remains a challenge. We present the outcomes using a combined technique of acute femoral shortening, stabilized with a long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis with a temporary monolateral fixator.

Aims

The aim of this study was to record the incidence of post-traumatic osteoarthritis (OA), the need for total hip arthroplasty (THA), and patient-reported outcome measures (PROMS) after surgery for a fracture of the acetabulum, in our centre.

Background

To compare quality of life during treatment in children and adolescents with tibial fracture treated with either a definitive cast or Ilizarov frame.

Introduction

Managing open tibial fractures according to national guidelines is a primary focus for major trauma centres, however pressures of capacity and expertise limit the capability to achieve all of these standards for every patient. Debate remains over the impact of particular aspects of guidance, especially in relation to the timing of surgical interventions. Evaluation of these tenants of care predominantly hinge on trends derived from low level scientific evidence, mainly due to the difficulty in completing high level studies. The aim of this study is to assess the complication rates and the associations with difficulties in achieving the national guidance standards.

Introduction

Muscle stiffness and joint contractures are common complications of limb lengthening. Authors have demonstrated less permanent soft tissue complications with intramedullary lengthening than external fixation. Our aim was to evaluate the joint response following intramedullary femoral lengthening and need for physiotherapy and alteration to rate/rhythm of lengthening.

Introduction

Our unit has extensive experience with the use of Ilizarov circular frames for acute fracture and nonunion surgery. We have observed and analysed fracture healing patterns which question the role of relative stability in fracture healing and we offer limb mechanical axis restoration as a more important determinant.

Background

Ilizarov hip reconstruction is a salvage option traditionally done with fixators, which often face limited compliance. We aimed at reviewing our early results of a novel technique with internal devices.

Background

To improve patient pathways we have, in selected patients, begun to acutely apply circular (rather than temporary monolateral) fixators with simultaneous or subsequent soft tissue closure. We present early results.

Introduction

Ilizarov fixator is an invaluable tool in managing complex orthopaedic problem. Many factors influence adverse events such as pin site infections and failure of treatment. Our study evaluated risk factors affecting patient compliance and unfavourable outcome of Ilizarov surgery.

Purpose

Angular deformity in the lower extremities can result in pain, gait disturbance, cosmetic deformity and joint degeneration. Up until the introduction of guided growth in 2007, which has since become the gold standard, treatment for correcting angular deformities in skeletally immature patients had been either an osteotomy, a hemiepiphysiodesis, or the use of staples.

Background

The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications.

Introduction

Fracture and deformity after frame removal is a known risk in 9–14.5% of patients after circular frame treatment. The aims of this study were to assess the effectiveness of our staged protocol for frame removal and risk factors for the protocol failure.

Introduction

Segmental bone defect is a challenging problem. We report our experience of bone transport by hexapod external fixator in patients with segmental defects if the tibia.

Purpose of study

To review the treatment and outcomes of paediatric pelvic ring injuries in the UK

Aims

The use of local antibiotic carriers in the treatment of chronic osteomyelitis is an important adjunct in dead space management. We present the outcomes of two different biodegradable antibiotic carriers used in the management of chronic osteomyelitis.

Purpose

Surgical correction of upper limb deformities in severe osteogenesis imperfecta (OI) is technically difficult and less absolving, hence we aimed to analyse the surgical complications of rodding the humeri in severe OI.

Aim

Simultaneous application of Ilizarov frames and free muscle flaps to treat osteomyelitis or infected non-unions is currently not standard practice in the UK, in part related to logistical issues, surgical duration and challenging access for microvascular anastomosis. We present the outcomes for 56 such patients.

Purpose

To review the natural history of posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition.

Background

It is an accepted fact that Ilizarov frames are difficult to live with. Professionals advise patients that things get easier over time, but, there is little evidence to support this. This study examined the course of patient's self-reported anxiety and depression during treatment with an Ilizarov frame.

Purpose

To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss.

Background

The circular Ilizarov frame is a well-established method of external fixation used in the acute treatment of fractures. In our unit, based on our experience, we have changed practice from an all-wire construct to a hybrid, incorporating one 5mm titanium half-pin in the distal reference construct. We were able to compare the all-wire construct against this hybrid in terms of time to union and complications.

Background

There exists no consensus opinion as to the most suitable post-operative rehabilitation and weight bearing status for proximal tibia articular fractures treated with internal fixation using plates and screws.