The Syn-VAR RCT is the first of its kind comparing hamstrings autograft v synthetic neoligament for MPFL reconstruction. Our aim is to evaluate short and long term patient related outcomes measures (PROMs) following synthetic / autologous MPFL reconstruction in a heterogenous cohort of patients with recurrent patellar instability. 20 patients meeting inclusion criteria were recruited and randomised. Standardised surgery was performed by a single surgeon in Altnagelvin Hospital with data collected over 3 years from 2016. Kujala score was the primary outcome measure with data captured preoperatively and 12 weeks/2 years postoperatively. Secondary outcomes included four other validated scores and complications including Norwich Patellar Instability, Lysholm, IKDC and BanffAbstract
Introduction
Method
Whiplash injury is surrounded by controversy in both the medical and legal world. The debate on whether it is either a potentially serious medical condition or a social problem is ongoing. This paper briefly examines a selection of studies on low velocity whiplash injury (LVWI) and whiplash associated disorder (WAD) and touches upon the pathophysiological and epidemiological considerations, cultural and geographical differences and the effect of litigation on chronicity. The study concludes that the evidence for significant physical injury after LVWI is poor, and if significant disability is present after such injury, it will have to be explained in terms of psychosocial factors.
Dual energy X-ray absorptiometry (DEXA) is the gold standard for assessing bone mineral density (BMD) and fracture risk in vivo. However, it has limitations in the spine because vertebrae show marked regional variations in BMD that are difficult to detect clinically. This study investigated whether micro-CT can provide improved estimates of BMD that better predict vertebral strength. Ten cadaveric vertebral bodies (mean age: 83.7 +/− 10.8 yrs) were scanned using lateral-projection DEXA and Micro-CT. Standardised protocols were used to determine BMD of the whole vertebral body and of anterior/posterior and superior/inferior regions. Vertebral body volume was assessed by water displacement after which specimens were compressed to failure to determine their compressive strength. Specimens were then ashed to determine their bone mineral content (BMC). Parameters were compared using ANOVA and linear regression.Introduction
Methods
The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration. Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed. Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture]. rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases.
The purpose of the study was to establish an algorithm for the treatment of pathological fractures in children. Pathological fractures can compromise radiographic and histological diagnosis. The need for histological diagnosis and indications for surgical treatment are not clearly defined. We reviewed our Centre’s Tumour Registry records of children who presented over the past 7 years with a fracture as the first manifestation of primary bone pathology. There were 23 patients (average age 12 years and 2 months). There were 9 fractures through simple bone cysts, all treated conservatively initially. All patients were subsequently treated with needle biopsy and bone marrow injection. Three patients suffered refracture and underwent flexible intramedullary nail fixation. There were 5 cases of fibrous dysplasia. Histological diagnosis was obtained in all cases, followed by prophylactic intramedullary nailing in 3 patients. There were 2 patients with giant cell tumour, 3 with aneurysmal bone cyst and one with chondroblastoma. Histological diagnosis preceded curettage and grafting in all cases. Finally, there were 3 patients with Ewing’s sarcoma of the femur. One underwent palliative intramedullary nailing for extensive local disease. The second patient was treated conservatively initially. She subsequently underwent segmental resection and vascularised fibular graft. The third patient underwent internal fixation in another unit for what was considered to be a benign lesion. The histological diagnosis of Ewing’s sarcoma was based on intra-operative specimens. Definitive surgery required wide resection and prosthetic replacement. We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. All lesions should be appropriately imaged and biopsied if aggressive characteristics are present. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.
We present an evaluation of basic surgical orthopaedic operative training in the last 15 years, using multiple trauma and elective training procedures in orthopaedics. Identifying the influence of competency training and EWTD on Basic Surgical Training. Whilst trying to identify the area’s the MMC should concentrate on to provide a competent trainng programme. We assessed clinical exposure using 45 Basic Surgical Trainee Logbooks, from posts in 1990 (n=6), 1995 (n=7), 2000 (n=10), and 2004–5 (n=22); and looked at numbers of carpel tunnel decompression, and emergency hip, wrist, and ankle surgeries conducted. As well as the number of external fixators trainees were exposed to. In the 2004–5 group we prospectively assessed competency and knowledge of fracture neck of femur surgery. From a peak in operative surgery in 1990 numbers have fallen. Today, BST’s participate in 165 emergency hip cases (mean 4.6 procedures per trainee), today, 4.8% (n=8) as primary surgeon. In 1990, and 2000 trainees were primary surgeon in 43.4% (n = 12/32) and 25.2% (n=33/131) respectively. Trainees are comfortable with closure of skin, subcutaneous and muscular layers but not access; 91% (n=20) required assistance in positioning, and reduction, and recognition of correct alignment. Only 9.1% (n=2) felt competent without senior supervision (mean Orthopaedic BST experience 15.3 months) in hip surgery; whilst none knew of an intra-operative technique to reduce young adult capsular hip fractures. With regards to wrist and ankle fixation the decline has been dramatic decline by 11.1 and 5.9 procedures per trainee. Whilst, the numbers of forearm manipulations peaked in 1990–1995; it has since dropped to less than 5 per trainee in 2005 from 15–16. In 2005, it was also seen that a in a 6 month period a trainee in a typical district general hospital would be lucky to see an external fixator applied (average 0.6 per trainee in 6 month period). The decline of elective surgery is shown in carpel tunnel decompressions attended. In 1990 9.8 (6–14) were conducted as a primary operator, in 2005, it was 0.5 (0–3). The greatest decline in procedures of 46.3% occurred between 2000, to 2005. A comparison of total operating showed 88.9 (n=79–125) procedures in 6 months were lost between 1990 and 2005; with a 58.6% loss in trauma. This study suggests deficiency in operative competence today due to reduced opportunities. Thus emphasis should be placed on rota’s being matched to operative exposure, as trainee case numbers have declined sharply particularly in the last 5 years. The MMC should therefore ensure that trainees in the ST1 to 3 years reach their competencies with adequate time in the operating theatre.
The management of pathological fractures in children remains controversial. The indications for surgical treatment are unclear and the need for histological diagnosis before or after definitive treatment is not clearly defined. We reviewed retrospectively the records of all patients under the age of 16 years who presented over the past 7 years with a fracture as the first manifestation of bone pathology. There were 26 patients (19 boys and 7 girls) of an average age of 12 years and 2 months (range 4.1–15.8 years). There were 9 cases of fracture through a simple bone cyst, 6 in the humerus and 3 in the femur. In all cases the fracture was treated conservatively initially. Subsequent management included needle biopsy in all, followed by bone marrow injection under the same anaesthetic. The patients suffered a refracture and were treated with flexible intra-medullary nail fixation. There were 5 cases of fibrous dysplasia, of which 2 in the femur, 2 in the tibia and one in the proximal radius. Histological diagnosis was obtained in all cases prior to definitive treatment. This included a locked intra-medullary nail in one patient and flexible nailing in another two. The remaining two patients are still under observation. There were 2 patients with giant cell tumour, 3 patients with aneurysmal bone cyst and one patient with chondroblastoma. Histological diagnosis preceded treatment with curettage and grafting in all these cases. There were 6 patients with malignant primary bone tumour, 1 adamantinoma, 2 osteosarcoma, and 3 with Ewings Sarcoma. The 3 patients with Ewing’s sarcoma involved the femur. One had extensive local disease and early intra-medullary nailing was performed for palliative reasons. The second patient was treated conservatively initially. Definitive surgery was performed after fracture healing and included segmental resection and vascularised fibular graft. The third patient was initially treated elsewhere. She was thought to have a benign lesion and internal fixation with a screw/plate device was performed. Histology from intra-operative specimens confirmed Ewing’s sarcoma. Definitive surgery required extensive resection and prosthetic replacement. The 2 patients with osteosarcoma had fracture of proximal humerus and distal femur. The former was treated by forequarter amputation as there was tumour involvement of brachial plexus and remains AWND at 7 years. The latter had resection and EPR of the distal femur. One patient with adamantinoma underwent segmental resection and reconstruction with VFFG We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic.
Firearm injury is a potentially increasing public health problem worldwide. It is increasingly the subject of media and public attention. We aim to analyze the epidemiology, pattern and outcome as experienced. Data such as age, sex, race, scene and nature of injury, firearm used, alcohol and drug factors, anatomy involved, surgical requirements, transfusion details, ICU/HDU stay, complications, deaths, and outcome were collected from medical notes, WYMAS and Coroners office of all patients who presented with firearm injuries from January 1995 to December 2001. Seventy-eight cases presented to our institution. There were 19 fatalities at the scene of injury. 69 were male. 51 sustained injuries in public places, 20 at their homes and 7 in outdoor areas. Low velocity firearms were involved in 49 cases. 50 were crime related. Alcohol was identified in 34 patients and illicit drugs in 6 cases. 19 cases had bony injury with associated vascular injury in one case. Primary neurological injury was diagnosed in 5 cases. Lower extremities and upper limb injuries accounted for 59% and 26%. 3 had head and neck wounds. 4 patients had thoracic trauma and 5 had abdominal injury. 86% required surgical intervention. 11 patients had a total of 16 complications, the most common being secondary infection. 6% of patients died at the emergency department and 3 after. Chest injuries caused 5 deaths and head wounds caused 3 deaths illustrating criminal intention to cause fatal body harm.
We have reviewed the patients with vertical shear fractures of the Pelvis and report on our treatment protocol and long-term functional outcome. Methods: Between January 1993 and January 2002, out of 581 pelvic ring injuries treated in our unit, we identified 31 vertical shear fractures in 29 (4.9%) patients (4 female). Data such as age, sex, aetiology, associated injuries, ISS, resuscitation and transfusion requirements were recorded. ICU/HDU stay, surgical stabilization, urological injuries, systemic complications, neurological injury and mortality were recorded and analysed. Functional outcome was assessed using the following generic tools: EuroQol EQ-5D, SF36v2, SMFA, Majeed score and VAS.
To assess the functional outcome of operative and non-operative treatment of distal humeral fractures in the elderly, patients above 75 years of age were studied. Demographic data including associated injuries and co-morbid conditions were recorded. The minimum follow-up was 16 months (range 16–92 months). Elbow function was analysed according to the OTA rating system. Radiographs were monitored for possible predictors of final functional outcome Out of 125 patients with distal humeral fractures, 29 were above the age of 75 years. The mean age at the time of admission was 84.6 years (range 75–100). One patient was lost to follow-up. In total there were 28 patients with 29 fractures. 5 of these were open fractures. As per the AO classification, there were 8 type A, 8 type B, and 13 type C fractures. 8 patients were treated non-operatively (3 type A, 2 type B, 3 type C) and 21 (5 type A, 6 type B, 10 type C) operatively. An olecranon osteotomy was performed in 12 cases, 2 underwent triceps tongue reflection, and 7 had triceps splitting. Local complications included 4 cases (1 deep and 3 superficial) of infection and 3 non-unions (including one at the olecranon osteotomy). In the non-operative group the mean loss of extension and mean flexion achieved were 34.0 and 70.0 degrees respectively, whereas in the operative group the corresponding values were 23.0 and 107 degrees. OTA grading revealed 3 excellent, 9 good, 7 fair and 2 poor results in the operated group whereas in the non-operated group there were 0 excellent, 2 good, 3 fair, and 3 poor results. There was direct correlation between loss of anterior tilt of the distal humerus and adverse outcome.
We prospectively studied 29 patients with distal femoral fractures stabilised using the less invasive stabilisation system [LISS]. Four patients were excluded from the final follow up [3 deaths and 1 case of quadriplegia]. The mean age of the remaining 25 patients [9 males] was 60.9 years and the mean follow up 18 months [12–24]. Eleven patients were tertiary referrals from other hospitals [7 cases were referred due to failure of primary fixation]. Overall, there were 12 cases of high-energy trauma [7 open fractures]. According to the AO classification there were 5 Type 33A, 2 Type 33B and 12 Type 33C fractures and 4 Type 32A, 1 Type 32B, 1 Type 32C fractures. Functional assessment was performed using the Modified HSS and the Schatzker and Lambert scores. The average time to union in 22 cases was 3.5 months [range, 2–5]. None of the acute cases required bone grafting with a 100% union rate. There were 3/7 cases of non-union in the salvage group still undergoing treatment. The overall results in the acute cases were good and in the salvage cases fair. While this is a small series of patients, our preliminary data indicate favourable results using the LISS in stabilizing acute distal femoral fractures. However, when the LISS is used as a revision tool despite the concept of preserving the bone biology, the results seem to be less satisfactory. The system appears to be user friendly and no technical difficulties were encountered.
There were 6 cases of residual varus deformity (2 with 15 and 4 with 20 degrees) and 3 cases of leg length discrepancy (2.5 cm, 2 and 1.5 cm respectively). All the fractures but 2 progressed to union (one is currently awaiting for a total knee replacement). Functional assessment according to American Knee assessment score was good in 25 cases (80.64%), fair in 4 cases (12.87%) and poor in 2 cases (6.49%). The overall functional score was 93.6%. 9 patients had to do some modifications in their current employment and 7 patients were unable to return to their previous employment. Evidence of radiological OA was present in 18 out of 31 cases (58.6%). A poor correlation between presence of radiological OA and functional outcome was noted.
The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union. 14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Seven fractures were originally open (grade IIIb). All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. Following initial stabilisation, all the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. The average length of follow-up was 24 months following exchange nailing. There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5/14 (35.7%) cases. 4 patients required further soft tissue debridement and a free flap to secure union. Of the remaining 5 patients, 1 required dynamisation, another required incision and drainage of peri-fracture abscess, the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24). In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis.
In the first few months of life, a notch may be seen on radiographs of the superolateral margin of the infant hip. It may be associated with a steeply inclined acetabular roof and may be an indicator of persistent neonatal instability or displacement of the femoral head.