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The Bone & Joint Journal
Vol. 106-B, Issue 3 | Pages 232 - 239
1 Mar 2024
Osmani HT Nicolaou N Anand S Gower J Metcalfe A McDonnell S

Aims

To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults.

Methods

The James Lind Alliance (JLA) methodology for Priority Setting Partnerships was followed. An initial survey invited patients and healthcare professionals from the UK to submit any uncertainties regarding soft-tissue knee injury prevention, diagnosis, treatment, and rehabilitation and delivery of care. Over 1,000 questions were received. From these, 74 questions (identifying common concerns) were formulated and checked against the best available evidence. An interim survey was then conducted and 27 questions were taken forward to the final workshop, held in January 2023, where they were discussed, ranked, and scored in multiple rounds of prioritization. This was conducted by healthcare professionals, patients, and carers.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_18 | Pages 12 - 12
1 Dec 2023
Basheer S Ali F Nicolaou N
Full Access

Introduction

Patellofemoral instability is one of the most common presentations to a children's orthopaedic clinic. Recurrent patellar dislocations and instability episodes are painful, disabling and increase the risk of irreversible chondral damage. The medial patellofemoral ligament is the primary static stabiliser to prevent lateral dislocation of the patella and is almost always torn or attenuated in these cases. Reconstruction of this ligament is commonly performed using autologous hamstring tendon however there has been some interest recently in use of quadriceps tendon as a graft. Children with patellar instability also present unique challenges due to the small size of the patella and the presence of open growth plates which may require adaptations to the common techniques.

Methods

Patients undergoing medial patellofemoral ligament reconstruction using quadriceps tendon autograft were identified using electronic theatre records. Prospectively collected clinical records and imaging findings were reviewed and underlying pathology, additional procedures at time of MPFL reconstruction, current function and need for further revision surgery determined.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_18 | Pages 2 - 2
1 Dec 2023
Basheer S Kwaees T Tang C Ali F Haslam P Nicolaou N
Full Access

Objectives

Congenital cruciate ligament deficiency is a rare condition that may occur in isolation or in association with longitudinal limb deficiencies such as fibular hemimelia or proximal femoral focal deficiency. Often anomalies of the menisci and their attachments can be very abnormal and impact on surgical management by standard techniques. Arthroscopic surgical knee reconstruction is undertaken to improve symptomatic instability and/or to stabilise and protect the knee for future planned limb lengthening surgery.

The aim of this study is to evaluate the arthroscopic findings of patients undergoing surgery for congenital cruciate ligament deficiency, and specifically to determine the frequency and types of meniscal anatomical variations seen in these cases.

Methods

Patients undergoing surgery for congenital cruciate ligament deficiency were identified from a prospectively collated database. Diagnosis was confirmed through review of the clinical notes and imaging. Operative notes and 4K saved arthroscopic images and video recordings for these cases were reviewed.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_18 | Pages 1 - 1
1 Dec 2023
Osmani H Nicolaou N Anand S Gower J Metcalfe A McDonnell S
Full Access

Introduction

The knee is the most commonly injured joint in sporting accidents, leading to substantial disability, time off work and morbidity (1). Treatment and assessment vary around the UK (2), whilst there remains a limited number of high-quality randomised controlled trials assessing first time, acute soft tissue knee injuries (3,4). As the clinical and financial burden rises (5), vital answers are required to improve prevention, diagnosis, treatment, rehabilitation, and delivery of care. In association with the James Lind Alliance, this BASK, BOSTAA and BOA supported prioritising exercise was undertaken over a year.

Methods

The James Lind Alliance methodology was followed; a modified nominal group technique was used in the final workshop. An initial survey invited patients and healthcare professionals to submit their uncertainties regarding soft tissue knee injury prevention, diagnosis, treatment, rehabilitation, and delivery of care. Seventy-four questions were formulated to encompass common concerns. These were checked against best available evidence. Following the interim survey, 27 questions were taken forward to the final workshop in January 2023, where they were discussed, ranked, and scored in multiple rounds of prioritisation by groups of healthcare professionals, patients, and carers.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 48 - 48
7 Aug 2023
Hampton M Reed D Ali F Nicolaou N Ajuied A
Full Access

Abstract

Introduction

There is currently very little evidence which can be used to guide surgeons treating skeletally immature patients with suspected meniscal injury. The aim of our modified Delphi study was to develop comprehensive recommendations for the management of isolated meniscal tears in skeletally immature children.

Methodology

An international, two round, modified Delphi consensus was completed. Included ‘experts’ were identified as having an established adult and/or paediatric knee practice and either: 1) Faculty at the international kid's knee meeting, 2) Active member of the complex national paediatric MDT group, or 3) faculty on recognised national course aimed at teaching knee surgeons regarding the management of meniscal lesions. A threshold of 70% was used to identify consensus.


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_13 | Pages 12 - 12
7 Aug 2023
Osmani H Nicolaou N Anand S Metcalfe A McDonnell S
Full Access

Abstract

Introduction

The knee is the most commonly injured joint in sporting accidents. They cause substantial disability, time off work and long-term problems. There remains a limited number of high-quality randomised controlled trials assessing first time, acute soft tissue knee injuries. Key areas requiring answers include prevention, diagnosis, treatment, rehabilitation and delivery of care. In association with the James Lind Alliance, this BASK, BOSTAA and BOA supported prioritising exercise was undertaken over a year.

Methodology

The James Lind Alliance methodology was followed. An initial survey invited patients and healthcare professionals to submit their uncertainties regarding soft tissue knee injury prevention, diagnosis, treatment, rehabilitation and delivery of care. Over 1000 questions were submitted. Seventy-four questions were formulated to encompass common concerns. These were checked against best available evidence. Following the interim survey, 27 questions were taken forward to the final workshop in January 2023, where they were discussed, ranked and scored in multiple rounds of prioritisation by groups of healthcare professionals, patients and carers.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_5 | Pages 40 - 40
1 Apr 2022
Hafez M Nicolaou N Dixon S Obasohan P Giles S Madan S Fernandes J Offiah A
Full Access

Introduction

Motorised intramedullary lengthening nails are considered more expensive than external fixators for limb lengthening. This research aims to compare the cost of femoral lengthening in children using the PRECICE magnetic lengthening nail with external fixation

Materials and Methods

Patients: Retrospective analysis of 50 children who underwent femoral lengthening. One group included patients who were treated with PRECICE lengthening nails, the other group included patients who had lengthening with external fixation. Each group included 25 patients aged between 11–17 years. The patients in both groups were matched for age. Cost analysis was performed following micro-costing and analysis of the used resources during the different phases of the treatments.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_5 | Pages 35 - 35
1 Apr 2022
See CC Al-Naser S Fernandes J Nicolaou N Giles S
Full Access

Introduction

Metabolic bone disease encompasses disorders of bone mineralization, abnormal matrix formation or deposition and alteration in osteoblastic and osteoclastic activity. In the paediatric cohort, patients with metabolic bone disease present with pain, fractures and deformities. The aim was to evaluate the use of lateral entry rigid intramedullary nailing in lower limbs in children and adolescents.

Materials and Methods

Retrospective review was performed for an 11-year period. Lower limb rigid intramedullary nailing was performed in 27 patients with a total of 63 segments (57 femora, 6 tibiae). Majority of patients had underlying diagnoses of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright disease). Mean age at surgery was 14 years. Indications for surgery included acute fractures, prophylactic stabilisation, previous nonunion and malunion, deformity correction and lengthening via distraction osteogenesis.


Orthopaedic Proceedings
Vol. 104-B, Issue SUPP_5 | Pages 41 - 41
1 Apr 2022
Hafez M Nicolaou N Offiah A Giles S Madan S Dixon S Fernandes J
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Introduction

The purpose of this research is to compare the quality of life in children during gradual deformity correction using external fixators with intramedullary lengthening nails.

Materials and Methods

Prospective analysis of children during lower limb lengthening. Group A included children who had external fixation, patients in group B had lengthening nails. Patients in each group were followed up during their limb reconstruction. CHU-9D and EQ-5DY instruments were used to measure quality of life at fixed intervals. The first assessment was during the distraction phase (1 month postop.), the second was during the early consolidation phase (3 months postop.) and the final one was late consolidation phase (6–9 months depends on the frame time)


Bone & Joint 360
Vol. 8, Issue 2 | Pages 2 - 8
1 Apr 2019
Shivji F Bryson D Nicolaou N Ali F


The Bone & Joint Journal
Vol. 100-B, Issue 5 | Pages 680 - 684
1 May 2018
Perry DC Wright JG Cooke S Roposch A Gaston MS Nicolaou N Theologis T

Aims

High-quality clinical research in children’s orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children’s orthopaedics.

Methods

A modified Delphi technique was used, which involved an initial scoping survey, a two-round Delphi process and an expert panel formed of members of the British Society of Children’s Orthopaedic Surgery. The survey was conducted amongst orthopaedic surgeons treating children in the United Kingdom and Ireland.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_8 | Pages 25 - 25
1 May 2018
Chilbule S Qureshi A Hill C Nicolaou N Giles SN Fernandes JA
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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.

Methods and results

Retrospective analysis was carried out for consecutive humeral roddings for severe OI in last 3 years. Surgical technique for all humeri included retrograde telescopic nailing (female or both of FD or TST rods) with entry from olecranon fossa, exploration of radial nerve followed by osteotomies. Deformities were quantified and sub-classified as per level of deformity). Variables such as number of osteotomies, radiological union, intraoperative and postoperative complications, improvement in ROM and subjective patient satisfaction were recorded. Total 18 humeri in 12 patients with type III OI (except 1) with mean age of 8.9 years underwent nailing. All patients achieved radiological union at 6–10 weeks. Total 8 complications (44.4 %) were reported within mean 8.4 months follow up. Four segments (22.2 %) had intraoperative fractures at distal third of the humerus while negotiating the nail. Significantly higher intraoperative complications were encountered in humeri fixed with both components combined and upper third level deformities, deformities > 900 and more than 2 osteotomies. Other complications were prominent implant at upper end (2) with growth and one each of contralateral fracture and distal humeral varus. All patients reported improvement in ROM and functional status.


Orthopaedic Proceedings
Vol. 98-B, Issue SUPP_15 | Pages 11 - 11
1 Sep 2016
Al-Naser S Nicolaou N Giles S Fernandes J
Full Access

The aim of the study was to review the effectiveness of rigid IM nailing in stabilisation and deformity correction of lower limb long bones in adolescents with metabolic bone disease which to our knowledge has not been studied before.

Medical records and radiographs were retrospectively reviewed looking at indications, deformity correction, number of osteotomies-if needed, bone healing, time to healing and incidence of complications.

Between Aug 2010 and Mar 2015 fifteen patients (24 segments) had rigid IM nailing. Ten patients had Osteogenesis Imperfecta, four with McCune Albright syndrome and one with hypophosphatemic rickets. 22 femora and two tibiae were IM nailed. The mean age of the patients was 13.1 (9.6–16.75 years). Eleven out 24 segments were previously rodded. Eight segments were for acute fractures. 13 bones had significant deformities requiring corrective osteotomies. One patient had previous fracture non union.

All patients were allowed to partial weight bear immediately postoperatively and were fully mobile six weeks following surgery. Mean follow up was 24 months (3–51 months) post-operatively. All deformities were corrected. All fractures and osteotomies radiologically united.

Mean radiological union time was 5.5 months (6 weeks – 11 months). Patients with acute fractures had mean radiological union time of 4 months. Patients who had osteotomies had a mean radiological union time of 7.1 months. The patient with previous non union had BMP at the same time and radiologically healed in 10 months. Two patients had persistent bisphosphonate osteotomy lines but were asymptomatic. One patient had removal of a prominent distal locking screw and one had persistent Trendelenburg gait.

Rigid intramedullary nailing is effective in stabilisation and deformity correction of long bones in adolescent patients with brittle bone disease. The technique has a low complication rate. We recommend the use of this technique in paediatric limb reconstruction in managing metabolic bone conditions.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_5 | Pages 14 - 14
1 May 2015
Butt D Reed D Jones M Kang M Birney K Nicolaou N
Full Access

Background:

Lower limb reconstruction is performed in trauma centres where uplifted tariffs support the treatment of severely injured patients. Calculation of Healthcare Resource Groups (HRG4) codes is affected by the accuracy of clinical coding, determining the financial viability of this service in a district general hospital (DGH).

Methods:

A prospective review of coding was performed for 17 sequential patients treated using ring fixation. Relevant clinical codes and HRG4 tariffs were obtained, allowing comparison with operation notes (including pertinent diagnostic information) and implant costs. Hexapod and paediatric cases were excluded.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 235 - 235
1 Sep 2012
Yeoh D Nicolaou N Goddard R Willmott H Miles K East D Hinves B Shepperd J Butler-Manuel A
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A reduced range of movement post total knee replacement (TKR) surgery is a well recognised problem. Manipulation under anaesthesia (MUA) is a commonly performed procedure in the stiff post operative TKR. Long term results have been variable in the literature.

We prospectively followed up 48 patients since 1996 from one centre, over an average of 7.5 years, (range 1 to 10 years) and report on the long term results.

The mean time to MUA post TKR was 12.3 weeks (range 3 to 48). Pre MUA, the mean flexion was 53°. The mean immediate passive flexion post MUA was 97°, an improvement of 44° (Range 10° to 90°, CI < 0.05). By one year, the mean flexion was 87°, improvement of 34°, (range −15° to 70°, CI< 0.05). At ten years the mean flexion was 86°.

We found no difference between those knees manipulated before or after 12 weeks. In addition there was no difference found in those knees which had a pre TKR flexion of greater or less than 90°. There were no complications as a result of MUA. However, one patient was eventually revised at two years secondary to low grade infection.

Our findings show that MUA is safe and effective method at improving the range of motion in a stiff post operative TKR. The improvement is maintained in the long term irrespective of time to MUA and range of motion pre TKR


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIV | Pages 5 - 5
1 May 2012
Nicolaou N Padman M Bell M Fernandes J
Full Access

PURPOSE OF THE STUDY

To assess if prolonged use of Bisphosphonates in Osteogenesis Imperfecta alters the pattern of femoral fractures.

Osteogenesis Imperfecta (OI) has been treated with Bisphosphonates for many years with some clear clinical benefits. In adult cohorts there are reports of a new pattern of atraumatic subtrochanteric fractures seen with Bisphosphonate treatment.

SUMMARY OF METHODS

This study assesses the location of femoral fractures in a cohort of 176 OI patients treated with Bisphosphonates over a two year period and compares it to a historical control group of 45 managed prior to the advent of this specific treatment.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIV | Pages 9 - 9
1 May 2012
Ghassemi A Nicolaou N Hill R
Full Access

PURPOSE

To report the experience and evolution of treatment of Congenital Pseudarthrosis of the Tibia in a single surgeon, consecutive series of 19 patients.

METHODS

A retrospective case series review, with radiological assessment and functional outcome scores including the Activity Scale for Kids (ASK) and the Oxford Ankle Foot Questionnaire (OAFQ) Child & Teenager version. Patients were classified as per Boyd & Andersen. Alteration in the Tibial mechanical axis was compared pre-treatment and at last review.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_II | Pages 156 - 156
1 Apr 2005
Nicolaou N Cumming D Gibb P
Full Access

Introduction Knee injuries are a common presentation to Accident and Emergency departments. Often many injuries that are referred are minor as a result of the difficulty in initial assessment, and cause an unnecessary increase in workload in Orthopaedic clinics. The purpose of this study was to evaluate current practice at our Knee Injury Clinic and to implement changes to make the service more efficient and effective. It forms a completed audit cycle of current practice.

Material and methods Part I: We assessed all referrals from our Accident & Emergency department in two separate 4 month periods to the Acute Knee Injury Clinic according to the following criteria (which need fulfilling for referral)-

Recent history of injury associated with one or more of the following:

Acute haemarthrosis

Clinical instability

Disproportionate pain

Locking

Referrals were assessed as fulfilling or not fulfilling the criteria, and also as to the ultimate diagnosed pathology.

Part II: From the results of these two audits, a multidisciplinary treatment proforma was created and distributed to Accident and Emergency. This included physiotherapy as a primary treatment option. Referrals were then reassessed as in the previous audits for a 4-month period.

Results and conclusions The Acute Knee Injury Pro-forma resulted in a 15% reduction in referrals not fulfilling the criteria (p=< 0.05). This equates to a reduced workload due to inappropriate referrals, while significant injuries such as Cruciate rupture are picked up due to the sensitivity of the criteria.

There was a significant increase in patients referred directly from Accident and Emergency to the physiotherapy department, which means minor injuries receive physiotherapy earlier than if they initially came to clinic.

The proforma was well received by the junior doctors in Accident and Emergency due to its simplicity.

Overall the use of the proforma has improved the standard of care at our unit.


The Journal of Bone & Joint Surgery British Volume
Vol. 85-B, Issue 7 | Pages 960 - 962
1 Sep 2003
Mehta JS Nicolaou N Kiryluk S Fordyce MJF

Venous ulceration is a chronic disabling complication of deep-vein thrombosis. The aim of this study was to estimate the incidence of venous leg ulcers five years or more after total hip replacement (THR) and to investigate some of the clinical features associated with their development.

We carried out a postal survey of all patients who had undergone a THR 5 to 12 years previously. Replies from 816 patients showed that 66 (8.1%) had a history of leg ulcers. The prevalence of active ulceration was 2.6% and 43 patients (5.3%) reported developing ulceration since their hip replacement. A clinical review determined that 31 (3.8%) of these were true venous ulcers. The ulcers occurred more commonly on the operated side and developed at a mean of 5.8 years (18 months to 12 years) after the first arthroplasty. A mean of 1.9 arthroplasties (1 to 5) (primary and revision) were carried out before the ulcers appeared. The overall incidence of ulcers was similar to that in the general population.