At-home softcast removal with no routine clinical follow-up has shown to be safe and effective following paediatric orthopaedic trauma. It minimises clinician contact time and reduces cost. However, there is limited data on the caregiver experience.

Retrospective analysis of paediatric fractures requiring application of circumferential softcast that was later removed at home. Two time points were included: (1)July–September 2022, (2)February–April 2023. Demographics data included age, fracture classification, angulation, manipulation requirement, complications or unplanned re-attendance. Caregivers were given an information leaflet on cast removal. Caregivers completed a telephone Likert questionnaire reviewing time taken to remove cast, qualitative descriptors of cast removal and overall satisfaction.

77 families were contacted at mean 93 days post injury. Mean age was 7.5 years. 41(53%) were distal radius and 20(26%) both-bone forearm fractures. The remaining were hand, elbow or tibia injuries. 40(52%) injuries required manipulation under procedural sedation with mean sagittal angulation 24 degrees. 13(17%) patients re-attended with cast problems. Caregivers estimated a mean 13 minutes to remove cast. 83% found it ‘extremely’ or ‘somewhat’ easy. 75% were ‘extremely’ or ‘somewhat’ satisfied. 71% were ‘extremely’ or ‘somewhat’ likely to recommend at-home cast removal. Qualitative descriptors ranged from from ‘traumatising’ to ‘fun’ and ‘straightforward’.

The experience at our tertiary centre confirms at-home softcast removal with no further orthopaedic follow-up is safe and feasible, even in those requiring manipulation under sedation. The majority of families reported a positive experience; this however is not universal. Adequate patient information resources are integral to a positive caregiver's experiences.

To our knowledge, we are the only centre in the UK where Achilles tenotomies (TA) for CTEV Ponseti correction are performed in outpatient clinic under local anaesthetic by an Advanced Physiotherapy Practitioner (APP) in orthopaedics. This study aims to present the outcomes and safety of this practice.

Retrospective analysis of cases of idiopathic CTEV undergoing Ponseti correction January 2020 to October 2022. Demographic data: Pirani score and number of casts before boots and bar. Patients were divided into five groups: Group 1: TA performed by an Orthopaedic consultant under general anaesthetic (GA) in theatre. Group 2: TA performed by an Orthopaedic consultant under local anaesthetic (LA) in theatre. Group 3: TA performed by APP under GA in theatre. Group 4: TA performed by APP under LA in theatre. Group 5: TA performed by an APP under LA in outpatient clinic. Complications recorded: revision TA, infection, neurovascular injury or need for re-casting. Mean follow up 18 months.

45 feet included. Mean Pirani score 5.5, age started casting 33 days and total number of casts 6. No significant difference in demographic details between groups. 6, 4, 20, 5 and 10 tenotomies were performed in groups 1, 2, 3, 4, and 5 respectively. Complications were 1 revision tenotomy from group 2, one from group 4 and 1 renewal of cast from 3.

This study demonstrates that TAs performed in outpatient clinic under LA by an APP is safe and feasible. No increase in complications were observed compared to TAs performed by orthopaedic consultants.

Purpose

To assess outcomes of manipulating upper extremity fractures with conscious sedation compared with formal reduction and casting in theatre under general anaesthesia and image intensifier control.

The purpose of this study was to describe the clinical course of patients with Down's syndrome (DS) and congentital talipes equinovarus (CTEV) treated with the Ponseti regimen.

The members of the United Kingdom Ponseti Users Group were contacted to provide details of patients with DS and CTEV, whom they had treated using the Ponseti regimen. Nine patients (13 feet: 7 right, 6 left) were identified, and the case notes were reviewed. Six patients were male, 3 female. In all but one case, the DS was diagnosed postnatally. Co-morbidites included atrioventricular septal defect, hearing deficiencies and plagiocephaly. The initial mean Pirani score was 4.5 (range 3.0 to 6.0). Casting was commenced at a mean of 25 days (range 12–84 days). The mean number of casts required was 7 (range 3 to 12), taking a mean of 6.5 weeks (range 3–12) to achieve correction. 6 of the 13 feet (46%) required a tendoachilles tenotomy, and 2 of 13 (15%) required re-casting. No patients have required a tibialis anterior transfer, soft tissue releases or bony procedures, at a mean follow up of 44 months (9–65 months).

The results of the Ponseti regimen have not been described in patients with DS. From this small series, we can conclude that all patients responded to the regime. A tendoachilles tenotomy was required in just under half, and further casting was required in only 15% of the treated feet. No patient has required further surgery. The tenotomy rate is lower than in most series, but otherwise, the results are comparable to those for idiopathic CTEV for which the Ponseti regimen has become the gold standard. Parents of children with DS can be reassured that in the short term their feet will respond well to Ponseti treatment

We compared the postoperative wound discharge rates and 3 months clinical results of three types of wound closure and dressing – 2-octylcyanoacrylate with Opstie (G+O), 2-octylcyanoacrylate with Tegaderm (G+T), and Opsite without 2-octylcyanoacrylate (O) in patients having primary total hip arthroplasty.

We randomised 141 patients scheduled for primary total hip arthroplasty into 3 arms of this study- G+O, G+T, or O. The extent of wound discharge was recorded on a diagrammatic representation of the dressing in situ on paper and graded each day. Dressings were left in-situ provided the extent of wound discharge allowed for this. The patient was clinically reviewed at 3 months to assess their scar length, cosmesis, scar discomfort, and evidence of superficial or deep wound sepsis.

A greater number of patients dressings remained dry on day 1 postoperatively in the two groups with 2-octylcyanoacrylate compared to the no glue group p=0.001. G+T group had a significantly lower proportion of patients with increased leakage of wounds on 2^nd postoperative day p=0.044. At 3 months review, there was no statistical difference in the Hollander score or scar discomfort.

In patients who have had primary total hip arthroplasty, usage of 2-octylcyanoacrylate for wound closure along with Tegaderm dressing reduces wound discharge. The same effect is not noted in glue with Opsite group. Whilst dressing changes required in the non-glue group compared from the two glue groups did not reach statistical significance, this may have clinical relevance for patients and nursing staff. No effect on postoperative length of stay, or wound complications was noted.

We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006.

Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications.

30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p<0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph.

We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery.

Procedure Based Assessments (PBAs) are one type of Workplace Based Assessment (WBA) introduced recently to orthopaedic training in the UK. They play an increasing role in the assessment of a trainee's surgical competence.

The study aims to determine the most valuable aspects of a PBA to a trainee, and the changes trainees suggest to improving the use of PBAs.

A link to an online questionnaire was sent by email via the eLogbook system to all orthopaedic trainees in the UK with a National Training Number (NTN). The free text responses were coded and categorised. Analysis of results was conducted using the online survey software and Microsoft Excel.

Of 668 responses, 616 met the inclusion criteria, making a response rate of 66% of all trainees with a NTN in the UK. There was a broad, representative spread of seniority and of geographical location. Trainees found the verbal feedback gained from their trainer to be most valuable (47%), followed by the assessment of competence (21%). Trainees identified the PBA form itself as the most important area for change (52.4%). This included increased numbers of PBAs (17.5%), more specific to the procedure (8.6%), more user friendly (15%), more levels of competence (4.5%) and a generic PBA (3.4%). Further suggestions included changing the role of PBAs, with 8.2% suggesting discontinuing their use entirely. Improving trainer investment in the use of PBA was also highlighted.

Trainees value PBAs to gain formal feedback more than their use as evidence of competence in a procedure. There are a number of changes suggested by trainees that could improve the use and effectiveness of PBAs, and we have incorporated these into recommendations made by the British Orthopaedic Trainees’ Association, which should inform the debate on the further development of this assessment tool, and on WBAs in general.

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemented prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult.

We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established, and a case note review was carried out.

There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 15 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. There were no peri-prosthetic fractures in the cemented group, p = 0.004 using Fisher's exact test. The case notes of these patients were analysed. We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of the patients had a completed falls assessment and 21% sustained their fracture during an admission to hospital) and confusion (50% had a degree of dementia that caused significant confusion).

Cemented implants should be considered in all patients, especially those who are cognitively impaired or have failed falls assessments; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaesthetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit.

We reviewed the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006.

Follow-up consisted of clinical and radiological review pre-operatively, at 6 weeks, 6 and 12 months, and annually until 10 years post-op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores.

30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis (16), primary osteoarthritis (12) and post-traumatic osteoarthritis (2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 20 out of the remaining 24 were available for follow-up. Complications included lateral malleoli fracture (3), superficial peroneal nerve injury (2), one early death, unrelated to the surgical procedure, delayed syndesmotic union (1), non-union (6) and deep infection (2), of which one underwent removal of the implant; the other receives long-term oral antibiotics. AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p<0.001). Radiological assessment revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph.

We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological loosening, and the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall, we feel that the Agility ankle is an acceptable alternative to arthrodesis, however patients should be warned of the risk of re-surgery

We aimed to review the outcome of Agility total ankle replacements carried out in our institution between 2002 and 2006.

Follow-up consisted of clinical and radiological review pre-operatively, then at 6 weeks, 6 and 12 months, and annually until 10 years post op. Clinical review included the American Orthopaedic Foot and Ankle Score, satisfaction and pain scores. Case notes were reviewed to determine intra and post-operative complications.

30 arthroplasties were performed in 30 consecutive patients. Pre-operative diagnosis was rheumatoid arthritis(16), primary osteoarthritis(12) and post-traumatic osteoarthritis(2). After a mean follow up of 6.2 years (1.4–10.1), 4 patients had died, and 22 out of the remaining 24 were available for follow-up. Intra operative complications included lateral malleoli fracture(3) and superficial peroneal nerve injury(2). Post operative complications included 1 early death, but this was not related to the surgical procedure. Two patients developed deep infections of the prosthesis. One underwent removal of the implant; the other is on long term oral antibiotic therapy. One patient had delayed union of the syndesmosis and six patients had non-union. On clinical assessment, patients' AOFAS scores improved from mean 40.4 pre-op to 83.5 post-op (p< 0.001). Radiological assessment of the tibial component revealed 25 (93%) patients had lucency in at least one zone in the AP radiograph.

We found a relatively high level of re-surgery and complications following Agility total ankle replacement. A 7% revision rate is much higher than would be tolerated in knee or hip arthroplasty, but compares favourably to other studies of TAR. Despite radiological features which suggest loosening, the high rate of re-surgery and complications; patients are generally satisfied with the procedure, reporting lower levels of pain and improved function. Overall we feel that the Agility ankle is an acceptable alternative to ankle arthrodesis, however patients need to be warned of the risk of re-surgery.

Introduction

Procedure Based Assessments (PBAs) were recently introduced for orthopaedic trainees and play an increasing role in assessment. The study aims to describe the attitudes of trainees to the educational benefit of PBAs and the factors which underlie these attitudes.

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemented prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult.

We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established and a case note review was carried out.

There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 14 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. The case notes of these patients were analysed.

We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of patients had a completed falls assessment and 35% sustained their fracture during an admission to hospital) and confusion (43% had a degree of dementia that caused significant confusion).

Cemented implants should be considered in those who have failed falls assessment, or are confused; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaesthetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit.

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemeted prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult.

We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established and a case note review carried out.

There were 397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 14 patients (4% of uncemented arthoplasties) had peri-prosthetic fractures. The case notes of these patients were analysed. There was a common link of significant cardiovascular risk, lack of falls assessment, and confusion.

Cemented implants should be considered in those who have failed falls assessment, or are confused; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaethetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit.

Teaching programmes for Orthopaedic Trainees take place in every region of the UK. The aim of this study was to survey Trainees from each region to compare levels of satisfaction.

A questionnaire was sent out electronically in June 2009, and was open to collect responses until December 2009. It was sent to all British Orthopaedic Trainees Association (BOTA) members to assess satisfaction and to ask for their comments and suggestions.

There were 449 responses, out of a potential 1200 (37%) from across all 26 regions. Overall 71% were satisfied or highly satisfied with the organisation of their programme, and 70% were satisfied or highly satisfied with the content. However, on analysis of the data looking at individual regions, there were marked differences in satisfaction levels. In three regions over 50% of Trainees were very satisfied with their teaching, in contrast to one region where 67% were unsatisfied or very unsatisfied.

199 Trainees (44%) made comments, which fell into themes of ‘how’ the teaching is organised, ‘what’ is taught, and by ‘whom’. Topics frequently mentioned were relevance to the FRCS exam, importance of clinical case presentations and involvement of Consultants.

Teaching Programmes are run differently in each region and there are contrasting levels of satisfaction amongst Trainees. The feedback from the Trainees in each region was fed back to the relevant Training Programme Director, and suggestions were made on how to improve these Teaching Programmes for the future.

Introduction: Tarsometatarsal joint (TMTJ) arthrodesis is traditionally performed through a dorsal approach and is associated with higher incidence of cutaneous nerve damage, prominent metalware and high non-union rates. It is postulated that applying fixation to the plantar (tension) side, rather than the dorsal (compression) side would create a more stable construct with higher union rates. A suitable surgical approach has not previously been described. The aim of this study is to define a plantar surgical approach to the TMTJ’s.

Methods: We dissected 10 cadaveric feet, identifying nerves, vessels, muscles and their innervation on the plantar aspect of the 1st and 2nd TMTJ’s.

Results: We found that in all specimens a plane of dissection could be created between the two terminal divisions of the medial plantar nerve between flexor digitorum brevis and abductor hallucis. Although exposure of the 1st TMTJ was relatively easy, access to the 2nd TMTJ was difficult due to its location at the apex of the transverse metatarsal arch and the overlying peroneus longus insertion. We found that the peroneus longus tendon had a variable insertion not only at the base of the 1st metatarsal but also at the medial cuneiform and the base of the 2nd metatarsal.

Discussion: This is a new surgical approach, following an internervous dissection plane. The feasibility of making an incision over the convex side of the rocker bottom deformity and the biomechanical advantage of a plantarly applied fixation device may make this an attractive surgical approach.

Introduction: The sural nerve is commonly encountered in many operations on the lateral part of the foot and ankle, such as fixation of distal fibula, 5th metatarsal and calcaneal fractures, and fusion of the subtalar or calcaneo-cuboid joints. However there is no consensus and quantitative description of the branches of sural nerve distal to the ankle in the reviewed literature. This study aims to describe these branches and quantify their relations.

Methods: The distal course of the sural nerve was dissected in 30 embalmed cadaveric limbs.

Results: A fibular branch was found in close proximity to the tip of the distal fibula in 63% of specimens. A dorsal branch at the level of the cuboid was found in 80% of specimens, however, its point of departure from the main nerve varied considerably. More distally a series of plantar branches of varying number, and at varying distances to each other was found. These branches were then described in relation to the following bony landmarks: the tip of the distal fibula, the calcaneo-cuboid joint, the tuberosity of the base the 5th metatarsal, the shaft of the metatarsal and the 5th metatarso-phalangeal joint. The distances between these landmarks were quantified using digital analysis.

Conclusion: The sural nerve has a number of previously undescribed but potentially important branches distal to lateral malleolus in the foot. Identifying these branches during surgery with relation to the various bony structures should minimise the risk of nerve injury.