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Bone & Joint Open
Vol. 2, Issue 2 | Pages 134 - 140
24 Feb 2021
Logishetty K Edwards TC Subbiah Ponniah H Ahmed M Liddle AD Cobb J Clark C

Aims

Restarting planned surgery during the COVID-19 pandemic is a clinical and societal priority, but it is unknown whether it can be done safely and include high-risk or complex cases. We developed a Surgical Prioritization and Allocation Guide (SPAG). Here, we validate its effectiveness and safety in COVID-free sites.

Methods

A multidisciplinary surgical prioritization committee developed the SPAG, incorporating procedural urgency, shared decision-making, patient safety, and biopsychosocial factors; and applied it to 1,142 adult patients awaiting orthopaedic surgery. Patients were stratified into four priority groups and underwent surgery at three COVID-free sites, including one with access to a high dependency unit (HDU) or intensive care unit (ICU) and specialist resources. Safety was assessed by the number of patients requiring inpatient postoperative HDU/ICU admission, contracting COVID-19 within 14 days postoperatively, and mortality within 30 days postoperatively.


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_1 | Pages 21 - 21
1 Feb 2021
Logishetty K Edwards T Liddle A Dean E Cobb J Clark C
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Background

In the United Kingdom, over 1 million elective surgeries were cancelled due to COVID-19, resulting in over 1.9 million people now waiting more than 4 months for their procedure – 3x the number last year. To address this backlog, the healthcare service has been asked to develop locally-designed ‘COVID-light’ facilities. In our local system, 822 patients awaited orthopaedic surgery when elective surgery was permitted to resume. The phased return of service required a careful and pragmatic prioritisation of patients, to protect resources, patients, and healthcare workers.

Aims

We aim to describe how the COVID-19 Algorithm for Resuming Elective Surgery (CARES) was used to consider 1) Which type of operation and patient should be prioritised? and 2) Which patients are safe to undergo surgery? The central tenets to this were patient safety, predicted efficacy of the surgery, and delivering compassionate care by considering biopsychosocial factors.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_17 | Pages 16 - 16
1 Nov 2014
Rafferty M Al-Nammari S Sleat G Clark C Dega R
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Introduction:

Failure to adequately treat an injury of the syndesmosis leads to poor functional outcomes and posttraumatic arthritis. Many techniques have been proposed to salvage chronic instability. We report on the largest series of chronic syndesmotic injuries to be managed by syndesmotic arthrodesis from Europe to date.

Aim:

To determine the radiographic and clinical outcomes for this technique at our institute.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_5 | Pages 21 - 21
1 Mar 2014
Currall V Kugan R Johal P Clark C
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For hallux valgus correction, distal first metatarsal osteotomy is generally used for minor to moderate deformities, diaphyseal osteotomy for moderate deformities and basal osteotomy or fusion for severe deformities. With the advent of locking plates, there has been renewed interest in opening wedge basal osteotomy. As little has been written about its geometry, we undertook this study in order to understand its power and limitations.

Proximal opening wedge osteotomies were performed on saw bone models in four orientations, with three different wedge sizes: 1. Perpendicular to the ground (PG); 2. Perpendicular to the shaft (PS); 3. Perpendicular to shaft with 30° declination (DEC); 4. 30° oblique (OB). Pre- and post-osteotomy measurements were made of axial and plantar translation and intermetatarsal angle.

Plantar translation and intermetatarsal angle correction increased with increasing wedge size. The DEC osteotomy produced the greatest increase in length of metatarsal shaft, while the PS osteotomy gave the least. The most plantar translation was achieved with the DEC osteotomy. Overall, the PS osteotomy gave the largest correction of the intermetatarsal angle.

Although there are several published clinical case series of the proximal opening wedge osteotomy, this is the first study to fully evaluate its geometry.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 59 - 59
1 Sep 2012
Riley N Rudge B Bayliss L Clark C
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Introduction

Hallux valgus is a common orthopaedic complaint with multiple surgical options. There are many methods available for assessing whether sufficient translation of the first metatarsal can be achieved with a metatarsal translational osteotomy alone. None of the current methods take into account the breadth of the metatarsal. With current PACS technology a radiograph can be zoomed to any size and we postulate that by using the surgeon's thumb (or any suitable digit), as a sizing tool, a safe clinical decision can be made concerning whether a translational metatarsal osteotomy alone will provide sufficient correction.

Method

We reviewed the preoperative radiographs (weightbearing AP) of twenty patients who had scarf and akin osteotomies and twenty patients with a deformity too great for scarf and akin osteotomies. The senior author (CC) taught the rule of thumb to one consultant and two registrars (total two registrars and two consultants). The radiographs were blindly randomised and the participants assessed each radiograph and decided whether sufficient translation could be achieved with a translational metatarsal osteotomy alone. The process was repeated three months later. Twenty patients were deemed sufficient for intra-user variability and significance based on a recent JBJS(A) article concerning radiographic measurements post proximal crescentic osteotomy (Shima et al. 2009).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XLIII | Pages 12 - 12
1 Sep 2012
Riley N Hobbs C Rudge B Clark C
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Introduction

Hallux valgus deformity is a common potentially painful condition. Over 150 orthopaedic procedures have been described to treat hallux valgus and the indication for surgery is pain intractable to nonoperative management.

Methods

A retrospective analysis of the treatment of complex hallux valgus with bifocal metatarsal and Akin osteotomies of the first ray performed by the senior author (CC). 22 patients were treated over a three year period from 2008 to 2011, 24 trifocal osteotomies were undertaken. Hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were all measured from pre- and postoperative radiographs. The patients were also clinically reviewed.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_II | Pages 286 - 287
1 May 2010
Rajkumar S Shahzad S Clark C Dega R
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Between October 2006 and September 2007, eight consecutive patients with syndesmotic diastasis of the ankle had Tight Rope suture –endobutton fixation. We present our early results following this fixation. There were 3 males and 5 females with a mean age of 42 years (range 21 – 67). All were followed up for a mean of 7 months. Five patients had right side involvement. Majority were twisting injuries. These patients were compared with a cohort group (10 patients) who had diastasis screw fixation for similar fractures during the same period.

Results: The mean post operative Olerud & Molander ankle subjective score was 86 points. The tourniquet time was significantly less in endobutton group compared to the diastasis screw group(mean of 56 minutes vs. 72 minutes). There was some difference in time to mobilisation between the two groups (mean of 10 days). The endobutton group patients were able to return to work and leisure activities earlier (mean of 4 weeks) compared to the diastasis group. Range of motion was similar in both groups. There were fewer complications in both groups with superficial infection and stiffness being the most common. Both groups were satisfied with the fixation.

Advantages of Tight rope fixation: The tourniquet time was reduced; there was no need for 2nd operation with its attendant risks. Earlier mobilisation was possible leading to early return to work and leisure activities.

We recommend the use of this new suture endobutton fixation for ankle diastasis with promising early functional results. Further prospective studies are needed to evaluate this new type of fixation device.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 495 - 495
1 Aug 2008
Maffulli N Sharp L Miedzybrodzka Z Cardy AH Inglis J Madrigal L Barker S Chesney D Clark C
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Introduction: Between 1 and 4 per 1000 births worldwide are affected by clubfoot. Clubfoot etiology is unclear, but both genetic and environmental factors are thought to be involved. Low folate status in pregnant women has been implicated in several congenital malformations and folate metabolism may be affected by polymorphisms in the MTHFR gene.

Methods: Using a case-parent triad design, we investigated whether the MTHFR C677T polymorphism, and maternal peri-conceptional folic acid supplement use, influenced risk of isolated clubfoot. 375 case-parent triads took part.

Results: Among children there was a significant trend of decreasing clubfoot risk with increasing number of Talleles: relative risk (RR ) CT vs CC=0.75 (95% CI: 0.57,0.97); RR TT vs CC=0.57 (95% CI: 0.37,0.91); p trend=0.006. This association was not modified by maternal folic acid use.

Conclusion: Maternal MTHFR genotype did not influence risk of clubfoot in the offspring overall, although a possible interaction with folic acid use was found. This is the first report of a specific genetic polymorphism associated with clubfoot. The direction of the association is intriguing and suggests DNA synthesis may be relevant in clubfoot development. However, clubfoot mechanisms are poorly understood and the folate metabolism pathway is complex. Further research is needed to elucidate these relationships.


Orthopaedic Proceedings
Vol. 87-B, Issue SUPP_III | Pages 339 - 339
1 Sep 2005
MacDonald S Rorabeck C Marr J Clark C Swafford J Macdonald D
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Introduction and Aims: The dilemma to retain or sacrifice the posterior cruciate ligament in a primary total knee arthroplasty continues to be an area of discussion. A randomised clinical trial was performed comparing clinical, radiographic and quality of life outcomes between patients receiving a posterior cruciate sparing versus posterior cruciate substituting knee implants.

Method: A multi-centred, prospective, randomised, blinded, clinical trial was performed to compare posterior cruciate retaining (CR) versus posterior cruciate substitution (PS) in osteoarthritic patients with an intact posterior cruciate ligament, undergoing total knee arthroplasty using the AMK® (Depuy®, Warsaw, Indiana) component. One hundred and fifty-two patients were randomised to receive one of the two devices. Patients were evaluated pre-operatively, at three, six, 12 months and annually thereafter. Patient demographics, radiographs, and multiple validated, outcome measures (WOMAC, SF-12, the Knee Society Clinical Rating System, and a stair climbing test) were evaluated. Patients and assessors were blinded to the implant design.

Results: One hundred and fifty-two patients were randomised at three centres; 72 in the CR group and 80 in the PS group. One patient was revised due to instability. Average follow-up was 5.14 years (range 2.97–6.99 years). There were no significant differences in baseline patient demographics between groups. There were no significant differences in outcome measures or radiographic findings. There were no significant differences in the Knee Society Clinical Rating System (CR- 159.18 versus PS- 156.49). There were no differences in knee extension at latest follow-up (CR- 1.02) and (PS- 1.10). There were no differences in knee flexion at latest follow-up (CR-111.00 ) and (PS- 113.61). No differences were noted in the WOMAC and SF-12 scores between the two groups.

Conclusion: In this prospective randomised clinical trial no significant differences involving radiographs and multiple outcome measures could be seen between a cruciate retaining versus a posterior stabilised total knee prostheses at a mean follow-up of 5.14 years. Long-term evaluation is necessary to comment on wear, osteolysis and implant longevity.