Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and day two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PTE rates were 0.6% and 0.5% respectively. This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters

Total shoulder arthroplasty (TSA) and Reverse Total shoulder arthroplasty (RSA) are two of the most performed shoulder operations today. Traditionally postoperative rehabilitation included a period of immobilisation, protecting the joint and allowing time for soft tissue healing. This immobilisation period may significantly impact a patient's quality of life (Qol)and ability to perform activities of daily living (ADL's). This period of immobilisation could be safely avoided, accelerating return to function and improving postoperative QoL. This systematic review examines the safety of early mobilisation compared to immobilisation after shoulder arthroplasty focusing on outcomes at one year. Methods. A systematic review was performed as per the PRISMA guidelines. Results on functional outcome and shoulder range of motion were retrieved. Six studies were eligible for inclusion, resulting in 719 patients, with arthroplasty performed on 762 shoulders, with information on mobilisation protocols on 736 shoulders (96.6%) and 717 patients (99.7%). The patient cohort comprised 250 males (34.9%) and 467 females (65.1%). Of the patients that successfully completed follow-up, 81.5% underwent RSA (n = 600), and 18.4% underwent TSA (n = 136). Overall, 262 (35.6%) patients underwent early postoperative mobilisation, and 474 shoulders were (64.4%) immobilised for a length of time. Immobilised patients were divided into three subgroups based on the period of immobilisation: three, four, or six weeks. There were 201 shoulders (27.3%) immobilised for three weeks, 77 (10.5%) for four weeks and 196 (26.6%) for six weeks. Five of the six manuscripts found no difference between clinical outcomes at one year when comparing early active motion versus immobilisation after RSA or TSA. Early mobilisation is a safe postoperative rehabilitation pathway following both TSA and RSA. This may lead to an accelerated return to function and improved quality of life in the postoperative period

Prompt mobilisation after the Fracture neck of femur surgery is one of the important key performance index (‘KPI caterpillar charts’ 2021) affecting the overall functional outcome and mortality. Better control of peri-operative blood pressure and minimal alteration of renal profile as a result of surgery and anaesthesia may have an implication on early post-operative mobilisation. Aim was to evaluate perioperative blood pressure measurements (duration of fall of systolic BP below the critical level of 90mmHg) and effect on the post-operative renal profile with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. 20 patients were randomly selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts were reviewed from all patients for data collection. The assessment criteria for perioperative hypotension: Duration of systolic blood pressure less than 90 mm of Hg and change of pre and post operative renal functions. Only one patient had a significant drop in systolic BP less than 90mmHg (25 minutes). 3 other patients had a momentary fall of systolic BP of less than 5 minutes. None of the above patients had mortality and had negligible change in pre and post op renal function. Only one patient in this cohort had elevation of post-operative creatinine levels but did not have any mortality. Only 1 patient died on day 3 post operatively who had multiple comorbidities and was under evaluation for GI cancer. Even in this patient the peri-operative blood pressure was well maintained (never below 90mmHg systolic) and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively) in this patient. The use of short-acting spinal anaesthesia has shown to be associated with a better control of blood pressure and end organ perfusion, less adverse effects on renal function leading to early mobilisation and a more favourable patient outcome with reduced mortality, earlier mobilisation, shorter hospital stay and earlier discharge in this elderly patient cohort

Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with tibiotalocalcaneal nails. 171 patients received a tibiotalocalcaneal nail over a six-year period, but only twenty met the inclusion criteria of being over sixty and having poor bone stock, verified by radiological evidence of osteopenia or history of fragility fractures. Primary outcome was mortality risk from co-morbidities, according to the Charlson co-morbidity index (CCI), and patients’ post-operative mobility status compared to pre-operative mobility. Secondary outcomes include intra-operative and post-operative complications, six-month mortality rate, time to mobilisation and union. The mean age was 77.82 years old, five of whom are type 2 diabetics. The average CCI was 5.05. Thirteen patients returned to their pre-operative mobility state. Patients with low CCI are more likely to return to pre-operative mobility status (p=0.16; OR=4.00). Average time to bone union and mobilisation were 92.5 days and 7.63 days, respectively. Mean post-operative AOFAS ankle-hindfoot and Olerud-Molander scores were 53.0 (range 17-88) and 50.9 (range 20-85), respectively. There were four cases of broken distal locking screws, and four cases of superficial infection. Patients with high CCI were more likely to acquire superficial infections (p=0.264, OR=3.857). There were no deep infections, periprosthetic fractures, nail breakages, non-unions. TTC nailing is an effective treatment methodology for low-demand geriatric patients with fragility ankle fractures. This technique leads to low complication rates and early mobilisation. It is not a life-changing procedure, with many able to return to their pre-operative mobility status, which is important for preventing the loss of socioeconomic independence

Metacarpal fractures represent up to 33% of all hand fractures; of which the majority can be treated non-operatively. Previous research has shown excellent putcomes with non-operative treatment yet surgical stabilisation is recommended to avoid malrotation and symptomatic shortening. It is unknown whether operative is superior to non-operative treatment in oblique or spiral metacarpal shaft fractures. The aim of the study was to compare non-operative treatment of mobilisation with open surgical stabilisation. 42 adults (≥ 18 years) with a single displaced oblique or spiral metacarpal shaft fractures were randomly assigned in a 1:1 pattern to either non-operative treatment with free mobilisation or operative treatment with open reduction and fixation with lag screws in a prospective study. The primary outcome measure was grip-strength in the injured hand in comparison to the uninjured hand at 1-year follow-up. The Disabilities of the Arm, Shoulder and Hand Score, ranges of motion, metacarpal shortening, complications, time off work, patient satisfaction and costs were secondary outcomes. All 42 patients attended final follow-up after 1 year. The mean grip strength in the non-operative group was 104% (range 73–250%) of the contralateral hand and 96% (range 58–121%) in the operatively treated patients. Mean metacarpal shortening was 5.0 (range 0–9) mm in the non-operative group and 0.6 (range 0–7) mm in the operative group. There were five minor complications and three revision operations, all in the operative group. The costs for non-operative treatment were estimated at 1,347 USD compared to 3,834USD for operative treatment; sick leave was significantly longer in the operative group (35 days, range 0–147) than in the non-operative group (12 days, range 0–62) (p=0.008). When treated with immediate free mobilization single, patients with displaced spiral or oblique metacarpal shaft fractures have outcomes that are comparable to those after operative treatment, despite some metacarpal shortening. Complication rates, costs and sick leave are higher with operative treatment. Early mobilisation of spiral or long oblique single metacarpal fractures is the preferred treatment. Trial registration number: ClinicalTrials.gov NCT03067454

Introduction and Objective. Ankle fractures are common and affect young adults as well as the elderly. An unstable ankle fracture treatment typically involves surgical fixation, immobilisation, and modified weight-bearing for six weeks. Non-weight bearing (NWB) cast immobilisation periods were used to protect the soft tissue envelope and osteosynthesis. This can have implications on patient function and may reduce independence, mobility and return to work. Newer trends in earlier mobilisation compete with traditional NWB doctrine, and weak consensus exists as to the best postoperative strategy. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Materials and Methods. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 hours versus non-weight-bearing (NWB) and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury). The exclusion criteria are skeletal immaturity and tibial plafond fractures. The primary outcome measure is the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. Results. We recruited 160 patients with an unstable ankle fracture. Participants’ ages ranged from 15 to 94 years (M = 45.5, SD = 17.2), with 54% identified as female. The mean time from injury to surgical fixation was 1.3 days (0 to 17 days). Patients in the immediate weight-bearing group had a 9.5-point higher mean OMAS at six weeks postoperatively (95% CI 1.48, 17.52) P = 0.021. The complications rate was similar in both groups. The rate of surgical site infection was 4.3%. One patient had DVT, and another patient had a pulmonary embolism; both were randomised to NWB. Length of hospital stay (LOS) was 1 ± 1.5 (0, 12) for the IWB group vs 1.5 ± 2.5 (0, 19) for the NWB group. Conclusions. There is a paucity of quality evidence supporting the postoperative management regimes used most commonly in clinical practice. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. In this large multicentre, randomised controlled trial, we investigated immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition using standard fixation methods. Our result suggests that IWB following ankle fracture fixation is safe and resulted in a better functional outcome. Once anatomical reduction and stable internal fixation is achieved, we recommend IWB in all types of ankle fractures in a compliant patient

The Caledonian Technique . TM. has been widely accepted as a safe and effective way of improving post-operative recovery and reducing length of stay following total knee arthroplasty. In keeping with the principles of the enhanced recovery programme its use has slowly spread from specialised units into district general hospitals. There is little evidence using PROMs that supports the use of the Caledonian Technique in the DGH setting. The primary aim of this study was to find out whether the Caledonian Technique was being successfully implemented in this district general setting for TKA. The secondary aim was to identify whether there was a difference in the patients’ perspectives of success post discharge. This is a prospective questionnaire-based cohort study of patients undergoing total elective TKA in this DGH. It was carried out at Forth Valley Royal Hospital, Larbert, Scotland between June 2011 and 2012. All patients undergoing elective TKA were asked to complete a questionnaire assessing pain, mobilisation, function and satisfaction at 6 weeks post-operatively. Case notes of all returned questionnaires were reviewed and surgeon, protocol followed (Caledonian or non-Caledonian), length of stay, analgesic requirements, discharge analgesia and complications recorded. We have shown that length of stay, analgesic requirement and cost were all less in the Caledonian group (n=17) compared to non-Caledonian (n=17). In addition there were statistically significant increases in patients mobilising on day 1 and achieving opiate free discharge in the Caledonian group. Patient satisfaction was higher in 11 out of 12 PROMs post discharge. This confirms that previously shown improvements in length of stay and early mobilisation seen in specialised units can also be achieved in the DGH setting. Secondly it also shows that there is no negative impact on patient satisfaction and outcomes following early mobilisation and discharge

Introduction and Objective. Objectives: To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusions. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Post-operative regimes involving the use of intra-articular local anaesthetic infiltration may allow early mobilisation in patients undergoing total knee arthroplasty. Few studies have evaluated such regimes outside specialist arthroplasty units. We aimed to determine whether an enhanced recovery programme including the use of local anaesthetic administration could be adapted for use in a district general setting. Following introduction of this regime to our unit, 100 consecutive patients undergoing primary total knee arthroplasty were reviewed. 56 patients underwent a standard analgesic regime involving a general or spinal anaesthetic and oral analgesics post operatively (group1). 48 patients underwent the newly introduced regime, which included pre-operative counselling, peri-articular local anaesthetic infiltration at operation and intra-articular local anaesthetic top-up administration post-operatively for 24 hours (group 2). Length of stay, post-operative analgesic requirements, and range of knee motion post-operatively were compared. Median length of stay was less for patients in group 2 compared with those in group 1 (4 days compared to 5 days, p<0.05). Patients in group 2 required lower total doses of opiate analgesia post-operatively. 90% of patients in group 2 were ambulant on the first post operative day, compared with less than 25% of patients in group 1. Mean knee flexion on discharge was greater in patients in group 2 compared with those in group 1 (85 degrees compared with 75 degrees). No infective complications from intra-articular catheter placement were observed. However, technical difficulties were encountered during the introduction period, including loss of catheter placement, leakage of local anaesthetic and adaptation of nursing time for top-up anaesthetic administration. A rehabilitation regime involving local anaesthetic infiltration for total knee arthroplasty can successfully be adapted for use in a district general setting. Our results suggest if initial technical difficulties are overcome, this regime can provide effective postoperative analgesia, early mobilisation and reduced hospital stay

Summary. Our results prove that Demineralised Cortical Bone (DCB) can be used as biological tendon graft substitute, combined with correct surgical technique and the use of suture bone anchor early mobilisation can be achieved. Introduction. Surgical repair of tendon injuries aims to restore length, mechanical strength and function. In severe injuries with loss of tendon substance a tendon graft or a substitute is usually used to restore functional length. This is usually associated with donor site morbidity, host tissue reactions and lack of remodelling of the synthetic substitutes which may result in suboptimal outcome. In this study we hypothesise that DCB present in biological tendon environment with early mobilisation and appropriate tension will result in remodelling of the DCB into ligament tissue rather that ossification of the DCB at traditional expected. Our preparatory cadaveric study (abstract submitted to CORS 2013) showed that the repair model used in this animal study has sufficient mechanical strength needed for this animal study. Methods. 6 mature female sheep undergone surgical resection of the distal 1 cm of the right patellar tendon and osteotomy of patellar tendon attachment at the tibial tuberosity under general anaesthesia. Repair was done using DCB with 2 suture bone anchor. Animals were allowed immediate mobilisation after surgery and were sacrificed at 12 weeks. The force passing through the operated and non-operated legs was assessed preoperatively and at week 3, week 6, week 9 and week 12 bay walking the animals over a force plate. Radiographs were taken immediately after euthanasia, the Patella-Tendon-tibia constructs were retrieved and pQCT scan was done. Histological analysis included tenocytes and chondrocytes cell counts, semi-quantitative scoring of the neo-enthesis and polarised microscopy. Result. In this study, none of the retrieved specimens showed any evidence of ossification of the DCB as proved by the pQCT analysis. One animal failed to show satisfactory progress after week 3, X-rays showed patella alta, on specimen retrieval no damage to the DCB was found, sutures and stitches were intact and no evidence of anchor pullout was found. Force plate analysis of the other 5 animals showed satisfactory progression over time with 44% functional weight bearing at week 3 progressing to 79% at week 12. There was full range of movement of the stifle joint after 12 weeks. Histological analysis proved formation of neo-enthesis with evidence of cellulisation, vascularisation and remodelling of the collagen leading to ligamentisation of the DCB. Discussion. Surgical reconstruction of damaged tendons is technically challenging, patellar tendon injuries presents even more challenging situation as it involves weight bearing joint. It is generally accepted that a period of immobilisation with passive range of movement exercises and protected weight bearing for up to 6 weeks post operatively is usually advised. Some surgeons use offloading metal wire to protect the repair for 6 weeks involving second surgical procedure to remove the wire. Demineralised bone is usually used in orthopaedics to utilise its osteogenic properties as bone graft substitute and to enhance osteogenesis in load bearing situations. In our study we explored a potential new use of the demineralised bone as tendon graft substitute, it acts as collagen scaffold allowing host cells to remodel its fibres into ligament like structure

Introduction. Hoffa fractures are rare, intra-articular fractures of the femoral condyle in the coronal plane and involving the weight-bearing surface of the distal femur. Surgical fixation is warranted to achieve stability, early mobilisation and satisfactory knee function. We describe a unique type of Hoffa fracture in the coronal plane with sagittal split and intra-articular comminution. There is scant evidence in current literature with regards to surgical approaches, techniques and implants. We report of our case with a review of the literature. Case report. A 40 year old male motorcyclist was involved in a high speed road traffic collision. X-rays confirmed displaced unicondylar fracture of the lateral femoral condyle. CT showed sagittal split of the Hoffa fragment and intra-articular comminution. MRI showed partial rupture of the anterior cruciate ligament. The patient underwent definitive surgical treatment via a midline skin incision and lateral parapatellar approach using cannulated screws, headless compression screws and anti-glide plate. Weightbearing was commenced at 8 weeks. Arthroscopy and adhesiolysis was performed at 12 weeks to improve range of motion. The patient was discharged at one year with a pain-free, functional knee. Discussion. Hoffa fractures are high-energy fractures, often seen in young male motorcyclists with flexed and slightly abducted knee. Most papers recommend surgical fixation, however there is no widely accepted surgical method or rehabilitation regime. Varying surgical approaches, screw direction, choice of implants, and post-operative care have been described. Surgical approach depends on the configuration of the fracture. The medial/lateral parapatellar approach is commonly used as it does not compromise future arthroplasty, but it does not allow access to fix posterior comminution. Arthroscopic-assistance may be used with good outcomes and less tissue dissection. AP screws are widely reported in the literature, most likely due to easier access to the fracture site. PA screws may provide better stability, but access is more difficult. Fixation often involves passing screws through the articular surface, therefore the area damaged should be kept to a minimum by using the smallest possible screw; headless compression screws leave a smaller footprint in the articular cartilage. Locking plate augmentation generally gives good outcomes. Conclusion. Hoffa fractures are rare and difficult to treat. Surgical treatment is the best choice for optimum post-operative knee function. There is no consensus on choice of surgical approaches, techniques and implants, as these are dependent on fracture configuration. In this particular case we emphasise the importance of using an anti-glide plate to address the sagittal component. Despite the need for a secondary procedure, the treatment has had positive outcomes and may be used as a guide for treatment of future Hoffa fractures of a similar sub-type

Background. To aid recovery, rehabilitation is an important adjunct to surgery. Acknowledging the MRC framework for complex interventions we assessed the evidence-base for components of comprehensive rehabilitation in total hip (THR) and total knee replacement (TKR) pathways. Methods. We conducted systematic reviews and meta-analyses of randomised controlled trials (RCT) of pre-surgical exercise and education, occupational therapy and post-operative physiotherapy. In feasibility RCTs we explored acceptability of pain self-management and occupational therapy before THR, and physiotherapy after TKR. We searched trial registers for ongoing RCTs. Results. Pre-surgical interventions. Systematic review identified 38 interventions targeting physical function before THR and TKR. Interventions showed functional benefit compared with controls, standardised mean difference (SMD) 0.32 (95% CI 0.20, 0.44; p<0.00001). In 27 studies targeting in-hospital recovery, intervention patients had lower anxiety, SMD 0.38 (95% CI 0.13, 0.63; p=0.003), and earlier mobilisation by 4 hours (95% CI 0.04, 0.30; p=0.009). In 20 studies, interventions targeting long-term recovery showed no benefit for function or pain. We randomised 88 patients into a feasibility RCT of group-based pain self-management. Attendees were highly satisfied but participation was low. Pre-operatively, many patients may perceive that only surgery can treat their symptoms. Occupational therapy. Systematic review identified 7 small RCTs in THR. Function improved in patients receiving occupational therapy, SMD 0.40 (95%CI 0.09, 0.70; p=0.01) but this was not sustained post-surgery. In our feasibility study with 44 patients randomised to pre-operative provision of aids and appliances or usual care, the intervention was delivered successfully and acceptable to participants. We identified no ongoing studies. Post-discharge physiotherapy. Systematic review identified 7 small studies suggesting that physiotherapy after TKR gives functional benefit at 3–4 months, SMD 0.37 (95%CI 0.12, 0.62; p=0.004) but not at later follow up. As noted in a recent review in THR, quality of evidence was limited. Our feasibility study evaluated six weeks of group-based activity-orientated rehabilitation in 46 TKR patients. The programme was well-received and attendance good. A fully-powered RCT is underway. We identified two ongoing studies targeting patients at risk of, or with, poor recovery. Conclusion. The evidence-base for comprehensive rehabilitation in THR and TKR is growing. Pre-surgical interventions may be effective but, in isolation, not acceptable to many patients. Ongoing definitive trials in TKR physiotherapy will guide future care. Well-designed trials of physiotherapy after THR and occupational therapy are needed. Ultimately, rehabilitation interventions throughout THR and TKR pathways may provide optimal care but this will need appropriate evaluation

Introduction. The incidence of distal femoral fractures in the geriatric population is growing and represents the second most common insufficiency fracture of the femur following fractures around the hip joint. Fixation of fractures in patients with poor bone stock and early mobilisation in feeble and polymorbide patients is challenging. Development of a fixation approach for augmentation of conventional LISS (less invasive stabilization system) plating may result in superior long-term clinical outcomes and enhance safe weight bearing. Objectives. The aim of this study was to investigate the biomechanical competence of two different techniques of augmented LISS plating for treatment of osteoporotic fractures of the distal femur in comparison to conventional LISS plating. Materials & methods. Unstable distal femoral fracture AO/OTA 33-A3 was set in artificial femora with low density simulating osteoporotic bone. Three study groups, consisting of 10 specimens each, were created for instrumentation with a 9-hole LISS plate, a LISS plate with an additional 3D-printed polyactide cylindrical intramedullary graft, as well as a LISS plate plus a medial 3.5mm LCP (locking compression plate) - double plating. All specimens were non-destructively tested under axial (20–150N) and torsional (0–4Nm) quasi-static loading. Each construct was tested with two different working length (WL) configurations (long and short) of the LISS plate. Relative movements between the most medial superior and inferior osteotomy aspects were investigated via three-dimensional motion tracking analysis. Results. Interfragmentary displacement along the femur axis (mm) under 150N axial loading was 2.03±0.23/1.65±0.27 for LISS with long/short WL, 0.18±0.06/0.18±0.04 for double plating with long/short WL, and 0.40±0.05/0.30±0.05 for LISS plus graft with long/short WL. Shear interfragmentary displacement (mm) under 4Nm torsional loading in internal rotation was 1.16±0.17/0.92±0.11 for LISS with long/short WL, 0.40±0.10/0.43±0.07 for double plating with long/short WL, and 1.09±0.13/0.82±0.11 for LISS plus graft with long/short WL. Double plating revealed significantly smaller longitudinal and shear displacement compared to the other two techniques for long and short WL, respectively (P≤0.010). In addition, LISS plus graft fixation was with significantly less longitudinal displacement in comparison to conventional LISS plating for long and short WL, respectively (P≤0.001). Long WL resulted in significantly higher longitudinal and shear displacement compared to short WL for LISS and LISS plus graft (P≤0.032), but not for double plating (P=1.000). Conclusion. Intramedullary grafting resulted in significantly increased fracture stability under axial loading in comparison to conventional LISS plating. However, it was not efficient enough to achieve comparable stability to double plating

Adductor canal blocks offer an alternative to femoral nerve block for postoperative pain relief in knee arthroplasty. They may reduce the risk of quadriceps weakness, allowing earlier mobilisation of patients postoperatively. However, little is known about the effect of a tourniquet on the distribution of local anaesthetic in the limb. Ultrasound-guided adductor canal blocks were performed on both thighs of five human cadavers. Left and right thighs of each cadaver were randomised to tourniquet or no tourniquet for one hour. Iohexol radio-opaque contrast (Omnipaque 350) was substituted for the local anaesthetic for X-Ray imaging. All limbs underwent periodic flexion and extension during this hour to simulate positioning during surgery. The cadavers were refrozen. Fiducial markers were inserted into the frozen tissue. X-rays were obtained in 4 planes (AP, lateral 45° oblique/medial oblique, lateral). University Research Ethics Approval was obtained and cadavers were all pre-consented for research, imaging and photography according to the Anatomy Act (1984). Analysis of radiographs showed contrast distribution in all thighs to be predominantly on the medial aspect of the thighs. The contrast margins were entire and well circumscribed, strongly suggesting it was largely contained within the aponeurosis of the adductor canal. Tourniquets appeared to push the contrast into a narrower and more distal spread along the length of the thigh compared to a more diffuse spread for those without. Proximal spread towards the femoral triangle was reduced in limbs without tourniquets. The results suggest that contrast material may remain within the adductor canal structures during adductor canal blocks. Tourniquets may cause greater distribution of contrast proximally and distally in the thigh, but this does not appear to be clinically significant. Further studies might include radio-stereo photometric analysis using the fiducial markers in the limbs and in vivo studies to show the effect of haemodynamics on distribution

At our district general hospital in the southwest of England, around 694 total knee replacements (TKR) are performed annually. Since spring 2013 we have been using an enhanced recovery protocol for all TKR patients, yet we have neither assessed compliance with the protocol nor whether its implementation has made a discernible and measurable difference to the delivery of care in this patient population. Enhanced recovery after surgery (ERAS) protocols are multi-modal care pathways designed to aid recovery. They are based on best evidence and promote a multi-disciplinary approach which standardises care and encompasses nutrition, analgesia and early mobilisation throughout the pre, intra and postoperative phases of an inpatient stay. ERAS has been found to reduce length of stay (LOS), readmission rates and analgesic requirements following surgery. 1, 2, 3. Additionally, they have been shown to improve range of knee movement following TKR and improve mobility, patient satisfaction whilst reducing mortality and morbidity. 4, 5, 6. With these benefits in mind, we sought to investigate how well our trauma and orthopaedic department was complying with a local ERAS protocol and whether we could replicate the benefits seen within the literature. Following approval from our local audit office in September 2015 we generated a patient list of elective TKR patients under the same surgeon before and after the implementation of the ERAS protocol. Using discharge summaries and patient notes we extracted data for 39 patients operated on prior to the ERAS implementation between January 2011 and December 2012 and 27 patients following its introduction between January 2014 and September 2015. Data collected included length of stay, time to discharge from inpatient physiotherapy and use of analgesia and antiemetics. Alongside this we audited the compliance with all facets of the local ERAS protocol. There was no statistically significant difference between the 2 groups in terms of demographics or pre-operative morbidity. Overall compliance with the ERAS protocol was good but there was some variability, especially with intraoperative medication and type of anaesthesia which was likely due to individual patient factors. Compliance with postoperative analgesia was especially good with 93% of patients receiving all 4 suggested analgesics within the ERAS group. Length of stay (LOS) was significantly reduced by 0.5 days per patient (p value < 0.4). Overall compliance with the ERAS protocol was good but there was some variability, especially with intraoperative medication and type of anaesthesia, which was likely due to individual patient factors. Compliance with postoperative analgesia was especially good with 93% of patients receiving all suggested analgesics within the ERAS group. In terms of LOS, we found a statistically significant difference between the pre-ERAS and ERAS group of 0.5 days per patient. Within the context of our DGH, a 0.5 day reduction in LOS translates to around 350 bed days per year and a potential saving of GBP 105,000 (EUR 132,000) making this a clinically significant finding

The aim is to report a rare technique for correction of intramedullary nail acute angular deformity. Intramedullary tibial nail fixation of diaphyseal tibial fractures is the gold standard treatment allowing early mobilisation whilst preserving the soft tissues around the fracture site. Most commonly, intramedullary nails fail by metal fatigue secondary to non union, without significant deformity of the metalwork. Plastic deformity of the nail can result following new acute trauma, particularly before bone union has occurred. This is a clinical challenge as a reamed intramedullary nail is designed to achieve three point fixation with close anatomical fit, such that removal of a bent nail is technically difficult and also risks further damage to bone and soft tissues. We report a case of a 20 year old patient treated with intramedullary nail fixation of a diaphyseal right tibial fracture who was subsequently assaulted 4 weeks post operatively. This produced an unacceptable deformation of the nail into 25 degrees valgus and procurvatum. To remove the nail, the authors used a previously reported but rare technique of partial (up to 50%) nail division on the convex surface of the apex using Midas Rex High Speed Drill to weaken the nail then manipulation to correct deformity with minimal stress. The technique produced minimal metal debris and allowed simple exchange nail replacement without further complication. The authors believe this is the first reported use of the technique from the United Kingdom

Repair of tendon injuries aims to restore length, mechanical strength and function. We hypothesise that Demineralised Cortical Bone (DCB) present in biological tendon environment will result in remodelling of the DCB into ligament tissue. A cadaveric study was carried out to optimize the technique. The distal 1cm of the patellar tendon was excised and DCB was used to bridge the defect. 4 models were examined, Model-1: one anchor, Model-2: 2 anchors, Model-3: 2 anchors with double looped off-loading thread, Model-4: 2 anchors with 3 threads off-loading loop. 6 mature sheep undergone surgical resection of the distal 1cm of the right patellar tendon. Repair was done using DCB with 2 anchors. Immediate mobilisation was allowed, animals were sacrificed at 12 weeks. Force plate assessments were done at weeks 3, 6, 9 and 12. Radiographs were taken and pQCT scan was done prior to histological analysis. In the cadaveric study, the median failure force for the 4 models; 250N, 290N, 767N and 934N respectively. In the animal study, none of the specimens showed evidence of ossification of the DCB. One animal failed to show satisfactory progress, X-rays showed patella alta, on specimen retrieval there was no damage to the DCB and sutures and no evidence of anchor pullout. Functional weight bearing was 79% at week12. Histological analysis proved remodelling of the collagen leading to ligamentisation of the DCB. Results prove that DCB can be used as biological tendon substitute, combined with the use of suture bone anchor early mobilisation can be achieved

In recent years there has been growing interest in enhanced recovery regimes in lower limb arthroplasty due to potential clinical benefits of early mobilisation along with cost-savings. Following adoption of this regime in a district general hospital, it was observed that traditional dressings were a potential barrier to its success with ongoing wound problems in patients otherwise fit for discharge. The aim of this audit was to assess current wound care practice, implement a potentially improved regime and re-evaluate practice. A prospective clinical audit was performed over a three month period involving 100 patients undergoing hip or knee arthroplasty. Fifty patients with traditional dressings were evaluated prior to change in practice to a modern dressing (Aquacel™ Surgical). Fifty patients were then evaluated with the new dressing to complete the audit cycle. Clinical outcome measures included wear time, number of changes, blister rate and length of stay. Statistical comparisons were performed using Mann Whitney or Fisher's Exact test (statistical significance, p<0.05). Wear time for the traditional dressing (2 days) was significantly shorter than the modern dressing (7 days), p<0.001, and required more changes (0 vs. 3 days), p<0.001. 20% of patients developed blisters with the traditional dressing compared with 4% with the modern dressing (p=0.028). Length of stay was the same for the modern dressing (4 days) compared with the traditional dressing (4 days). However, in the modern group 75% of patients were discharged by day 4 whereas in the traditional group this took until day 6. This audit highlights the problems associated with traditional dressings with frequent early dressing changes, blistering and delayed discharge. These adverse outcomes can be minimised with a modern dressing specifically designed for the demands of lower limb arthroplasty. Units planning to implement enhanced recovery regimes should consider adopting this dressing to avoid compromising patient discharge

The aim of management of an adult distal humeral fracture is to restore mobility, stability and pain-free elbow function. Good results are usually achieved in the majority of fractures treated with ORIF, but the management of comminuted fractures in elderly, frail patients with osteoporotic bone remains controversial. The literature focuses on elbow replacement if stable internal fixation cannot be achieved, with “bag-of-bones” management now rarely discussed eg. key-note paper - 10 successful cases reported by Brown RF & Morgan RG in 1971 (JBJS 53-B(3):425-428). We present the experience in two units in which conservative management has been actively adopted in selected cases by consultants with a subspecialty interest in the elbow. All patients over the age of 60 with distal humeral fractures (2007 – 2009) who had been treated conservatively were reviewed clinically and radiologically. Duration of follow-up and outcome, including the Oxford and quick DASH scores, were recorded, with the fractures classified using the AO system. There were 25 patients, 19 female and 6 male. 19/25 patients have been successfully treated conservatively with a mean Range Of Movement: Extension/Flexion: 45/125, Pronation/Supination 74/70. Only 5 underwent subsequent total elbow replacement and one delayed ORIF. There is a significant complication rate following surgical treatment with ORIF or elbow replacement in elderly, frail patients, including infection, painful non-union and/or stiffness. We believe that there is a role for initial conservative treatment in selected patients with low, displaced, comminuted humeral fractures in osteoporotic bone. Initial early mobilisation as pain allows can give good functional results without the risks of operation. It does not preclude future surgery if conservative treatment fails, but this is not required in the majority of cases

Repair of the rotator cuff requires secure reattachment, but large chronic defects cause osteoporosis of the greater tuberosity which may then have insufficient strength to allow proper fixation of the tendon. Recently, suture anchors have been introduced, but have not been fully evaluated. We have investigated the strength of suture-to-anchor attachment, and the use of suture anchors in repairs of the rotator cuff either to the greater tuberosity or the lateral cortex of the humerus. The second method gave a significant increase in the strength of the repair (p = 0.014). The repairs were loaded cyclically and failed at low loads by cutting into bone and tendon, casting doubt on the integrity of the repair in early mobilisation after surgery. Repairs with suture anchors did not perform better than those with conventional transosseous attachment