The aim of this study was to report the incidence of arthrofibrosis of the knee and identify risk factors for its development following a fracture of the tibial plateau. We carried out a retrospective review of 186 patients (114 male, 72 female) with a fracture of the tibial plateau who underwent open reduction and internal fixation. Their mean age was 46.4 years (19 to 83) and the mean follow-up was16.0 months (6 to 80). A total of 27 patients (14.5%) developed arthrofibrosis requiring a further intervention. Using multivariate regression analysis, the use of a provisional external fixator (odds ratio (OR) 4.63, 95% confidence interval (CI) 1.26 to 17.7, p = 0.021) was significantly associated with the development of arthrofibrosis. Similarly, the use of a continuous passive movement (CPM) machine was associated with significantly less development of arthrofibrosis (OR = 0.32, 95% CI 0.11 to 0.83, p = 0.024). The effect of time in an external fixator was found to be significant, with each extra day of external fixation increasing the odds of requiring manipulation under anaesthesia (MUA) or quadricepsplasty by 10% (OR = 1.10, p = 0.030). High-energy fracture, surgical approach, infection and use of tobacco were not associated with the development of arthrofibrosis. Patients with a successful MUA had significantly less time to MUA (mean 2.9 months; . sd. 1.25) than those with an unsuccessful MUA (mean 4.86 months;. sd. 2.61, p = 0.014). For those with limited movement, therefore, performing an MUA within three months of the injury may result in a better range of movement. . Based our results, CPM following operative fixation for a fracture of the tibial plateau may reduce the risk of the development of arthrofibrosis, particularly in patients who also undergo prolonged provisional external fixation. Cite this article: Bone Joint J 2015;97-B:109–14

Introduction. Stiffness of the knee after total knee arthroplasty (TKA) impairs knee function and reduces patient satisfaction. Limited preoperative range of motion (ROM) and a diagnosis of osteoarthritis seem to be associated with postoperative stiffness, and medical comorbidities such as diabetes mellitus have been discussed as predisposing factors. The present study was undertaken in order to analyse both patient-related and surgical factors that could be associated with the need for mobilization under anaesthesia (MUA) after TKA. Methods. We designed a case-control-study and extracted the study population from our local arthroplasty register. We identified all patients in our register that required MUA following primary TKA (n=35) and then randomly selected 4 control patients for each case of MUA. Incomplete medical records resulted in the exclusion of 18 patients, leaving 157 patients. Univariate analysis was used in order to investigate differences between the two groups with respect to demographics, pre- and postoperative ROM, medical or psychiatric comorbidities, and the type of implant. Variables with a proposed influence on outcome were entered into a binary logistic regression model, and risk ratios (RR) were calculated with 95% confidence intervals (CI). Results. Regression analysis showed that age at operation, the presence of chronic obstructive lung disease (COLD), and preoperative flexion significantly affected outcome: Increasing age decreased the risk for needing MUA with a RR of 0.88 (CI 0.82–0.94, p<0.001) per year. Patients with COLD had significantly higher risk of needing MUA with a RR of 9.82 (CI 1.84–52.3, p=0.007). Impaired preoperative flexion was an important predictor of postoperative stiffness with a RR of 0.97 (CI 0.95–0.99, p=0.027), implicating that the risk for MUA decreased by approximately 3% for each additional degree of flexion. Gender, BMI, cardiovascular comorbidity, the presence of rheumatoid arthritis, diabetes mellitus, previous knee injury, and the type of implant did not significantly affect the risk for MUA. In univariate analysis, patients requiring MUA had significantly lower knee flexion at discharge than control patients (78° vs. 61°, p<0.001). Interpretation. We conclude that the presence of COLD, impaired preoperative knee flexion, and younger age increase the risk for needing MUA after primary TKA. The finding that COLD increases the risk for MUA is novel: It is known that patients with COLD have higher systemic levels of inflammatory mediators, and we are tempted to speculate that postoperative arthrofibrosis could be a result of enhanced systemic inflammatory activity. In our hands, the choice of implant and comorbidities other than COLD were not associated with an increased risk for MUA

Increasing demands on our emergency department (ED) has resulted in the reduction of manipulations (MUAs) at the ‘front door’. We hypothesised that MUAs undertaken in theatre is rising with adverse financial implications. We performed a retrospective audit of operating lists in our institution from 2013–2016. Cost estimates were determined by our finance department. We used the NICE guidelines on management of non-complex fractures (NG38 Feb2016) as our audit standard. Data on 1372 cases performed over a three-month representative period during 2013–2016 was analysed. MUAs were 13% of the total theatre workload, with an annual increase in volume noted. Additionally, simple displaced distal radius fractures were routinely receiving a MUA (with or without K-wires) as a primary procedure in theatre. When this workload is combined it makes up 22% of the total theatre workload. Average theatre time was 57 minutes per case. Delays to definite procedure ranged from 8 to 120 hours. Cost of hospital admission and theatre utilisation was approximately £1000 per patient. Conversely, the cost of a MUA in the ED was estimated at £150. Given that we currently undertake around 15 manipulations in theatre a month, performing such work in the ED it would save approximately £153,000 a year to our health board. This audit identifies that MUAs of common orthopaedic injuries undertaken in theatre can lead too significant clinical and financial costs. We have proposed a strong financial argument to management for a twice weekly ‘manipulation list’ in the ED which is currently under review

Background. Distal radial fractures in the elderly population have been traditionally managed by closed techniques, primarily due to their poor bone quality and low functional demands. Since the introduction of the volar locking plate (VLP), which provides a good fixation in osteoporotic bones, there maybe an increased use of open reduction and internal fixation (ORIF) in the elderly population. Aim. We aimed to determine the changes in the management of these fractures in Scotland, and whether this differs between specialist regional centres and district general centres. Patients and Methods. We retrospectively analysed distal radius fractures, in patients aged over 70 years in the period between 1989 and 2008. Data were obtained from the national statistical centre based on admission code and from discharge summaries. Data included patient demographics and treatment method; either open reduction and internal fixation (ORIF), Kirschner wire, or manipulation under anaesthetic (MUA). Results. Incidence of distal radius fractures has increased by 75% from 1989 to 2008. In 2003 there were 94 (13.6%) ORIF, 109 (15.1%) K-wire and 492 (71.3%) MUA. In 2008 there were 131 (22.5%) ORIF, 81 (14.2%) K-wire and 361 (63.3%) MUA. There has been a 34% increase in the number of ORIF and a 26% decrease in K-wire procedures. There is a difference in the proportion treated by ORIF in university hospital and district general hospital trusts; 11.8% more fractures are treated by ORIF in university hospitals (p<0.5). Conclusion. There has been an increasing tend to use VLP in the place of K wire fixation. However a vast majority of elderly patients are still treated primarily with MUA. There is an increased tendency to use VLP in university hospital trusts than in distict general hospitals. This may be a reflection of the availability and preferences of specialist orthopaedic hand surgeons

Aims and objectives. The aim of this study was to assess the radiographic outcome by using Lindstrom grading for the management of Malone 2A and 2B fractures by 3 different methods of treatment. The three different methods included manipulation under anaesthesia, k-wire fixation and open reduction internal fixation. Methods and materials. Between March 2006 and February 2007, 62 intra-articular distal radius fractures were retrospectively selected. 31 patients including 21 females and 9 males with an average age of 62 years were classified as Malone 2A fractures and 32 patients including 18 females and 14 males with an average age of 64.5 years were classified as Malone 2B fractures. 18 patients had manipulation under anaesthetic (MUA) and immobilisation in a plaster of paris (POP) cast, 27 patients had manipulation and k-wire fixation and 17 patients had open reduction internal fixation (ORIF) of the fractures. All the patients had radiographic assessment at 6 weeks post op using Lindstrom grading. Grade 1 and 2 were considered acceptable, grade 3 and 4 were considered unacceptable. Results. In Malone 2A fractures the acceptable number of fractures were as follows −5/10 (50%) of the MUA group, 6/13(46.1%) in the k wire fixation group and 6/7 (85.7%) in the ORIF group. In Malone 2B fractures, the acceptable numbers were - nil in MUA group, 4/14 (28.6%) in k wire fixation group and 8/10 (80%) in the ORIF group. Conclusion. MUA and k wire fixation were not a good option for Malone 2B fractures as these fractures showed the best outcome with 80% acceptable results after ORIF. Malone classification can be used as a reliable predictor for deciding the treatment method for intra articular distal radius fractures as seen by the high acceptable results after ORIF for both type 2A and 2B fractures

Aims

The purpose of this study was to determine the weightbearing practice of operatively managed fragility fractures in the setting of publically funded health services in the UK and Ireland.

Aims

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.

ARI is a busy trauma unit (catchment: 500 000 people). In September 2010 a day-case Hand Trauma Service (HTS) started. Previously cases were often postponed due to prioritisation of orthopaedic emergencies; therefore increasing inpatient stay and associated costs. We aim to characterise presenting cases, evaluate improvements in service provision and financial costs. Data was collected from the first HTS year (Sept 10–11), and the preceding year (Sept 09–10). Data was collected on patient characteristics, operation, operative time, anaesthetic type and number of inpatient days. The cost of inpatient stay was calculated from the NHS Scotland resource allocation committee data. Pre HTS there were 410 cases (500 operative hours). 141 wound explorations, 22 nail-bed repairs, 34 metacarpal ORIF, 68 phalangeal ORIF, 5 scaphoid fixations, 69 tendon repairs, 30 terminalisations, 5 MUA, 19 nerve repairs, 17 unclassified. Accounting for 510 inpatient nights (mean: 1.25, range: 0–8), costing £204,387.60 (mean: £500.95). 123 cases required image intensification (II). Most patients had GA. During the first HTS year there were 282 operations. Most operations were day-case. 77 cases were performed under LA, 81 regional blocks and 34 under GA. During this year cases requiring II continued to be performed in the main theatre. The HTS has increased time available in main theatres. It has reduced inpatient stay costs, potentially saving £141,267.90. Performing more operations under LA/regional block decreases the risks associated with anaesthesia. Provision of II for the HTS would permit more cases to be performed, improving the service provision and further reducing costs

Radiological evidence of post-traumatic osteoarthritis (PTOA) after fracture of the tibial plateau is common but end-stage arthritis which requires total knee arthroplasty is much rarer.

The aim of this study was to examine the indications for, and outcomes of, total knee arthroplasty after fracture of the tibial plateau and to compare this with an age and gender-matched cohort of TKAs carried out for primary osteoarthritis.

Between 1997 and 2011, 31 consecutive patients (23 women, eight men) with a mean age of 65 years (40 to 89) underwent TKA at a mean of 24 months (2 to 124) after a fracture of the tibial plateau. Of these, 24 had undergone ORIF and seven had been treated non-operatively. Patients were assessed pre-operatively and at 6, 12 and > 60 months using the Short Form-12, Oxford Knee Score and a patient satisfaction score.

Patients with instability or nonunion needed total knee arthroplasty earlier (14 and 13.3 months post-injury) than those with intra-articular malunion (50 months, p < 0.001). Primary cruciate-retaining implants were used in 27 (87%) patients. Complication rates were higher in the PTOA cohort and included wound complications (13% vs 1% p = 0.014) and persistent stiffness (10% vs 0%, p = 0.014). Two (6%) PTOA patients required revision total knee arthroplasty at 57 and 114 months. The mean Oxford knee score was worse pre-operatively in the cohort with primary osteoarthritis (18 vs 30, p < 0.001) but there were no significant differences in post-operative Oxford knee score or patient satisfaction (primary osteoarthritis 86%, PTOA 78%, p = 0.437).

Total knee arthroplasty undertaken after fracture of the tibial plateau has a higher rate of complications than that undertaken for primary osteoarthritis, but patient-reported outcomes and satisfaction are comparable.

Cite this article: Bone Joint J 2015;97-B:532–8.