This prospective Randomised Controlled Trial compared two surgical approaches with respect to accuracy of guidewire and tibial nail position. Sixty-seven patients with tibial fractures were randomised to semi-extended (SE) or standard (S) approaches of nail insertion. Fluoroscopy was performed at guidewire insertion and final nail position. The SE approach is more proximal with the guidewire inserted posterior to the patella, theoretically allowing a better angle for more accurate nail placement. Measurements were taken in the Anteroposterior and lateral planes of both the nail and guidewire to determine deviation from the optimal angle of insertion (relative to the long axes of the tibial shaft). Thirty-nine and twenty-eight patients were treated with semiextended and standard approaches respectively. The semiextended approach resulted in improved nail placement to statistical significance in both planes, with mean deviation from the optimal angle of insertion as below:. Guidewire AP 3.2° (SE) versus 4° (S) Lateral 27.1° (SE) versus 30.2° (S). Nail AP 2.4° (SE) versus 4.2° (S) Lateral 17.9° (SE) versus 21.8° (S). Poor positioning of the guidewire leads to excessive anterior placement of the nail by eccentric reaming. Anterior positioning of the guidewire and nail in the lateral plane was assessed. This was expressed as a percentage from the anterior cortex of the tibia. Guidewire: Lateral 9.7% (SE) versus 9.3% (S). Nail: Lateral 23.4% (SE) 19.3% (S) (p 0.043). Semiextended nailing allows a better angle for guidewire placement and a more optimal final nail position. This facilitates accurate nail placement particularly in difficult proximal third fractures

Introduction. Femorotibial malalignment exceeding ±3° is a recognised contributor of early mechanical failure after total knee replacement (TKR). The angle between the mechanical and anatomical axes of the femur remains the best guide to restore alignment. We investigated where the femoral head lies relative to the pelvis and how its position varies with respect to recognised demographic and anatomic parameters. We have tested the hypothesis of the senior author that the position of the centre of the femoral head varies very little, and if its location can be identified, it could serve to outline the mechanical axis of the femur without the need for sophisticated imaging. Patients & Methods. The anteroposterior standing, plain pelvic radiographs of 150 patients with unilateral total hip replacements were retrospectively reviewed. All patients had Tönnis grade 0 or 1 arthritis on the non-operated hip joint. All radiographs were obtained according to a standardised protocol. Using the known diameter of the prosthetic head for calibration, the perpendicular distance from the centre of the femoral head of the non-operated hip to the centre of pubic symphysis was measured with use of TraumaCad software. Anatomic parameters, including, but not limited to, the diameter of the intact femoral head, were also measured. Demographic data (gender, age, height, weight) were retrieved from our database. Results. There were 72 men and 78 women with a mean age of 67.0 years. The mean distance of the centre of the femoral head to the pubic symphysis was 89.1 mm (standard deviation [SD], 5.8 mm). This distance was higher in men (mean, 90.5 mm; SD, 5.6 mm) than in women (mean, 87.7 mm; SD, 5.8 mm) (p=0.003). No statistically significant correlations between this distance and body-mass index or age (p=0.57 and p=0.28, respectively) were revealed. However, height was strongly correlated with this distance (r=0.52, p < 0.01), as was the diameter of the femoral head (r=0.61, p < 0.01). The latter was significantly larger in men than in women (p < 0.01). Conclusion. This is the first study to demonstrate that the position of the centre of the femoral head has very little variability, irrespective of patient age or body-mass index. As expected, it varies with patient's height and gender. Although statistically significant, the difference between genders is < 3 mm and can be explained by the smaller femoral head size of females. Our findings should prove useful during TKR surgery, as they facilitate intra-operative identification of the centre of the femoral head. Based on these results, simple trigonometry shows that if a surgeon measures 9 cm from the symphysis pubis, a line from this point to the centre of the knee will be within 2° and 2.2° of the true mechanical axis in 98% (i.e. ± 3 SD of the mean) of male and female patients, respectively

Pain produced by the tourniquet is a common source of complaint for patients undergoing carpal tunnel decompression. Practice varies as to tourniquet position. There is little evidence to suggest benefit of one position over another. Our aim was to compare the experience of both the patient and the surgeon with the tourniquet placed either on the arm or the forearm. Ethical approval was granted. Following power calculation and a significance level set at 0.05, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomised to arm or forearm group. Visual Analogue Scores (VAS) (0–100) for pain, blood pressure and heart rate were taken at 2 minute intervals. The operating surgeon provided a VAS for bloodless field achieved and obstruction caused by the tourniquet. The demographics of the groups was similar. There were no statistically significant differences in any measure between the groups. Average tourniquet times were 8.8 minutes (forearm) and 8.2 minutes (arm). The average VAS score for forearm and arm was 13 and 11 respectively for bloodless field, 9 and 2 for obstruction. Average overall VAS for pain was 27 in each group, however interval VAS scores for pain were higher in the arm group. The average change Mean Arterial Pressure was −5 mmHg (forearm) −2 mmHg (arm) pulse rate was −1 bpm (forearm) and −2 bpm (arm). Tourniquet placement on the arm does not result in significant difference in patient pain, physiological response or length of operation. Surgeons reported less obstruction and better bloodless fields with an arm tourniquet, however there was a trend for forearm tourniquet to result in less pain for the patient

Introduction. Due to the commercial launch of newly developed ceramic-on-metal (COM) bearings, we compared the deformation and stresses in the liner with ceramic-on-ceramic (COC), metal-on-metal (MOM) as well as ceramic-on-polyethylene (COP) bearings using a finite-element (FE)-model, analyzing a variety of head size and implant position. Liner deformation in terms of change in inner diameter as well as peak stresses were evaluated. Methods. The FE-model consisting of a commercial THR, the proximal femur and a section of the hemipelvis was created based on our previously published approach. Static load and muscle forces were applied according to the maximum load during gait. Polyethylene was modelled using a nonlinear definition with isotropic hardening, cobalt-chromium was modelled elastic-plastic and ceramic was modelled linear-elastic. Validity of the model was checked using an experimental setup with artificial bone and strain gauges located at the rim of the liner. Implant material (COM vs. COC vs. MOM vs. COP), head size (28 mm vs. 36 mm) and cup position (45° inclination/15° anteversion vs. 60° incl./0° antev.) were varied. Results. The experimental validation showed high correlation between strain measurements and FE-results. Liner deformation was evaluated by change in diameter at different levels. Change in head size had a high influence on cup deformation in COM, COC and MOM bearings, most possibly due to decreased liner thickness using bigger heads. Differences in MOM, COC and COM liner deformation were only in sub-micrometer range and not further evaluated. Evaluation of von Mises stress and minimum principal stress showed high differences between the bearing couples, implant positions and head sizes. COM liner stress was less sensitive to the steep cup position, but principal stress amounts were about ten times higher than in polyethylene liners. Thereby, MOM liners developed about 13 % less peak stress than COM. COC liners showed 11 % to 16 % higher stresses than COM. In accordance with published results, bigger head size correlated with lower principal stresses in the liner. Also, bigger heads were less sensitive to steep cup positions. Discussion. Deformation of the liner in total hip replacement has an important influence on lubrication, wear and clinical long-term success. The deformation occurring during intraoperative impaction and press-fit of the metal shell was not included in this study, hence the results are only valid considering the late postoperative phase when the implant is fully integrated in the bone. The FE-analysis showed no significant difference in liner deformation between COM, COC and MOM bearings. However, principal stresses were slightly higher in COM under the same conditions, but lower than COC

This ongoing prospective RCT compares two surgical approaches with respect to accuracy of guidewire and tibial nail position. 29 patients with tibial fractures were randomised to semi-extended (SE) or standard (S) approaches of tibial nail insertion. Fluoroscopy obtained guidewire and final nail position. The SE approach is more proximal with the guidewire inserted posterior to the patella, theoretically allowing more accurate wire and nail placement. Measurements were taken in both planes of the nail and guidewire to determine deviation from optimum angle of insertion (relative to the long axes of the tibial shaft). 14 and 15 patients were treated with semi-extended and standard approaches respectively. The semi-extended approach results in better guidewire and nail placement in both planes with mean deviation from the optimal angle of insertion as below:. Guidewire AP 4.5° (SE) versus 4.04° (S) Lateral 24.59° (SE) versus 33.36° (S). Nail AP 3.21° (SE) versus 3.68° (S) Lateral 17.73° (SE) versus 24.04° (S). Anterior knee pain may be due to excessive anterior placement of the nail. We assessed anterior placement of the guidewire and nail in the lateral plane. This was expressed as a percentage from the anterior cortex of the tibia. Mean results are below:. Guidewire 9.7% (SE) versus 9.3% (S). Nail 19.5% (SE) versus 16.3% (S). Semi-extended nailing may allow for better guidewire position and as such nail placement. This may reduce anterior knee pain

The longitudinal midline and medial-parapatellar incision are commonly used in Total Knee Arthroplasty (TKA). Medial-parapatellar incision n offers a smaller wound, avoids creation of thin skin flaps and easier exposure in obese patients. This incision creates a lateral skin flap which may be subject to poor blood supply and delayed wound healing.

We undertook a Randomised Controlled Trial (n=20) comparing midline and medial-parapatellar incisions. Cutaneous blood-flow was measured using a Doppler Imager. Interstitial fluid measurements for lactate, pyruvate, lactate/pyruvate ratio and glucose were obtained from subcutaneous microdialysis catheters. Wound cosmesis was graded and skin sensation tested.

Immediately post-op there was no significant difference in subcutaneous blood flow, but by day 3 patients with medial-parapatellar incisions showed greater bloodflow than midline incisions, particularly on the medial side (387 vs 278units p=0.148). At both day 1 and 3 post-op the lateral flap of the medial parapatellar incision showed decreased blood flow compared to the medial side, though these failed to reach significance. In contrast the midline incision showed no discernable difference in blood flow between the medial and lateral flaps. Concentrations of subcutaneous glucose increased from 4 hours post-op in the midline group, returning to baseline by 24hours. In contrast, the parapatellar group remained at base line throughout. Lactate concentrations increased over time in both groups peaking at 12hours post-op. No difference was noted between incision types with regard to wound cosmesis.

We conclude that the use of a medial-parapatellar incision results in only minimal biochemical changes, which are unlikely to alter wound healing. Medial-parapatellar incision is therefore a safe alternative to a midline incision and can be utilised in appropriate complex cases to aid surgical exposure.

Aims. To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results. Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611

Aims. Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery. Methods. A prospective feasibility study was performed in which consecutive tibial plateau fracture patients were treated with 3D surgical planning, including patient-specific drilling guides applied to standard off-the-shelf plates. A postoperative CT scan was obtained to assess whether the screw directions, screw lengths, and plate position were performed according the preoperative planning. Quality of the fracture reduction was assessed by measuring residual intra-articular incongruence (maximum gap and step-off) and compared to a historical matched control group. Results. A total of 15 patients were treated with 3D surgical planning in which 83 screws were placed by using drilling guides. The median deviation of the achieved screw trajectory from the planned trajectory was 3.4° (interquartile range (IQR) 2.5 to 5.4) and the difference in entry points (i.e. plate position) was 3.0 mm (IQR 2.0 to 5.5) compared to the 3D preoperative planning. The length of 72 screws (86.7%) were according to the planning. Compared to the historical cohort, 3D-guided surgery showed an improved surgical reduction in terms of median gap (3.1 vs 4.7 mm; p = 0.126) and step-off (2.9 vs 4.0 mm; p = 0.026). Conclusion. The use of 3D surgical planning including drilling guides was feasible, and facilitated accurate screw directions, screw lengths, and plate positioning. Moreover, the personalized approach improved fracture reduction as compared to a historical cohort. Cite this article: Bone Jt Open 2024;5(1):46–52

Introduction. Knee arthroscopy can be used for ligamentous repair, reconstruction and to reduce burden of infection. Understanding and feeling confident with knee arthroscopy is therefore a highly important skillset for the orthopaedic surgeon. However, with limited training or experience, furthered by reduced practical education due to COVID-19, this skill can be under-developed amongst trainee surgeons. Methods. At a single institution, ten junior doctors (FY1 to CT2), were recruited as a part of a five, two-hour session, training programme utilising the Simbionix® ARTHRO Mentor knee arthroscopy simulator, supplemented alongside educational guidance with a consultant orthopaedic knee surgeon. All students had minimal to no levels of prior arthroscopic experience. Exercises completed included maintaining steadiness, image centring and orientation, probe triangulation, arthroscopic knee examination, removal of loose bodies and meniscectomy. Pre and post experience questionnaires and quantitative repeat analysis on simulation exercises were undertaken to identify levels of improvement. Results. Comparing pre and post experience questionnaires significant improvements in levels of confidence were noted in the following domains: naming arthroscopic instruments, port positioning and insertion, recognising normal anatomy arthroscopically, holding and using arthroscopic instruments and assisting in a live theatre setting (p<0.05). Significant improvements were also noted in time taken to complete and distance covered in metres, of the simulated exercises on repeat performance (p<0.05). Conclusion. Overall, with only five sessions under senior guidance, using a simulator such as the ARTHRO Mentor, significant improvements in both levels of confidence and skill can be developed even among individuals with no prior experience

Lateral-entry wiring (LEW) for displaced supracondylar humeral fractures (SHFs) has been popularised internationally. BOAST guidance suggests either LEW or crossed wires; the latter has reported lower risk of loss of fracture reduction –we explore technical reasons why. We reviewed 8 years of displaced SHFs in two regional centres. Injuries were grouped using the Gartland Classification, with posterolateral or posteromedial displacement assessment for Gartland 3 injuries. We identified any loss of fracture reduction, and reviewed intra-operative imaging to identify learning points that may contribute to early rotational displacement (ERD). 345 SHFs were included, between 2012 and 2020. Gartland 2 (n=117) injuries had a 3.42% risk. ERD. Gartland 3 crossed wirings (n=114) had a 6.14% risk of ERD, with those moving all being posterolaterally displaced. Gartland 3, posterolaterally displaced LEW (n=56) had a 35.7% risk of ERD. Gartland 3, posteromedially displaced LEW (n=58) had a 22.4% risk of ERD. All injuries with ERD except 3 had identifiable learning points, the commonest being non-divergence of wires, or wires not passing through both fracture fragments. LEW requires divergent spread and bicolumnar fixation. Achieving a solid construct through this method appears more challenging than crossed wiring, with rates of ERD 3–5× higher. Low-volume surgeons should adhere to BOAST guidelines and choose a wiring construct that works best in their hands. They can also be reassured that should a loss of position occur, the risk of requirement for revision surgery is extremely low in our study (0.3%), and it is unlikely to affect long term outcomes

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Correct femoral tunnel position in anterior cruciate ligament reconstruction (ACLR) is critical in obtaining good clinical outcomes. We aimed to delineate whether any difference exists between the anteromedial (AM) and trans-tibial (TT) portal femoral tunnel placement techniques on the primary outcome of ACLR graft rupture. Adult patients (>18year old) who underwent primary ACLR between January 2011 – January 2018 were identified and divided based on portal technique (AM v TT). The primary outcome measure was graft rupture. Univariate analysis was used to delineate association between independent variables and outcome. Binary logistic regression was utilised to delineate odds ratios of significant variables. 473 patients were analysed. Median age at surgery was 27 years old (range 18–70). A total of 152/473, (32.1%) patients were AM group compared to 321/473 (67.9%) TT. Twenty-five patients (25/473, 5.3%) sustained graft rupture. Median time to graft rupture was 12 months (IQR 9). A higher odds for graft rupture was associated with the AM group, which trended towards significance (OR 2.03; 95% CI 0.90 – 4.56, p=0.081). Older age at time of surgery was associated with a lower odds of rupture (OR 0.92, 95% CI 0.86 – 0.98, p=0.014). There is no statistically significant difference in ACLR graft rupture rates when comparing anteromedial and trans-tibial portal technique for femoral tunnel placement. There was a trend towards higher rupture rates in the anteromedial portal group

Aims

The purpose of this study was to develop a convolutional neural network (CNN) for fracture detection, classification, and identification of greater tuberosity displacement ≥ 1 cm, neck-shaft angle (NSA) ≤ 100°, shaft translation, and articular fracture involvement, on plain radiographs.

Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

Aims

In the Netherlands, general practitioners (GPs) can request radiographs. After a radiologically diagnosed fracture, patients are immediately referred to the emergency department (ED). Since 2020, the Máxima Medical Centre has implemented a new care pathway for minor trauma patients, referring them immediately to the traumatology outpatient clinic (OC) instead of the ED. We investigated whether this altered care pathway leads to a reduction in healthcare consumption and concomitant costs.

Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

Aims

The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.