Aims

We aimed to evaluate the long-term impact of fracture-related infection (FRI) on patients’ physical health and psychological wellbeing. For this purpose, quality of life after successful surgical treatment of FRIs of long bones was assessed.

Introduction: Limb lengthening with external fixators has been associated with many complications including pin tract infections, damage to neurovascular structures, joint stiffness, delayed consolidation, and pain. These can lead to a detrimental functional outcome and psychological upset with a consequent negative impact on patients’ quality of life. The Intramedullary Skeletal Kinetic Distractor (ISKD) is a fully implantable device that may offer a better functional and psychological outcome. The aim of this study therefore was to evaluate the functional and psychological outcome in a series of patients undergoing femoral lengthening with the ISKD. Methods: Twenty patients underwent intramedullary lengthening via ISKD. Eighteen of these had lost femoral bone length secondary to trauma, and two were affected by congenital limb shortening (one had both femora lengthened at different time intervals). Patients completed Toronto Extremity Salvation Score (TESS) (to evaluate subjective physical disability), and Short Form 36 (SF36) questionnaires pre and post-operatively. Results: Patients’ post operative TESS scores demonstrated a significant improvement in patient perception of their physical disability. SF36 responses after surgery improved in several areas including physical functioning, role limitation due to emotional problems, social functioning, mental health, pain experienced and change in health; the greatest improvements seen in role limitation due to emotional problem, social functioning, mental health, pain, and change in health. Discussion: These results indicate that limb lengthening with the ISKD improves patients’ overall quality of life decreasing post operative pain, improving their social functioning and mental health, overall ISKD lengthening improves how the patients perceive their health and physical disability

We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit. An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended. Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment). We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100). Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment. Level of evidence: IV (case series)

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Aims

To identify unanswered questions about the prevention, diagnosis, treatment, and rehabilitation and delivery of care of first-time soft-tissue knee injuries (ligament injuries, patella dislocations, meniscal injuries, and articular cartilage) in children (aged 12 years and older) and adults.

Aims

Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs.

Aim. To use Patient Reported Outcome Measures (PROMs) to determine the effectiveness of lumbar spinal surgery at a single UK institution. Methods. Consecutive patients who underwent lumbar spinal surgery (discectomies or decompressions) from 1 January 2011 to 13 March 2013 at a UK District General Hospital were assessed. The procedures were performed or supervised by a senior Consultant Orthopaedic spinal surgeon. All patients completed PROM questionnaires before and three months following surgery. These included Visual Analogue Scores (VAS), SF-12, Oswestry Disability Index (ODI) and Roland Morris Low Back Pain Questionnaire (RMQ). Results. A total of 230 patients had surgery. Of these, 189 (82%) completed both pre- and post-operative questionnaires. All PROMs showed improvement: VAS for constant back pain improved from 4.1 to 2.1 and exacerbations of back pain from 5.8 to 2.4. VAS for constant leg pain improved from 6.3 to 1.7 and for exacerbations of leg pain from 8.2 to 1.8. Mean ODI from 47 to 21; RMQ from13 to 5; and SF12-psychological and physical components increased by 7.2 and 12.4, respectively. Those patients with better psychological health pre-operatively, (high SF-12 score, >60 [n=14]) had a reduction in mean score (decrease of 3.2) post-operatively. However, those with poorer psychological health pre-operatively (low SF-12 score, <30 [n=18]) showed a marked improvement in mean score post-operatively (increase of 18.9). Conclusions. These results show that lumbar spinal surgery is safe and effective at a District General Hospital. Baseline psychological scores may help predict psychological outcomes following surgery. This warrants further prospective evaluation. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting. Conflicts of interest: No conflicts of interest. Sources of funding: No funding obtained

Purpose and background. Effective reassurance is an essential element of treatment for conditions that do not require further investigations, referrals and on-going monitoring. However, research defining what reassurance should consist of and how to deliver it is scarce. The aim of this review was to identify consultation-related processes that improved patients' outcomes, in order to build an evidence-based model of effective reassurance in primary care. Method and results. A literature search identified prospective observational studies that explicitly measured consultation-related factors in appropriate primary care patient groups. The findings from empirical studies were combined with theoretical and systematic reviews to develop a model of effective reassurance. Scrutiny of 8193 Abstracts yielded 29 empirical studies fitting inclusion criteria, and 64 reviews. The majority of studies measured patient satisfaction. Clinical outcomes (e.g. health status / symptom reduction) appear to improve with patients' active participation in the consultation. Behavioural outcomes (e.g. adherence/ health care utilization) were only measured in a handful of studies, but may improve when information was given in the final stage of the consultation. Psychological outcomes (e.g. health concerns) were consistently improved by patient-centred approaches. Conclusion. The synthesis of empirical evidence and theory resulted in a model with two distinct stages: Affective reassurance, which focuses on eliciting patient concerns empathically and leads to trust in the clinician. Cognitive reassurance should then follow, involving iterative and interactive education, leading to enablement and impacting on medium and long term outcomes. Conflicts of Interest. None. Source of Funding. None

Background: Sciatica is an important cause of pain and disability but relatively few studies have looked at predictors of outcome in sciatica populations. Prognostic studies in non-specific low back pain are more common, but it has been suggested that the prognostic indicators for sciatica may be different. Our aim was to systematically review and describe the literature investigating the predictors of outcome in sciatica populations. Methods: A systematic literature search of the databases (Medline, EMBASE, and CINAHL) and reference list of identified articles was conducted. Studies were included if they described subjects with sciatica, had a follow-up period of at least three months and measured outcomes including pain, disability, recovery, psychological outcomes or return to work. Methodological quality was assessed using a 15 item checklist. Results: 596 papers were identified but only 12 met the criteria for inclusion. A combination of individual (e.g. gender, BMI), biomedical (e.g. size of disc prolapse, neurological deficit), social (e.g. job satisfaction, social status, manual labour) and psychological (distress, mental health) predictors of outcome were reported. Conclusions: There are few high quality studies that have investigated prognostic factors associated with persistence of sciatic symptoms. Those identified explored a range of different factors, in a variety of settings and in subjects with variable duration of symptoms. Although the studies are difficult to interpret due to heterogeneity of the techniques used in analysis and presentation, they seem to suggest that clinical, occupational and individual factors might be more strongly associated with outcome than psychological factors in sciatica populations. Conflicts of Interest: None. Funding: None

Background. Social context may be important in chronic pain. One focus is reactions to pain between persons with LBP and their partners. Researchers have investigated partner reactions and found influences on pain levels and psychological outcomes, but little is known about factors underpinning these reactions. Aim. To investigate the associations of relationship quality and perceived partner responses with LBP intensity and disability. Method. Participants with partners (n=174) in a cohort study of LBP in primary care were included. Data on pain intensity, disability (RMDQ), perceptions of negative or solicitous partner responses (MPI), relationship quality (RDAS) and depression and anxiety (HADS) was collected. Results. Consensus (e.g. agreement about affection and sex) and satisfaction (frequency of arguments/disagreements) were significantly associated with pain intensity (p 0.01 and p 0.02). Solicitous partner responses (e.g. providing comfort, physical assistance) were significantly associated with patient disability (p 0.04). These significant associations only became apparent when depression was entered into the model, suggesting effect modification. Stratification by depression revealed associations between consensus and pain among those with high depression levels (p 0.04) and associations between solicitousness and disability in those with low depression levels (p 0.01). Overall, the models accounted for 14-17% of the variance in pain intensity and 26-29% of the variance in disability. Conclusion. Results show associations of solicitousness, satisfaction and consensus with pain intensity and disability. However the effect varies by the presence of depression. Further research should investigate further the pathway of relationship quality, depression and pain

The cost of claims for personal injury after whiplash injury costs the economy of the United Kingdom some £3 billion per year. The majority of vehicle occupants subjected to rear-end shunt either suffer no effects or make a complete recovery however a minority suffer adverse psychological and social consequences which may be largely unrelated to the severity of the initial physical insult. The early psychological reactions include feelings of being shocked, frightened and angry which are related to the victim’s subjective perception of accident severity. During the days after many victims continue to experience anxiety and distress manifest in physical, emotional, cognitive and social complaints – which may be severe enough to constitute the diagnosis of acute stress disorder which has a high risk of subsequent PTSD (Post – Traumatic Stress Disorder). Ongoing apparently disproportionate disability can take a number of forms but is usually an unconscious process resulting from the interaction of physical, psychological and social variables. The risk factors for a poor psychological outcome include pre-accident characteristics, the nature of the accident, beliefs favouring chronicity, quality of care along with independent post-accident events and in many cases the effect of litigation

Purpose: To assess the long term radiological, clinical and psychological outcome of patients treated surgically for displaced acetabular fractures. Methods: Over 79 patients were followed up in our outpatient clinic. AP pelvis and Judet view radiographs were taken and evaluated. This was followed by a detailed history and clinical examination. Outcome recorded using the modified Merle d’Aubigne scale. The SF36v2 questionnaire was also administered. Results: Using the modified Merle d’Aubigne scale:. Excellent 18%, Good 51%, Fair 13% and Poor 18%. Using the SF36v2 health questionnaire (Norm based scoring 1998 US population where 50 is the average score):Transformed physical score (PCS) 44.54 and transformed mental score (MCS) 50.27. Conclusions: The results represent the learning curve for a single surgeon specifically trained in this speciality. These results compare favourably with those of Matta (JBJS Nov 1996 78A), whose ‘excellent’ & ‘good’ results with a shorter follow up period was 76%. Letournel’s results at 12 years showed a 69% ‘excellent’ & ‘very good’ grade using a slightly different grading system.We have many patients in the ‘good’ grade that have normal walking and range of motion, but miss the ‘excellent’ grade because of slight or intermittent pain. |The results seem to support the surgical treatment of displaced ace-tabular fractures. Most studies show results for short term follow up. Long term follow up studies have implications in predicting the future with regard to medical legal claims

Background: This meta-analysis aims to evaluate the quality of life in post traumatic amputees in comparison with a limb salvage group, using peer-reviewed studies in these areas. Methods: Electronic databases were searched for studies on lower limb amputation and limb reconstruction following trauma. A manual review of the literature and abstracts was also conducted. Only studies having more than 24 months of follow up, and those using generic scales using physical and psychological parameters (SIP or SF36), were included. Two reviewers performed the search, inclusion, and data extraction independently. Results: 214 studies were identified after extensive searching, Eleven studies fulfilled all the inclusion criteria, reviewing the outcomes of 1874 patients including 899 cases of amputation and 975 cases of reconstruction. Outcome assessments were based on two generic scales of measurement for quality of life, namely SIP or SF 36. In the studies using SF36, the mean Physical Component Summary (PCS) for the amputation group was 39.76 +/−7.06 and mean Mental Component Summary (MCS) was 52.05+/−3.39. The mean PCS for the reconstruction group was 38.5+/−0.78 and the mean MCS was 50.76 +/− 3.09. The mean physical SIP score for amputation was 13.033 with SEM of 3.048, and the psychological SIP score was 15.953 with SEM of 1.153. The mean Physical SIP for reconstruction was 10.686 with SEM of 1.034 and the psychological SIP was 10.754 with SEM of 0.647. The Unpaired t test was used to compare the outcomes of amputation and reconstruction, studies using SF36 and SIP scores were compared independently. Our results show that physical morbidity in both groups is not significantly influenced by the modality of surgical intervention, but there is a statistically significant difference noted in psychological morbidity, the group with reconstruction being better. These results were consistent in studies using either of the two generic scales namely, SF36 or SIP scores. Conclusion: This meta-analysis provides evidence that limb reconstruction in lower limb trauma yields better psychological outcomes without significant difference in physical morbidity compared to amputation

In skeletally immature patients, resection of bone tumours and reconstruction of the lower limb often results in leg-length discrepancy. The Stanmore non-invasive extendible endoprosthesis, which uses electromagnetic induction, allows post-operative lengthening without anaesthesia. Between 2002 and 2009, 55 children with a mean age of 11.4 years (5 to 16) underwent reconstruction with this prosthesis; ten patients (18.2%) died of disseminated disease and one child underwent amputation due to infection. We reviewed 44 patients after a mean follow-up of 41.2 months (22 to 104). The mean Musculoskeletal Tumor Society score was 24.7 (8 to 30) and the Toronto Extremity Salvage score was 92.3% (55.2% to 99.0%). There was no local recurrence of tumour. Complications developed in 16 patients (29.1%) and ten (18.2%) underwent revision.

The mean length gained per patient was 38.6 mm (3.5 to 161.5), requiring a mean of 11.3 extensions (1 to 40), and ten component exchanges were performed in nine patients (16.4%) after attaining the maximum lengthening capacity of the implant. There were 11 patients (20%) who were skeletally mature at follow-up, ten of whom had equal leg lengths and nine had a full range of movement of the hip and knee.

This is the largest reported series using non-invasive extendible endoprostheses after excision of primary bone tumours in skeletally immature patients. The technique produces a good functional outcome, with prevention of limb-length discrepancy at skeletal maturity.

Disarticulation of the hip in patients with high-grade tumours in the upper thigh results in significant morbidity. In patients with no disease of the proximal soft tissue a femoral stump may be preserved, leaving a fulcrum for movement and weight-bearing. We reviewed nine patients in whom the oncological decision would normally be to disarticulate, but who were treated by implantation of an endoprosthesis in order to create a functioning femoral stump. The surgery was undertaken for chondrosarcoma in four patients, pleomorphic sarcoma in three, osteosarcoma in one and fibrous dysplasia in one. At follow-up at a mean of 80 months (34 to 132), seven patients were alive and free from disease, one had died from lung metastases and another from a myocardial infarction. The mean functional outcome assessment was 50 (musculoskeletal tumor society), 50 and 60 (physical and mental Short-form 36 scores).

Implantation of an endoprosthesis into the stump in carefully selected patients allows fitting of an above-knee prosthesis and improves wellbeing and the functional outcome.

We have reviewed 22 patients at a mean of 30 years (28 to 31) after a whiplash injury. A complete recovery had been made in ten (45.5%) while one continued to describe severe symptoms. Persistent disability was associated with psychological distress but both improved in the period between 15 and 30 years after injury. After 30 years, ten patients (45.5%) were more disabled by knee than by neck pain.

We describe the application of a non-invasive extendible endoprosthetic replacement in skeletally-mature patients undergoing revision for failed joint replacement with resultant limb-length inequality after malignant or non-malignant disease. This prosthesis was developed for tumour surgery in skeletally-immature patients but has now been adapted for use in revision procedures to reconstruct the joint or facilitate an arthrodesis, replace bony defects and allow limb length to be restored gradually in the post-operative period.

We record the short-term results in nine patients who have had this procedure after multiple previous reconstructive operations. In six, the initial reconstruction had been performed with either allograft or endoprosthetic replacement for neoplastic disease and in three for non-neoplastic disease. The essential components of the prosthesis are a magnetic disc, a gearbox and a drive screw which allows painless lengthening of the prosthesis using the principle of electromagnetic induction. The mean age of the patients was 37 years (18 to 68) with a mean follow-up of 34 months (12 to 62). They had previously undergone a mean of six (2 to 14) open procedures on the affected limb before revision with the non-invasive extendible endoprosthesis.

The mean length gained was 56 mm (19 to 107) requiring a mean of nine (3 to 20) lengthening episodes performed in the outpatient department. There was one case of recurrent infection after revision of a previously infected implant and one fracture of the prosthesis after a fall. No amputations were performed. Planned exchange of the prosthesis was required in three patients after attainment of the maximum lengthening capacity of the implant. There was no failure of the lengthening mechanism. The Mean Musculoskeletal Tumour Society rating score was 22 of 30 available points (18 to 28).

The use of a non-invasive extendible endoprosthesis in this manner provided patients with good functional results and restoration of leg-length equality, without the need for multiple open lengthening procedures.

This review discusses the causes, outcome and prevention of whiplash injury, which costs the economy of the United Kingdom approximately £3.64 billion per annum. Most cases occur as the result of rear-end vehicle collisions at speeds of less than 14 mph. Patients present with neck pain and stiffness, occipital headache, thoracolumbar back pain and upper-limb pain and paraesthesia. Over 66% make a full recovery and 2% are permanently disabled. The outcome can be predicted in 70% after three months.