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Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_8 | Pages 16 - 16
1 May 2018
Moore D Noonan M Kelly P Moore D
Full Access

Purpose. Angular deformity in the lower extremities can result in pain, gait disturbance, cosmetic deformity and joint degeneration. Up until the introduction of guided growth in 2007, which has since become the gold standard, treatment for correcting angular deformities in skeletally immature patients had been either an osteotomy, a hemiepiphysiodesis, or the use of staples. Methods. We reviewed the surgical records and diagnostic imaging in our childrens hospital to identify all patients who had guided growth surgery since 2007. All patients were followed until skeletal maturity or until their metalwork was removed. Results. 113 patients, with 147 legs were assessed for eligibility. Three were excluded for various reasons including inadequate follow-up or loss of records. Of the 144 treated legs which met the criteria for final assessment 32 (22.2%) were unsuccessful, the other 112 (77.8%) were deemed successful at final follow up. Complications were few, but included infection in one case and metal failure in another. Those with a pre-treatment diagnosis of idiopathic genu valgum/genu varum had a success rate of 83.6%. Conclusions. In our hands, guided growth had a seventy-eight percent success rate when all diagnosis were considered. Those procedures that were unlikely to be successful included growth disturbances due to mucopolysaccharide storage disease (28% failure rate), Blounts disease (66.6% failure rate) and achondroplasia (37.5% failure rate). If you exclude those three diagnoses, success rate for all other conditions was 81.4%. We continue to advocate the use of guided growth as a successful treatment option for skeletally immature patients with limb deformity


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_14 | Pages 1 - 1
10 Oct 2023
Haque S Downie S Ridley D Dalgleish S Nicol G
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There is little published literature to support the claim that a successful total knee replacement (TKR) is predictive of future good outcomes on the contralateral side. The objective was to identify whether outcome from the first of staged TKRs could be used to predict the outcome of the contralateral TKR.

This was a retrospective cohort study of 1687 patients over a 25-year period undergoing staged bilateral TKRs in a UK arthroplasty centre. A control group of 1687 patients undergoing unilateral TKR with matched characteristics was identified. Primary outcomes were satisfaction and Knee Society Score (KSS) at one year.

Preoperative status was comparable for pain, ROM and KSS (mean 41, 45, 43±14). At one year follow up, dissatisfaction was similar for all groups (4% first of staged TKR, 4% second of staged TKR, 5% controls). If the first TKR had a good outcome, the relative risk of a contralateral bad outcome was 20% less than controls (95% CI 0.6–1.2). If the first TKR had a poor outcome, the risk of a second poor outcome was 4 times higher (95% CI 2.8–6.1), increasing from 6% to 27% (absolute risk).

Patients undergoing the second of staged TKRs with a previous good outcome are likely to do well in their second procedure (94 in 100 will go on to have a second good outcome). Of those with a previous poor outcome, 27 in 100 will have a second poor outcome. The trend was persistent despite correcting for gender, age, BMI, and diagnosis.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_16 | Pages 7 - 7
1 Apr 2013
Hak D Lin S Hammerberg M Stahel P
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Objective. The development of surgical site infection in the early weeks following open reduction and internal fixation (ORIF) is a challenging problem. There are no evidence-based guidelines to direct the number of surgical debridements prior to definitive wound closure. The purpose of this study was to assess the success of infection resolution, and to identify risk factors for failure, in post-operative infections treated with a single debridement and primary wound closure. Methods. We retrospectively reviewed 61 postoperative infections (60 patients) that developed following fracture ORIF that were treated with a single debridement and primary closure. Data was collected from a review of the patients’ medical record. Variables were compared between the two groups using univariate and multivariate logistic regression analysis. Results. Twenty nine cases (48%) in 28 patients achieved successful outcome following a single debridement and primary closure without hardware removal. Risk factors for treatment failure, identified by multivariate analysis, were AO/OTA classification B and C type fractures (odds ratio = 2.539; 95% confidence interval = 1.110, 5.807; p = 0.027) and elevated C-reactive protein at admission (odds ratio = 1.017; 95% confidence interval = 1.002, 1.032; p = 0.026). Conclusions. Acute postoperative infection following ORIF treated by a single debridement and primary closure with hardware retention is successful in only half of the cases


Bone & Joint Open
Vol. 2, Issue 11 | Pages 958 - 965
16 Nov 2021
Craxford S Marson BA Nightingale J Ikram A Agrawal Y Deakin D Ollivere B

Aims. Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. Methods. Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. Results. A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. Conclusion. Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958–965


Orthopaedic Proceedings
Vol. 105-B, Issue SUPP_6 | Pages 2 - 2
20 Mar 2023
Brennan C Slevin Z Savaridas T
Full Access

The suprascapular nerve is an ideal target for nerve blockade to alleviate shoulder pain given its widespread innervation to the shoulder girdle. Many techniques have been described. To widen the availability of this treatment we investigate whether an anatomical landmark technique can be easily learned by novice injectors to provide efficacious blockade. Five injectors were recruited with varying experience; from the novice medical student to an orthopaedic consultant. Five torsos (10 shoulders) were used. A single page of written instruction and illustration of the Dangoisse landmark technique was provided prior to injection of a Thiel embalmed cadaver bilaterally. A pre-mixed injectate with blue dye was used. Cadavers were dissected and the presence or absence of dye staining reported by 3 observers and a consensus agreement reached. Dissection demonstrated diffuse staining in the suprascapular fossa. 90% of shoulders were found to have adequate staining of the suprascapular nerve directly, or its distal branches, in a manner which would provide adequate anaesthesia. The inter-observer agreement was good (k = 0.73) for staining at the supraspinous fossa and excellent (k=0.87) for staining distally. The technique was easily performed by novice injectors with a 100% success rate. We demonstrate that this technique is reproducible by a range of clinicians to effectively provide anaesthesia of the SScN. The main risks are ineffective block (10% in this series) and of intravascular injection. Within a resource strained healthcare environment greater uptake of this technique is likely to be of benefit to a wider array of patients


Orthopaedic Proceedings
Vol. 106-B, Issue SUPP_17 | Pages 3 - 3
11 Oct 2024
Jennings A Dalgleish S Baines C
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This project hoped to evaluate a new role, encompassing an in-hours registrar physician being based on the orthopaedic wards for advice, patient reviews, and patient journey optimisation. This service aimed to provide input for all patients who required them outwith the already established ortho-geriatric service. The success of this role was assessed through feedback questionnaires, as well as through the auditing of functional indicators such as the burden on the on-call orthopaedic registrar and other departments for advice from junior doctors, plus the number of medical emergencies. The survey received a total of 42 responses from various staff roles. All respondents thought the role had improved patient care or the functioning of the department. Respondents thought the role primarily enhanced patient care and safety and led to increased support for junior doctors and nursing staff. Data showed a 44% reduction in medical emergency calls since the role began. Total calls outwith the department for medical support reduced by 100% in hours and 50% out of hours when analysed over 22 days. Over a 14 day period, calls to the on-call orthopaedic registrar also reduced by 100% in hours, with no significant difference out of hours. This role has improved patient care and safety and allowed faster medical support with reduced impact on orthopaedic and general medical services. Feedback has been very positive from all staff. The major limitation is lack of 24 hour support. Next steps will include expanding the role, as well as introduction of framework for professional development


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_12 | Pages 9 - 9
1 Oct 2021
Scott-Watson M Adams S Dixon M Garcia-Martinez S Johnston M Adams C
Full Access

Success treating AIS with bracing is related to time worn and scoliosis severity. Temperature monitoring can help patients comply with their orthotic prescription. Routinely collected temperature data from the start of first brace treatment was reviewed for 14 patients. All were female with an average age of 12.4 years (range 10.3–14.6) and average 49o Cobb angle (30–64). Our current service recommendation is brace wear for 20 hours a day. Patients complied with this prescription 38.0% of the time, with four patients averaging this or more. Average brace wear was 16.3 hours per day (3.5–22.2). There were 13 patients who had completed brace treatment. The majority had surgery (7/13; 54%) or were considering surgery (1/13; 8%). There were 5 who did not wish surgery at discharge (5/13; 38%); 1 achieved a 40o Cobb angle, with 4 larger (53o;53o;54o;68o). The Bracing in AIS Trial (BrAIST) study measured “success” as less than a 50o Cobb angle, so using this metric our cohort has had a single “success”. Temperature monitors allowed an analysis of when patients were achieving their brace wear. When comparing daywear (8am-8pm) to nightwear (8pm-8am), patients wore their brace an average of 7.6 hours a day (2.5–11.2) and 8.7 hours a night (0.4–11.5). We conclude the minority of our patients comply with our current 20 hour orthotic prescription. The “success” of brace treatment is lower than comparison studies despite higher average compliance but starting with a larger scoliosis. Brace wear is achieved during both the day and night


The Bone & Joint Journal
Vol. 106-B, Issue 7 | Pages 720 - 727
1 Jul 2024
Wu H Wang X Shen J Wei Z Wang S Xu T Luo F Xie Z

Aims

This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

Methods

A total of 1,047 limb osteomyelitis patients aged 18 years or older who underwent debridement and intraoperative culture at our clinic centre from 1 January 2011 to 31 December 2020 were included. Patient characteristics, infection eradication, and complications were analyzed between culture-negative and culture-positive cohorts.


Bone & Joint Open
Vol. 4, Issue 5 | Pages 378 - 384
23 May 2023
Jones CS Eardley WGP Johansen A Inman DS Evans JT

Aims

The aim of this study was to describe services available to patients with periprosthetic femoral fracture (PPFF) in England and Wales, with focus on variation between centres and areas for care improvement.

Methods

This work used data freely available from the National Hip Fracture Database (NHFD) facilities survey in 2021, which asked 21 questions about the care of patients with PPFFs, and nine relating to clinical decision-making around a hypothetical case.


Bone & Joint Open
Vol. 5, Issue 2 | Pages 147 - 153
19 Feb 2024
Hazra S Saha N Mallick SK Saraf A Kumar S Ghosh S Chandra M

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.

Methods

We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d’Aubigné score and Matta’s radiological grading at one year and at latest follow-up.


The Bone & Joint Journal
Vol. 106-B, Issue 6 | Pages 613 - 622
1 Jun 2024
Shen J Wei Z Wu H Wang X Wang S Wang G Luo F Xie Z

Aims

The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

Methods

Between May 2012 and December 2020, 203 patients with infected segmental bone defects treated with the IMT were enrolled. The digital medical records of these patients were retrospectively analyzed. Factors associated with unfavourable outcomes were identified through logistic regression analysis.


Bone & Joint Open
Vol. 5, Issue 2 | Pages 117 - 122
9 Feb 2024
Chaturvedi A Russell H Farrugia M Roger M Putti A Jenkins PJ Feltbower S

Aims

Occult (clinical) injuries represent 15% of all scaphoid fractures, posing significant challenges to the clinician. MRI has been suggested as the gold standard for diagnosis, but remains expensive, time-consuming, and is in high demand. Conventional management with immobilization and serial radiography typically results in multiple follow-up attendances to clinic, radiation exposure, and delays return to work. Suboptimal management can result in significant disability and, frequently, litigation.

Methods

We present a service evaluation report following the introduction of a quality-improvement themed, streamlined, clinical scaphoid pathway. Patients are offered a removable wrist splint with verbal and written instructions to remove it two weeks following injury, for self-assessment. The persistence of pain is the patient’s guide to ‘opt-in’ and to self-refer for a follow-up appointment with a senior emergency physician. On confirmation of ongoing signs of clinical scaphoid injury, an urgent outpatient ‘fast’-wrist protocol MRI scan is ordered, with instructions to maintain wrist immobilization. Patients with positive scan results are referred for specialist orthopaedic assessment via a virtual fracture clinic.


The Bone & Joint Journal
Vol. 106-B, Issue 4 | Pages 387 - 393
1 Apr 2024
Dean BJF Riley N Little C Sheehan W Gidwani S Brewster M Dhiman P Costa ML

Aims

There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures.

Methods

This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion.


Bone & Joint Open
Vol. 4, Issue 7 | Pages 516 - 522
10 Jul 2023
Mereddy P Nallamilli SR Gowda VP Kasha S Godey SK Nallamilli RR GPRK R Meda VGR

Aims

Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

Methods

Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30).


Bone & Joint Open
Vol. 5, Issue 8 | Pages 621 - 627
1 Aug 2024
Walter N Loew T Hinterberger T Alt V Rupp M

Aims

Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI.

Methods

A prospective longitudinal study was conducted at a level 1 trauma centre from January 2020 to December 2022. In total, 56 patients treated for FRI were enrolled. The ICD-10 symptom rating (ISR) and an expectation questionnaire were assessed at five timepoints: preoperatively, one month postoperatively, and at three, six, and 12 months.


The Bone & Joint Journal
Vol. 106-B, Issue 10 | Pages 1182 - 1189
1 Oct 2024
Nisar S Lamb J Johansen A West R Pandit H

Aims

To determine if patient ethnicity among patients with a hip fracture influences the type of fracture, surgical care, and outcome.

Methods

This was an observational cohort study using a linked dataset combining data from the National Hip Fracture Database and Hospital Episode Statistics in England and Wales. Patients’ odds of dying at one year were modelled using logistic regression with adjustment for ethnicity and clinically relevant covariates.


The Bone & Joint Journal
Vol. 104-B, Issue 9 | Pages 1073 - 1080
1 Sep 2022
Winstanley RJH Hadfield JN Walker R Bretherton CP Ashwood N Allison K Trompeter A Eardley WGP

Aims

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

Method

Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded.


The Bone & Joint Journal
Vol. 104-B, Issue 8 | Pages 963 - 971
1 Aug 2022
Sun Z Liu W Liu H Li J Hu Y Tu B Wang W Fan C

Aims

Heterotopic ossification (HO) is a common complication after elbow trauma and can cause severe upper limb disability. Although multiple prognostic factors have been reported to be associated with the development of post-traumatic HO, no model has yet been able to combine these predictors more succinctly to convey prognostic information and medical measures to patients. Therefore, this study aimed to identify prognostic factors leading to the formation of HO after surgery for elbow trauma, and to establish and validate a nomogram to predict the probability of HO formation in such particular injuries.

Methods

This multicentre case-control study comprised 200 patients with post-traumatic elbow HO and 229 patients who had elbow trauma but without HO formation between July 2019 and December 2020. Features possibly associated with HO formation were obtained. The least absolute shrinkage and selection operator regression model was used to optimize feature selection. Multivariable logistic regression analysis was applied to build the new nomogram: the Shanghai post-Traumatic Elbow Heterotopic Ossification Prediction model (STEHOP). STEHOP was validated by concordance index (C-index) and calibration plot. Internal validation was conducted using bootstrapping validation.


The Bone & Joint Journal
Vol. 104-B, Issue 8 | Pages 987 - 996
1 Aug 2022

Aims

The aim of this study was to describe the demographic details of patients who sustain a femoral periprosthetic fracture (PPF), the epidemiology of PPFs, PPF characteristics, and the predictors of PPF types in the UK population.

Methods

This is a multicentre retrospective cohort study including adult patients presenting to hospital with a new PPF between 1 January 2018 and 31 December 2018. Data collected included: patient characteristics, comorbidities, anticoagulant use, social circumstances, level of mobility, fracture characteristics, Unified Classification System (UCS) type, and details of the original implant. Descriptive analysis by fracture location was performed, and predictors of PPF type were assessed using mixed-effects logistic regression models.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXVII | Pages 372 - 372
1 Sep 2012
Bainbridge C Houston A Jones G Milner R Wilbrand S
Full Access

Introduction. In Europe, injectable collagenase clostridium histolyticum (CCH) is a novel, minimally invasive, non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). We evaluated the efficacy and tolerability of 5 CCH injections using a protocol designed to follow clinical practice. Methods. This was a 20-center, 9-month, open-label study in which DC patients with primary flexion deformities 20° (100° for MP; 80° for PIP) received 3 CCH (0.58 mg) injections/joint (5 injections/patient) at 30-day intervals. The primary endpoint was clinical success, defined as a reduction in contracture to 5° 30 days after the last injection (“Day 30”). After first injection into a prioritized joint, patients opted to receive up to 2 more injections into the same cord or cords from other affected joints whether or not they achieved clinical success with the first joint. Adverse events (AEs) were monitored. Results. For the primary endpoint, 71% of MP (n=343) and 41% of PIP (n=244) joints showed a reduction in contracture to 5° with CCH injections. Of joints that did not achieve clinical success, 66% of MP (n=100) and 38% of PIP joints (n=144) showed 50% reduction in contracture after CCH. For range of motion (ROM), mean±SD increase from baseline to Day 30 was 33.0±16.2° for MP and 27.5±18.5° for PIP joints. Most commonly reported AEs were localized edema, bruising, pain, swelling, and tenderness; most resolved without intervention. Two serious AEs, deep vein thrombosis in the leg and tendonitis with partial tendon/ligament injury, were deemed possibly and probably related to treatment, respectively. Conclusions. Results from this open-label study, designed to follow clinical practice, provide support for the efficacy of CCH in correcting the flexion deformity of MP/PIP joints caused by DC. Clinical success and ROM improvements were comparable to those observed in randomized, placebo-controlled trials. This study was funded by Auxilium Pharmaceuticals, Inc