Aims. Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes. Methods. A total of 1,199 patients with femoral neck fractures presented to a large UK teaching hospital over a three-year period. All patients had nutritional assessments performed using the Malnutrition Universal Screening Tool (MUST). Malnutrition risk was compared to mortality, length of hospital stay, and discharge destination using logistic regression. Adjustments were made for covariates to identify whether malnutrition risk independently affected these outcomes. Results. Inpatient mortality was 5.2% (35/678) in the group at low risk of malnutrition, 11.3% (46/408) in the medium-risk group, and 17.7% (20/113) in the high-risk group. Multivariate analysis showed each categorical increase in malnutrition risk independently predicted inpatient mortality with an odds ratio (OR) of 1.59 (95% confidence interval (CI) 1.14 to 2.21; p = 0.006). An increased mortality rate persisted at 120 days post-injury (OR 1.64, 95% CI 1.20 to 2.22; p = 0.002). There was a stepwise increase in the proportion of patients discharged to a residence offering a greater level of supported living. Multivariate analysis produced an OR of 1.34 (95% CI 1.03 to 1.75; p = 0.030) for each category of MUST score. Median length of hospital stay increased with a worse MUST score: 13.9 days (interquartile range (IQR) 8.2 to 23.8) in the low-risk group; 16.6 days (IQR 9.0 to 31.5) in the medium-risk group; and 22.8 days (IQR 10.1 to 41.1) in the high-risk group. Adjustment for covariates revealed a partial
We report a cost-effectiveness analysis of Primary Total Ankle Replacements (TAR). In addition, we looked for factors that could be predictors of increased gain in Quality-Adjusted Life Years (QALYs). Pre-operative and six-month post-operative data for TAR was obtained over seven-and-a-half-years in NHS Lothian. The EuroQol general health questionnaire (EQ-5D-3L) measured health-related Quality of Life and the Manchester-Oxford Foot Questionnaire (MOXFQ) measured joint function. Predictors, tested for significance with QALYs gained, were pre-operative scores and demographic data including age, gender, BMI and Deprivation category. Continuous variables were assessed with Pearson
Though knee osteoarthritis (OA) is diagnosed and monitored radiographically, full thickness cartilage loss (FTCL) has rarely been correlated with radiographic classification. This study aims to analyse which classification system correlates best with FTCL and assessing their reliability. Prospective study of 300 consecutive patients undergoing total knee arthroplasty (TKA) for OA. Two blinded examiners independently graded preoperative radiographs using 5 systems: Kellgren-Lawrence (KL); International Knee Documentation Committee (IKDC); Fairbank; Brandt; and Ahlback. Interobserver agreement was assessed using the intraclass correlation coefficient. Intraoperatively, anterior cruciate ligament (ACL) status and FTCL in 16 regions of interest were recorded. Radiographic classification and FTCL were correlated using the Spearman
The objective of this study was to compare differences in alignment following robotic arm-assisted bi-unicompartmental knee arthroplasty (Bi-UKA) and conventional total knee arthroplasty (TKA). This was a prospective, randomised controlled trial of 70 patients. 39 TKAs were implanted manually, as per standard protocol at our institution, and 31 Bi-UKA patients simultaneously received fixed-bearing medial and lateral UKAs, implanted using robotic arm-assistance. Preoperative and 3-month postoperative CT scans were analysed to determine hip knee ankle angle (HKAA), medial distal femoral angle (MDFA), and medial proximal tibial angle (MPTA). Analysis was repeated for 10 patients by a second rater to validate measurement reliability by calculating the intra-class
Cam type femoroacetabular impingement (FAI) is due to an aspheric femoral head, which is best quantified by the alpha angle described on MRI and CT-scan. Radiographic measurement of the alpha angle is not well codified and studies from the literature cannot conclude on the best view to measure it. Most authors also describe a mixed type FAI which associates an aspheric femoral head with an excessive anterior acetabular coverage of the femoral head. Anterior center edge (ACE) angle has been described on the false profile view to measure anterior acetabular coverage in hip dysplasia and has never been evaluated in FAI. In this study, we developed a new lateral hip view which associates a lateral view of the femoral neck and a false profile view of the acétabulum, which we called profile view in impingement position (PVIP). Twenty six patients operated for FAI had CT-scan, the PVIP and the false profile view of one or two hips according to pain. A control group of 19 patients who did not suffer from the hip had the PVIP. Alpha angles were measured twice on 17 CT scan of FAI patients by two observers and compared with the alpha angles measured on the corresponding hip PVIP by a correlation analysis. Alpha angles were measured twice on 45 PVIP in FAI patient and on 19 PVIP in the control group by three observers. ACE angles were measured once on 15 PVIP and on 15 false profile views. Means were compared by two tail paired t-tests, intra- and inter-observer reliability were measured by intraclass correlation coefficient. Mean alpha angle on CT scan was 65.8° and 65.6° for observers 1 and 2 respectively (p>0.05). It was 63.6° and 64.3° on the PVIP (p>0.05). No significant difference was found between CT scan and radiographic measurements, and Pearson's
25–40% of unicompartmental knee replacement (UKR) revisions are performed for unexplained pain possibly secondary to elevated proximal tibial bone strain. This study investigates the effect of tibial component metal backing and polyethylene thickness on cancellous bone strain in a finite element model (FEM) of a cemented fixed bearing medial UKR, validated using previously published acoustic emission data (AE). FEMs of composite tibiae implanted with an all-polyethylene tibial component (AP) and a metal backed one (MB) were created. Polyethylene of thickness 6–10mm in 2mm increments was loaded to a medial load of 2500N. The volume of cancellous bone exposed to <−3000 (pathological overloading) and <−7000 (failure limit) minimum principal (compressive) microstrain (µ∊) and >3000 and >7000 maximum principal (tensile) microstrain was measured. Linear regression analysis showed good correlation between measured AE hits and volume of cancellous bone elements with compressive strain <−3000µ∊:
The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI). From posteroanterior digital radiographs of healed DRFs in 398 female patients aged 70 years or older, and 32 unfractured control wrists, the relationships of RI, quantifiably, to four linear measurements made perpendicular to reference distal radial shaft (DRS) and ulnar shaft (DUS) axes were analyzed: 1) DRS to radial aspect of ulnar head (DRS-U); 2) DUS to volar-ulnar corner of distal radius (DUS-R); 3) DRS to proximal capitate (DRS-PC); and 4) DRS to DUS (interaxis distance, IAD); and, qualitatively, to the distal ulnar fracture, and its intersection with the DUS axis.Aims
Methods
Leg length discrepancy (LLD) can adversely affect functional outcome and patient satisfaction after total hip arthroplasty. We describe a novel intraoperative technique for femoral component insertion. We aimed to determine if this technique resulted in the desired femoral placement, as templated, and if this was associated with a reduced LLD. A series of fifty consecutive primary total hip replacements were studied. Preoperative digital templating was performed on standardised PA radiographs of the hips by the senior surgeon. The preoperative LLD was calculated and the distance from the superior tip of the greater trochanter to the predicted shoulder of the stem was calculated (GT-S). Intraoperatively, this length was marked on the rasp handle and the stem inserted to the predetermined level by the surgeon. This level corresponded to the tip of the greater trochanter and formed a continuous line to the mark on the rasp handle. Three independent blinded observers measured the GT-S on the postoperative radiographs. We assessed the relationship between the senior author's GT-S (preoperative) and the observers' GT-S (postoperative) using a Person correlation. The observers also measured the preoperative and postoperative LLD, and the inter-observer variability was calculated as the intra-class
To validate the Modified Forgotten Joint Score (MFJS) as a new patient-reported outcome measure (PROM) in hip and knee arthroplasty (THR/TKR) against the UK's gold standard Oxford Hip and Knee Scores (OHS/OKS). The MFJS is a new assessment tool devised to provide a greater discriminatory power, particularly in well performing patients. It measures an appealing concept; the ability of a patient to forget about their artificial joint in everyday life. Postal questionnaires were sent out to 400 THR and TKR patients who were 1–2 years post-op. The data collected from the 212 returned questionnaires was analysed in relation to construct and content validity. 77 patients took part in a test-retest repeatability assessment. The MFJS proved to have an increased discriminatory power in high-performing patients in comparison to the OHS and OKS, highlighted by its more normal frequency of distribution and reduced ceiling effects. 30.8% of patients (n=131) achieved excellent OHS/OKS scores of 42–48 this compared to just 7.69% of patients who achieved a proportionately equivalent MFJS score of 87.5–100. The MFJS proved to have an increased test-retest repeatability based upon its intra-class
Introduction. One of the most common complications of ceramic on ceramic hip replacement is squeaking. The association of Accolade stem and Trident acetabular system has been reported to have squeaking incidence of up to 35,6%. There is doubt if this phenomenon occurs due to: the stem titanium alloy, the V40 femoral neck, the recessed liner of the trident cup or even the mal-seating of the trident insert on the cup. Objectives. Primary: The purpose of the present study was to determine the incidence of squeaking in association with the use of Exeter stem and Trident ceramic acetabular system. Secondary: Analysis of the correlation of the cup abduction angle and squeaking. Methods. During the period from March 2004 to December 2008, two surgeons performed 87 total hip arthroplasties in 77 patients with use of a ceramic-on-ceramic bearing (Exeter stem, alumina head, Trident ceramic acetabular system). Seventy six patients (86 THA) were available for review after at least 18 months follow-up. The incidence of squeaking and other noises was analyzed. Cup abduction angle was measured. The Pearson
We introduced a self-care pathway for minimally displaced distal radius fractures, which involved the patient being discharged from a Virtual Fracture Clinic (VFC) without a physical review and being provided with written instructions on how to remove their own cast or splint at home, plus advice on exercises and return to function. All patients managed via this protocol between March and October 2020 were contacted by a medical secretary at a minimum of six months post-injury. The patients were asked to complete the Patient-Rated Wrist Evaluation (PRWE), a satisfaction questionnaire, advise if they had required surgery and/or contacted any health professional, and were also asked for any recommendations on how to improve the service. A review with a hand surgeon was organized if required, and a cost analysis was also conducted.Aims
Methods
Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data. We analyzed prospectively collected registry data from 2,108 patients aged ≥ 65 years who were admitted to a single major trauma centre over five years (1 October 2015 to 31 July 2020). We divided the sample equally into two, creating derivation and validation samples. In the derivation sample, we performed univariate analyses followed by multivariate regression, starting with 27 clinical variables in the registry to predict Clinical Frailty Scale (CFS; range 1 to 9) scores. Bland-Altman analyses were performed in the validation cohort to evaluate any biases between the Nottingham Trauma Frailty Index (NTFI) and the CFS.Aims
Methods
Introduction. High Tibial Osteotomy has become an increasingly popular management option for patients with painful medial compartment osteoarthritis. The Fujisawa method used to calculate the angle of correction is well-documented but there have been no studies to look at the reliability and accuracy of web-based systems to calculate this angle. Patients and Methods. Patients undergoing valgus high tibial osteotomy between October 2004 and February 2010 who had full-length lower-limb views on the Picture Archiving and Communications System (PACS). The Fujisawa angle and length of osteotomy were calculated by the surgeon and two Orthopaedic registrars who had been appropriately trained. Results. Thirty X-rays were reviewed in 28 patients. Mean difference between measurements was 0.43 mm (SD 2.45) There was a statistically significant correlation between all three raters (P < 0.001). The greatest correlation was between the Consultant and the more senior trainee (r=0.86) with the lowest correlation between the Consultant and the more junior trainee (r=0.70). Concordance
Introduction. Dislocation following total hip arthroplasty THA is a major short term complication not infrequently resulting in revision arthroplasty. Malposition of the acetabular component in THA results in a higher rate of dislocation as well as increased wear and osteolysis. The aim of this study was to assess the effect of mode of fixation on positioning of the acetabular component. Patients, materials and methods. For all THAs performed at our hospital in 2008, angle of acetabular inclination was measured using PACS by two independent observers. Interobserver and intraobserver reliability were assessed (Pearson's
Background. Overlooked compartment syndrome represents a devastating complication for the patient. Invasive compartment pressure measurement continues to be the gold standard. However, repeated measurements in uncertain cases may be difficult to achieve. We developed a new, noninvasive method to assess tissue firmness by pressure related ultrasound. Methods. Decreased tissue elasticity by means of rising compartment pressures was mimicked by infusion of saline directly into the anterior tibial compartment of 6 human specimens post mortem. A pressure transducer (Codman) monitored the pressure of the anterior tibial compartment. A second transducer was located in a saline filled ultrasound probe head to allow a simultaneous recording of the probe pressure provoked by the user. The ultrasound images were generated at 5 and 100mmHg probe pressures to detect the tissue deformity by B-mode ultrasound. The fascial displacement was measured before and after compression (d). Subsequently, increments of 5mmHg pressure increases were used to generate a standard curve (0–80mmHg), thus mimicking rising compartment pressures. The intra-observer reliability was tested using 10 subsequent measurements. A correlation was determined between d and the simulated intacompartmental pressure (ICP) in the compartment. The Pearson
The last decade has seen a marked increase in surgical rib fracture fixation (SRF). The evidence to support this comes largely from retrospective cohorts, and adjusting for the effect of other injuries sustained at the same time is challenging. This study aims to assess the impact of SRF after blunt chest trauma using national prospective registry data, while controlling for other comorbidities and injuries. A ten-year extract from the Trauma Audit and Research Network formed the study sample. Patients who underwent SRF were compared with those who received supportive care alone. The analysis was performed first for the entire eligible cohort, and then for patients with a serious (thoracic Abbreviated Injury Scale (AIS) ≥ 3) or minor (thoracic AIS < 3) chest injury without significant polytrauma. Multivariable logistic regression was performed to identify predictors of mortality. Kaplan-Meier estimators and multivariable Cox regression were performed to adjust for the effects of concomitant injuries and other comorbidities. Outcomes assessed were 30-day mortality, length of stay (LoS), and need for tracheostomy.Aims
Methods
Aims and objectives. The aim of this study was to statistically analyse the calcaneal fractures occurring in the community and distribution within the various age groups divided into decades. Methods and materials. Records of calcaneal fractures were retrieved from the audit department of the hospital using the various codes to identify patients reviewed in the clinics or admitted to the hospital between 1997 and 2009. The data collected included the total number of calcaneal fractures, total number in either gender, age at the time of incident, month of the year the incident occurred. Annual distribution of incidence of forearm fractures was calculated for every year and every month of the year. The age of the patients was divided into decades. Linear regression analysis and
Introduction. Surgical site infections (SSI) are related to a surgical procedure and affect the surgical wound or deeper tissues. With continuing emphasis on clinical governance and quality control, there is increasing demand from both patients and government for methods of assessing surgical results. Rates of morbidity and mortality may play important roles in these assessments. When crude comparisons between hospitals in the incidence of SSI are made, these should at least be stratified by the type of procedure. The aim of this study is to fix SSI incidence in relation to surgical procedure. Methods. This report contains data of 19.948 procedures collected from 1996 to 2008 at a Specialist Orthopaedic Hospital and analyzed by a specific software designed for the study of infection in orthopaedic and trauma surgery. The SSI surveillance is focused on categories of surgical procedure (Hip Arthroplasty, Knee Arthroplasty, Spine Surgery and Hip Fracture Surgery) with each category containing a defined set of similar procedures. A basic of demographic data and details about operation itself are collected for each procedure. Patients are followed up throughout their hospital stay and after hospital discharge. We present the incidence of SSI by risk group and surgical procedure. SSI are categorized in type, moment of diagnosis and micro-organisms reported. Analysis of the data was performed (SPSSv15.0 ®). Statistical methods used to determine significance were the independent samples t test, Pearson X2 test, Odds ratio and Spearman
Purpose. The purpose of this retrospective study was to investigate the acetabular morphology of pincer impingement hips in order to better understand damage pattern in these patients. We compared MRI measurements made at different postions from anterior to posterior on the acetbulum in patients with pure pincer type FAI to those made in patients with pure cam-type to collect parameters that may be useful in the diagnosis and classification of pincer impingement. Material and Methods. From an initial consecutive retrospective population of 1022 patients that underwent MRI with clinical impingement signs 78 hips which were selected with as clear cam (n=57) or pincer (n=21) impingement on plain radiographics. On these MR Imaging was performed with a 1.5-Tesla system. For analysis, a lateral angle of overcoverage on coronal MRI (MR_LCE), the MR extrusion index and the alpha angle (after Nötzli) were used. In addition to these the gamma angle, the acetabular depth and the angle of lateral acetabular overcoverage were described clock-wise on 7 radial slides from anterior to posterior. These were compared between the cam and pincer population using students-t-test. Measurements were obtained by two observers and inter-observer variability was assessed. Results. The acetabular depth showed in all 7 positions significant smaller values for pincer-type in comparison to cam-type impingement. Highest difference was found is superior-posterior position. The acetabular angle is also significant smaller for pincer than for cam in all radial positions. Highest difference of the acetabular angle is located in superior (pincer −102.93°/cam 109.62°) and anterior-superior position (pincer 102.48°/cam 108.77 °). The gamma angle showed significant differences in all radial positions except anterior position. The highest difference is located in superior-posterior position (pincer 86.18 °/cam 08.77°). The mean MR extrusion index was significant lower for pincer type (12.73%) compared to cam-type patients (17.76%) (p=0.004). LCE angle and extrusion index on MRI displayed a Person
Introduction. Malrotation following total knee replacement is directly related to poor outcome. The knowledge of proximal and distal rotational axes and angles of the femur is therefore of high importance. The aim of the study was to determine whether the most used proximal and distal femoral angles; femoral anteversion angle (FAA) and posterior condylar angle (PCA) were different within individuals, between right, left and gender. As well, we studied whether the “inferior condylar angle” is correlated to the PCA and therefore useful in determining the rotation of the distal femur. Material and Methods. From 36 cadavers the femora were obtained and after removing the soft tissue a Computed Tomography (CT) scan was made. Three angles were measured: (i) the FAA between femoral columnar line (FHNL) and posterior condylar line (PCL), (ii) the PCA between anatomical transepicondylar line (TEL) and PCL, (iii) the inferior condylar angle (ICA) between the TEL and inferior condylar line (ICL). Statistical analysis of comparative relationships between the different angles was examined by calculating