Introduction. Muscle stiffness and joint contractures are common complications of limb lengthening. Authors have demonstrated less permanent soft tissue complications with intramedullary lengthening than external fixation. Our aim was to evaluate the joint response following intramedullary femoral lengthening and need for physiotherapy and alteration to rate/rhythm of lengthening. Method. A retrospective review of documentation for all femoral Precice nails in our centre inserted between 2012 and 2017. This involved 98 nails (68 antegrade, 30 retrograde) in 88 patients (59 males, 29 females) with a mean age of 32 years (range 12–69 yrs). We excluded cases where there was no documentation regarding Range of Movement (ROM). Bilateral lengthenings were recorded as separate cases. This left 50 antegrade, 16 retrograde cases with hip ROM data and 55 antegrade, 26 retrograde cases with Knee ROM data. Results. Hip. In the antegrade group 20 cases (39%) developed no stiffness throughout treatment. ROM decreased in 61% (n=30) of cases and the median length at which this occurred was 3cm. Where a retrograde nail was inserted 62.5% of cases (n=10) maintained normal range of motion. The median length at which ROM decreased was 3.25cm, this occurred in 6 cases (37.5%). . Knee. Where the antegrade nail was inserted, 22 cases (40%) did not develop stiffness. There was reduced ROM in 33 cases (60%), occurring at a median distance of 2cm. The median distance at which reduced ROM occurred with the retrograde nails was 1.5cm, this occurred in 23 cases (88.5%). 3 cases did not develop stiffness. All cases regained full ROM. Conclusion. Although there was no permanent loss, Joint Stiffness still occurs with intramedullary limb lengthening and there remains the need for regular physiotherapy. There are no data from other institutions for comparison. Rehabilitation guidelines and a proforma to accurately monitor patients ROM throughout treatment have been developed

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 correlation coefficient. On average, each knee had 6.8±3.1 regions of FTCL, most common medially. The commonest patterns of FTCL were medial with patellofemoral (48%) and tricompartmental (30%). ACL status was associated with pattern of FTCL (p=0.02). All classification systems demonstrated moderate ICC, but this was highest for IKDC: whole knee 0.68 (95%CI 0.60–0.74); medial compartment 0.84 (0.80–0.87); and lateral compartment 0.79 (0.73–0.83). Correlation with FTCL was strongest for Ahlback (Spearman rho 0.27–0.39) and KL (0.30–0.33), though all systems demonstrated medium correlation. The Ahlback was the most discriminating in severe OA. Osteophyte presence in the medial compartment had high positive predictive value for FTCL, but not in the lateral compartment. The Ahlback and KL systems had the highest correlation with confirmed cartilage loss. However, the IKDC system displayed best interobserver reliability, with favourable correlation with FTCL in medial and lateral compartments, though less discriminating in severe disease

Accurate documentation of operative findings is a fundamentally important part of any procedure and forms part of the Royal College of Surgeons of England's guidelines to good care, especially to “ensure that there are legible operative notes (typed if possible) for every operative procedure.” However, many hospitals fall short of this guideline when it comes to arthroscopic procedures because of the difficulty in reproducing visually representative and easy-to-understand images. There is an inability to properly record and archive findings of arthroscopic procedures. We, along with the British Orthopaedic Association, have developed an interactive, free Web-based operative note template that allows the surgeon to draw findings on diagrams of the joints commonly undergoing arthroscopy, type the findings, and then print as many copies as required. The use of the forms has allowed for quicker, easier, and more accurate documentation of arthroscopic procedures. The forms can then be saved to a database and used as a research tool

Neurological examination in children presenting with upper limb fractures is often poorly performed. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our own hospital and performed a further 3 month clinical review to detect any resulting change in practice. In the initial study period, 121 patients presented with upper limb fractures. 10 children (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients, however, none of the nerve injuries were detected on initial assessment. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’ and 2 (20%) had no documented examination. Following introduction of the guideline, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (p=0.02). Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. Introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

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Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era.

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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.

There is much debate regarding the use of continuous-compartment-pressure-monitoring (CCM) in the diagnosis of acute compartment syndrome (ACS). We retrospectively reviewed the management of all patients (aged 15 and over) who were admitted with a fracture of the tibial diaphysis, across 3 centres, during 2013–2015. Patient demographics, pre-existing medical problems, initial treatment, subsequent complications, methods of compartment monitoring, and follow-up were all included in the data collection. We separated patients into monitored (MG) and non-monitored groups (NMG), and compared the outcomes of their treatment. Data analysis was performed using SPSS and statistical significance was set as p < 0.05. 287 patients were included in this study (116 NMG vs. 171 MG). There were no significant differences observed in age, sex, previous medical problems, length of stay, AO classification of fracture and post-operative complications between the groups. 21 patients were suspected to have developed ACS (n=8 NMG 6.9percnt;, n=13 MG 7.6percnt;) and were treated with acute decompression fasciotomies. The average time from admission to fasciotomy was 20.3 hours (21.25hrs NMG, 19.5hrs MG p=0.448). There was no significant difference in the average length of hospital stay and documentation of complications at follow up between the 2 groups. There were no reported cases of soft tissue infections associated with the use of CCM. This study illustrates that CCM does not increase the rate of fasciotomies in this patient group, or reduce the time to fasciotomy significantly. There was no evidence to suggest that use of CCM is associated with superficial or deep infection

Objectives . A rigorous approach to developing, delivering and documenting rehabilitation within randomised controlled trials of surgical interventions is required to underpin the generation of reliable and usable evidence. This article describes the key processes used to ensure provision of good quality and comparable rehabilitation to all participants of a multi-centre randomised controlled trial comparing surgery with conservative treatment of proximal humeral fractures in adults. Methods . These processes included the development of a patient information leaflet on self-care during sling immobilisation, the development of a basic treatment physiotherapy protocol that received input and endorsement by specialist physiotherapists providing patient care, and establishing an expectation for the provision of home exercises. Specially designed forms were also developed to facilitate reliable reporting of the physiotherapy care that patients received. Results. All three initiatives were successfully implemented, alongside the measures to optimise the documentation of physiotherapy. Thus, all participating sites that recruited patients provided the sling immobilisation leaflet, all adhered to the physiotherapy protocol and all provided home exercises. There was exemplary completion of the physiotherapy forms that often reflected a complex patient care pathway. These data demonstrated equal and high access to and implementation of physiotherapy between groups, including the performance of home exercises. Conclusion . In order to increase the validity and relevance of the evidence from trials of surgical interventions and meet international reporting standards, careful attention to study design, conduct and reporting of the intrinsic rehabilitation components is required. The involvement of rehabilitation specialists is crucial to achieving this. Cite this article: Bone Joint Res 2014;3:335–40

NICE guidelines state that patients undergoing hip or knee arthroplasty should start as an in-patient and then continue pharmacological VTE prophylaxis for 28–35 days. Retrospective review of all elective hip and knee arthroplasties during one calendar month gave a baseline measurement of how many patients had VTE prophylaxis prescribed on their discharge summary. A new, electronically completed, bespoke Trauma and Orthopaedic discharge summary was created with a discreet area clearly marked for VTE prophylaxis, to serve as a reminder to prescribe it. In March 2012, 93 patients underwent hip/knee arthroplasty. 76% (71/93) were prescribed VTE prophylaxis to take home, there was no clinical reason explaining the failure to prescribe prophylaxis in the remaining 24%. In July 2013, after implementation of the change, 117 patients underwent hip/knee arthroplasty. 99% (116/117) were prescribed VTE prophylaxis to take home. Repeat audit in October 2013 showed that 103 patients underwent hip/knee arthroplasty and 100% were prescribed VTE prophylaxis. A simple but clear change to paperwork, brought about a rapid and seemingly lasting change in the prescription of out-patient VTE prophylaxis. The improvement was seen before and after a change of the Junior Doctor workforce suggesting the change in documentation was the main influencing factor

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Patients receiving cemented hemiarthroplasties after hip fracture have a significant risk of deep surgical site infection (SSI). Standard UK practice to minimize the risk of SSI includes the use of antibiotic-loaded bone cement with no consensus regarding type, dose, or antibiotic content of the cement. This is the protocol for a randomized clinical trial to investigate the clinical and cost-effectiveness of high dose dual antibiotic-loaded cement in comparison to low dose single antibiotic-loaded cement in patients 60 years and over receiving a cemented hemiarthroplasty for an intracapsular hip fracture.

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The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion.

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

The aims of this study were to undertake a prospective randomised trial to compare functional outcome, and range of motion after treatment of medial collateral ligament injuries by either early unprotected mobilisation or mobilisation with a hinged brace. Patients were randomised into either unprotected mobilisation or mobilisation with a hinged brace. Assessments occurred at 2 weeks, 6 weeks, 3 months and 6 months. Outcome measures included validated questionnaires (International Knee Documentation Committee and Knee Injury and Osteoarthritis Outcome Score scores), range of motion measurements and strength testing. Eighty six patients (mean age 30.4) were recruited. There were 53 men and 33 women. The mode of injury was sport in 56 patients (65%) with football, rugby and skiing being the most common types of sport involved. The mean time to return to full weight bearing was 3 weeks in both groups. The mean time to return to work was 4.6 weeks in the braced group and 4.1 weeks in the non-braced group (p=0.79). Return to running was at a mean of 14.3 weeks in the braced group and 12.8 weeks in the non-braced group (p=0.64). Return to full sport was 22 weeks in the braced group and 22.1 weeks in the non-braced group (p=0.99). There was no significant difference in range of movement or pain scores between the two groups at 2,6,12 and 24 weeks. The use of a hinged knee brace does not influence recovery after a medial collateral injury

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This study sought to compare the rate of deep surgical site infection (SSI), as measured by the Centers for Disease Control and Prevention (CDC) definition, after surgery for a fracture of the hip between patients treated with standard dressings and those treated with incisional negative pressure wound therapy (iNPWT). Secondary objectives included determining the rate of recruitment and willingness to participate in the trial.

Introduction. Following tear of its tendon, the muscle undergoes retraction, atrophy and fatty infiltration. These changes are inevitable and considered irreversible and limit the potential of successful repair of musculotendinous units. It was the purpose of this study to test the hypothesis that administration of anabolic steroids can prevent these muscular changes following experimental supraspinatus tendon release in the rabbit. Methods. The supraspinatus tendon was experimentally released in 20 New Zealand rabbits. Musculotendinous retraction was monitored over a period of 6 weeks. The seven animals in group I had no additional intervention, six animals in group II had local and seven animals in group III had systemic administration of nandrolone deconate during six weeks of retraction. At the time of sacrifice, in-vivo muscle performance as well as radiologic and histologic muscle changes were investigated. Results. Supraspinatus retraction was significantly higher in group I (1.8 ± 0.2cm) than in group II (1.5 ± 0.3cm, p = 0.044) or III (1.2 ± 0.3cm, p = 0.001). The reduction in radiological cross sectional area, as a measure for atrophy, was significant in groups I (p = 0.013) and II (p = 0.030) and insignificant in group III (p = 0.149). Histologically, there was no fatty infiltration in the treated groups II (p = 1.000) and III (p = 0.812), but in the untreated group I (p = 0.0312). The work of the respective muscle during one standardized contraction with supramaximal stimulation decreased markedly in groups I (p = 0.056) and II (p = 0.0528), and also but less in group III (p = 0.23). Conclusion. This is the first documentation of prevention of important muscle alterations after chronic retraction of the musculotendinous unit caused by rotator cuff tear. Nandrolone deconate administration in the post tendon release phase prevented fatty infiltration of the supraspinatus muscle and reduced functional muscle impairment caused by myo-tendinous retraction

Background. Second-generation high-carbon CoCrMo-alloy metal-on-metal total hip arthroplasty (THA) was introduced in the late 1980s following reports of early loosening, impingement, pronounced wear, and hypersensitivity in the first-generation metal-on-metal articulations. There has been inconsistent data that specifically addresses the clinical performance and longevity of second-generation metal-on-metal THA. The purpose of this study was to evaluate the survival of second-generation metal-on-metal primary THA and to assess the influence of demographic factors on implant survival in a large patient cohort. Methods. One thousand two hundred and seventy second-generation 28 mm metal-on-metal primary THA in 1121 patients were performed at one institution from 1994 to 2004. According to the International Documentation and Evaluation System patients were followed routinely at one year, two years and every five years thereafter. Clinical and radiographic outcome data was prospectively recorded using a hospital joint registry. At a mean follow-up of 6.8 years postoperatively, the probability of survival of THA was estimated using the method of Kaplan and Meier. Relative risk factors for implant failure that included age, gender, BMI, type of implant fixation and size of implant components were calculated using the Cox proportional-hazards model. Results. Sixty three (5%) hips were revised because of aseptic loosening (28 hips), infection (8 hips), periprosthetic fracture (8 hips), recurrent dislocation (8 hips), pain without implant loosening (7 hips) and breakage of the cup (4 hips). The probability of survival at ten years, with revision for any reason as the endpoint, for the THA as a whole was 0.90 (95% confidence interval, 0.87 to 0.94). The probability of survival for the cup was 0.90 (95% confidence interval, 0.86 to 0.93) and for the stem 0.94 (95% confidence interval, 0.91 to 0.97). No demographic factors or covariates were found to significantly affect survivorship. Conclusion. Second-generation metal-on-metal primary THA did not demonstrate a superior probability of survival at ten years compared with previous reports on other weight-bearing surfaces. Based on these findings and with consideration of concerns that relate to putative local and systemic toxicity of metal debris, the use of second-generation metal-on-metal articulations for primary THA remains moot

The defining weapon of the conflicts in Iraq and Afghanistan has been the Improvised Explosive Device (IEDs). When detonated under a vehicle, they result in significant axial loading to the lower limbs, resulting in devastating injuries. Due to the absence of clinical blast data, automotive injury data using the Abbreviated Injury Score (AIS) has been extrapolated to define current NATO injury thresholds for Anti-vehicle (AV) mine tests. We hypothesized that AIS, being a marker of fatality rather than disability would be a worse predictor of poor clinical outcome compared to the lower limb specific Foot and Ankle Severity Score (FASS). Using a prospectively collected trauma database, we identified UK Service Personnel sustaining lower leg injuries from under-vehicle explosions from Jan 2006–Dec 2008. A full review of all medical documentation was performed to determine patient demographics and the severity of lower leg injury, as assessed by AIS and FASS. Clinical endpoints were defined as (i) need for amputation or (ii) poor clinical outcome. Statistical models were developed in order to explore the relationship between the scoring systems and clinical endpoints. 63 UK casualties (89 limbs) were identified with a lower limb injury following under-vehicle explosion. The mean age of the casualty was 26.0 yrs. At 33.6 months follow-up, 29.1% (26/89) required an amputation and a further 74.6% (41/89) having a poor clinical outcome (amputation or ongoing clinical problems). Only 9(14%) casualties were deemed medically fit to return to full military duty. ROC analysis revealed that both AIS=2 and FASS=4 could predict the risk of amputation, with FASS = 4 demonstrating greater specificity (43% vs 20%) and greater positive predictive value (72% vs 32%). In predicting poor clinical outcome, FASS was significantly superior to AIS (p<0.01). Probit analysis revealed that a relationship could not be developed between AIS and the probability of a poor clinical outcome (p=0.25). Foot and ankle injuries following AV mine blast are associated with significant morbidity. Our study clearly demonstrates that AIS is not a predictor of long-term clinical outcome and that FASS would be a better quantitative measure of lower limb injury severity. There is a requirement to reassess the current injury criteria used to evaluate the potential of mitigation technologies to help reduce long-term disability in military personnel. Our study highlights the critical importance of utilising contemporary battlefield injury data in order to ensure that the evaluation of mitigation measures is appropriate to the injury profile and their long-term effects

Introduction. The treatment of trochanteric and subtrochanteric fractures remains controversial, and new implants are constantly being developed trying to improve outcome and minimize the number of complications in these fractures. In Norway the Sliding Hip Screw(SHS), with or without a Trochanteric Stabilizing Plate (TSP), is still the most commonly used implant, but worldwide nailing of these fractures is increasing. This trend, however, has not been supported by documentation of better clinical results compared to the SHS in well designed studies. Therefore, in the present study we compared the recently launched Trigen Intertan nail (Smith and Nephew) with the SHS in the treatment of trochanteric and subtrochanteric fractures. Patients and Methods. In a prospective, randomized multicenter study with 697 patients, we compared the Trigen Intertan nail with the SHS regarding postoperative pain, functional mobility, complications, and reoperation rates. Patients older than 60 years with trochanteric and subtrochanteric fractures were included in 5 hospitals. At day 5, and 3 and 12 months postoperatively, pain was measured using a Visual Analogue Scale (VAS), and the Timed Up and Go-test (TUG-test) was performed to evaluate functional mobility. Complications and reoperations were recorded at discharge, and after 3 and 12 months. Results. 328 patients were evaluated at day 5 postoperatively. At mobilization patients treated with the nail had less pain compared to the SHS (VAS 47 vs. 53, p=0.02). Still, a difference of 6 points may not be of clinical significance. There was no difference in pain at rest or in early functional mobility. The length of postoperative hospital stay was also similar for the two groups (8.5 and 8.4 days respectively). At 3 (457 patients) and 12 months (374 patients) there was no difference in pain or TUG-test performance. At discharge, and after 3 and 12 months the overall reoperation rate for the groups was similar, and there was no difference regarding general complications. The results were comparable for the two groups, regardless of fracture classification (stable or unstable fractures). However, postoperative femoral fractures still seems to be an issue even with modern nails. 5 postoperative femoral fractures were encountered in the Intertan group, whereas 1 occurred in the SHS-group. Conclusion. Overall, there was no major difference in the results for the Intertan nail and the SHS in our study. Both methods provided predictable and good results in the treatment of trochanteric and subtrochanteric fractures. We found however less pain at mobilization for patients operated with a nail at day 5 postoperatively compared to the SHS. No difference in pain or function was evident at any later follow up. There was no difference in reoperation rates between the groups, but more postoperative ipsilateral femoral fractures occurred in the Intertan group. The clinical results in this study do not support the trend towards more nailing of trochanteric and subtrochanteric fractures

INTRODUCTION. The lifetime of UHMWPE implants may be limited by wear and oxidative degeneration. Wear produced particles are in general biologically active, and may induce osteolysis. As threshold of PE wear rate below which osteolysis is rarely observed is postulated to be less tahn 0.1 mm per year. Moreover, PE delamination and breakage are consequences of the embrittlement of the PE due to oxidation. Both demonstrate, that improving the clinical behaviour of UHMWPE means reduction of wear particles. The first can be achieved by cross-linking the second by the anti-oxidative stabiliser vitamin E. The highly cross-linked PE vitamys ® used for the isoelastic monobloc cup RM Pressfit (Mathys AG Bettlach, Bettlach, Switzerland) is mixed with 0.1% of synthetic vitamin E and is the first and only highly cross-linked PE used in total hip replacement that meets all requirements for the best grade UHMWPE in yield strength, ultimate tensile strength and elongation at break. METHODS AND MATERIAL. With the first implantation of RM Pressfit vitamys® a prospective multicentre study was started. So far 256 cases in 7 clinics from Europe and New Zealand are included. This report presents the first clinical experiences of one Swiss clinic from the multicentre study. Prospective data collection includes Harris Hip score (HHS), patient satisfaction and radiographic analysis. Clinical and radiographic follow-up is done after 6 weeks, 6, 12 and 24 months, and thereafter for long-term results. Standardized documentation of surgery and postoperative course is performed. RESULTS. 81 patients were included in the study. Mean age at implantation is 69 years. The indication was primary OA in 57% and secondary OA in 36%, the others were treated either for necrosis, fracture or hip dysplasia. 68% of the patients received a 36mm femoral head, 31% a 32mm and 1% a 28mm. Intraoperatively two minor complications occurred, one femur and one trochanter fissure. No complications occurred during implantation of the cup. Most of the cups (59%) were implanted with an inclination of 40°-50°, 30% with 35°-40°. There were no signs of early loosening and a good Harris Hip Score was achieved. DISCUSSION. The principals of this monobloc cup with its isoelastic property and the thin titanium coating is a proven concept. Ihle et al. (JBJS 2008) reported 91% survival rate with revision for aseptic loosening as endpoint after 20 years. They found an increase of cup revisions after 14 to 16 years after implantation due to osteolysis probably due to PE wear. At short term, we haven't encountered any problems related to the implantation of this cup. So far one patient in the entire multicentre study needed a stem revision after periprosthetic femur fracture. To prove the durability of this novel material a follow-up of 14 years and more will be required

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The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization.