Reconfiguration of elective orthopaedic surgery presents challenges and opportunities to develop outpatient pathways to reduce surgical waiting times. Dupuytren's disease (DD) is a benign progressive fibroproliferative disorder of the fascia in the hand, which can be disabling. Percutaneous-needle-fasciotomy (PNF) can be performed successfully in the outpatient clinic. The Aberdeen hand-service has over 10 years' experience running dedicated PNF clinics. NHS Grampian covers a vast area of Scotland receiving over 11749 referrals to the orthopaedic unit yearly. 250 patients undergone PNF in the outpatient department annually. 100 patients who underwent PNF in outpatients (Jan2019–Jan2020). 79M, 21F. Average age 66 years range (29–87). 95 patients were right hand dominant. DD risk factors: 6 patients were diabetic, 2 epileptic, 87 patients drank alcohol. 76 patients had a family history of DD. Disease severity, single digit 20 patients, one hand multiple digits in 15 patients, bilateral hands in 65 patients of which 5 suffered form ectopic manifestation suggestive of Dupuytren's diasthesis. Using Tubiana Total flexion deformity score pre and post fasciotomy. Type 1 total flexion deformity (TFD) between 0–45 degrees pre PNF n=60 post N= 85, Type 2 TFD 45–90 degrees pre PNF n=18 post N=9, Type 3 TFD 90–135 pre PNF n=15 post N= 5, Type 4 TFD >135 pre PNF n=1 post PNF N=1. Using Chi-square statistical test, a significant difference was found at the p<0.05 between the pre and post PNF TFD. Complication: 8 recurrence, 1 skin tear. No patients sustained digital nerve injury. Outpatients PNF clinics are a valuable resource

Background. In poliomyelitis; hand to knee gait is the sum of quadriceps weakness and fixed knee flexion deformity. Limb shortening is another added problem. Usually, each problem is attacked separately; with variable end results and complication rates for each procedure. Patients and methods. 22 patients (16–46 y.); with poliomyelitis with hand to knee gait due to fixed knee flexion deformity of mild to moderate degree (10–400); and limb shortening of 4.5–9.5 cm., were managed simultaneously by a single operation. A distal femoral metaphyseal anterior closing wedge (recurvatum) corrective osteotomy was done to treat acutely the fixed knee flexion deformity(and subsequently hand to knee gait). A modified Wagner or Orthofix frame was applied as a mono-plane mono-axial lengthening device to stabilize the osteotomy and to lengthen the short limb. Lengthening was started in all cases two weeks post-operatively. Results. All cases showed full correction of the deformity with elimination of the hand to knee gait problem and all showed - the desired - limb length equalization. The femora were lengthened to an average of 6.4 cm.(= 21% of original femoral bone length), range of lengthening was: 4–9 cm. (= 11–26%). The average healing index was 37 days per centimeter (with a range of 31 to 53 days per centimeter.). Conclusion. Simultaneous management of hand to knee and limb shortening could be achieved by a single osteotomy which is used to extend the knee acutely and for distraction two weeks later using a mono-lateral frame. Results were good, complications were few and accepted and the procedure is well tolerated by the patients

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

Background. Symptomatic flexion deformity of proximal interpahalangeal joint (PIPJ) is one of the most common foot deformities and usually treated with arthrodesis. In general, percutaneous K-wires are used to stabilize the joint after excision of cartilage. K-wires projecting out of the toe need special care and can occasionally be dislodged accidentally. Furthermore issues such as cellulitis, pin tract infections, rarely osteomyelitis and need for removal make alternative fixation methods desirable. Smart toe is an intra-osseous titanium memory implant, which is stored frozen. It expands on insertion and does not require removal. Methods. 30 consecutive K-wire PIPJ arthrodesis were compared with 30 Smart toe PIP fusions with a mean follow up of 6 months. Post operative forefoot scores and complications were documented. Results. Patient satisfaction was higher and complications were lower with Smart toe fusions than with K-wire arthrodesis. Conclusions. Fusion of PIP joints with smart toe is an effective and safer alternative to using K-wires. Although more expensive, higher patient satisfaction and lower complication rate may offset the extra cost of the implant

Introduction. Dupuytren's disease (DD) is a fibro-proliferative disorder of the palmar fascia whereby a collagen cord contracts affected joints, resulting in flexion deformity that can impair hand function. Currently, surgery is the only effective treatment option in Europe. This 2-part study, consisting of a surgeon survey and chart audit, was designed to assess current surgical practice patterns by DD severity. We report results from the surgeon survey. Methods. A total of 687 participants, including 579 orthopedic surgeons (of which 383 were hand specialists) and 108 plastic surgeons, who had been practicing for >3 and <30 years and operated on 5 DD patients between September and December 2008 were surveyed in 12 countries (UK, Germany, France, Italy, Spain, Hungary, Czech Republic, Poland, Netherlands, Sweden, Denmark, Finland). The survey included queries about procedures performed, factors involved in the decision to use a procedure, satisfaction with the procedure, use of physiotherapy, and recurrence. Results. Regardless of specialty, about 95% of surgeons performed fasciectomy in the previous 12 months. Rates for needle aponeurotomy (NA; 36%) and fasciotomy (70%) were comparable across specialties; a larger proportion of plastic surgeons (65%) used dermofasciectomy (DF) than did orthopaedic (39%) and hand surgeons (44%). Decisions to use NA/fasciotomy were driven mainly by patient comfort and quality-of-life issues (eg, aged >70 y, aesthetics, activity impairment); surgeon satisfaction was linked to shorter recovery times, reduced patient burden, few complications, and restored finger function. Decisions to use open surgeries were based mostly on DD characteristics (eg, contracture severity, speed of progression, recurrence), and surgeon satisfaction was linked to intervention efficacy and durability of the outcome. The percentage of surgeons prescribing physiotherapy and the duration of therapy increased with complexity of the first procedure: NA=86%, 5.3 weeks; fasciotomy=94%, 5.4; fasciectomy=97%, 6.7; and DF=99%, 8.7. On average, 90% of patients were enrolled in a physiotherapy program after undergoing a procedure for DD. Using survey responses, recurrence rates appeared to decrease and time to recurrence increased with procedure complexity: NA=44%, 17 months; fasciotomy=32%, 21; fasciectomy=20%, 29; and DF=20%, 34. Conclusions. To our knowledge, based on the number of participants and countries, this is the largest survey to date to collect, quantify, and describe information about the surgical management of DD in Europe. Although data from all countries were combined and results from the specialties were collapsed, it is a critical first step toward understanding DD treatment patterns. Opportunities to learn more about country- and specialty-specific practices will be presented elsewhere. This study was funded by Pfizer Inc

Aims

No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.

Background. Extendable proximal femoral replacements(PFR) are used in children with bone tumours in proximity to the proximal femoral physis, previously treated by hip disarticulation. Long-axis growth is preserved, allowing limb salvage. Since 1986, survival outcomes after limb salvage and amputation have been known to be equal. Method. Retrospective review of all patients <16years undergoing extendable PFR at Royal National Orthopaedic Hospital (UK) between 04/1996 and 01/2006, recording complications, failures, procedures undertaken and patient outcomes. Results. 8 patients (mean age 8.9±3 years) underwent extendable PFR for Ewing's Sarcoma(5), Osteosarcoma(1), Chondrosarcoma(1) and rhabdomyosarcoma(1). 2 primary PFRs failed (infection of unknown source & local recurrence, both at 26months); 2 required revision for full extension (1 became infected at revision, requiring 2 stage revision). 3 patients had the original prosthesis in situ at last follow-up (mean 7.2;range 3–10.5years). 1 patient had no implant complications, but died (neutropaenic sepsis) 63 days after implant insertion. 2 were treated for recurrence but disease free at last review. 5 were continuously disease free. 5 patients were lengthened a mean 3.7cm; 2 were not lengthened.1 had incomplete data. 5 patients suffered subluxation/dislocation (mean 15.6months), 3 recurrently. Each underwent a mean 1.6 open & 1.4 closed procedures for the displaced joint. 3 patients had 4 open reductions and acetabuloplasties and 2 patients were converted to THR, with 3 major complications: 2 sciatic nerve palsies and 1 (THR) infection. The 5th patient was due for acetabuloplasty but had hip disarticulation for recurrence. Acetabular erosion occurred in 3; 2 were revised to THR (3.5 & 6.8years). 3 patients suffered peri-prosthetic supracondylar fracture (treated conservatively). 5 patients were revised to THR (mean 5.9years): 2 for dislocation, 2 for acetabular erosion & 1 for infection. 1 underwent amputation and another died. Only 1 surviving implant was not converted to THR: this patient had progressive acetabular erosion at 10.5 years & will eventually require THR. The amputee had poor hip function prior to disarticulation but went on to become an international Paralympic sportsman and had very good function 11.4 years post-disarticulation. 3 patients had fixed hip adduction deformity. 1 was isolated and treated with adductor tenotomy, whilst 2 were associated with knee flexion deformity (one required in-patient physiotherapy; the other prosthetic shortening). Conclusions. Extendable PFR permits limb salvage with psychological & functional benefits, but complications are common and some are specific to PFR. Surgery for these may result in further complications. Patients should be warned of the high conversion rate to THR. All the above should be borne in mind when selecting patients. As illustrated above, functional outcome is sometimes better with amputation

Background. Extendable partial femoral replacements (EPFR) permit limb salvage in children with bone tumours in proximity to the physis. Older designs were extended through large incisions or minimally invasive surgery. Modern EPFR are lengthened non-invasively. Lengthening improves functional score (Futani, 2006) but has been associated with complications including infection (Jeys, 2005). This study is the first to look specifically at the relationship between EPFR lengthening and complications. Method. Retrospective review of 51 paediatric (<16 years) oncology patients undergoing primary (1 °) EPFR (minimally/noninvasive) between 06/1994 and 01/2006. Exclusions: 1 patient with 5cm extension without medical intervention and 5 patients with incomplete data. Results. There was a negative relationship between age at 1 ° operation and EPFR lengthening (p = 0.03). Mean lengthening for all (including revision) EPFR was 3cm (range 0–13.05). 28 (64%) patients were lengthened a mean 4.8cm at a mean 7 procedures each. 18 were not lengthened, of which 12 were deceased at last followup and 1 had undergone amputation. Lengthening of secondary prostheses contributed a mean 3.7cm to limb length. 2 tertiary implants were lengthened noninvasively by 1.2cm (3 lengthenings) and 1.275cm (5 lengthenings). 16 of 21 failed 1 ° femoral components had been lengthened. The 21 implants underwent a mean 4.2 lengthenings in comparison to mean 1.3 lengthenings in the 28 that did not fail. Number of 1 ° prosthetic lengthenings was positively related to risk of component failure (p = 0.035) and total number of complications (p = 0.049). Complication rate was also related to total lengthening of 1 ° prosthesis (in cm) (p = 0.004). There was a statistically insignificant (p = 0.059) trend towards increased infection rate with higher number of minimally invasive lengthening procedures. Complications were commoner in those undergoing lengthening (mean 3 vs 1.75 in non-lengthened prostheses). Number of lengthenings correlated with number of complications (p = 0.001). Total lengthening of distal EPFR correlated with incidence of knee fixed flexion deformity (FFD)(p = 0.034). Median lengthening was 3cm in those with FFD and 0cm in those without (p = 0.019). Open lengthening procedures caused 6 complications: 2 deep & 3 superficial infections and recurrent subluxation requiring acetabuloplasty in a proximal replacement. Summary/Conclusions. The inverse relationship between age at 1 ° operation and lengthening is expected if the aim of offsetting limb length discrepancy during growth is being achieved. Lengthening is associated with increased complications (particularly infection and FFD) and femoral component failure, suggesting that lengthening procedures are implicated in the cause of some complications. 5 infective complications after lengthening were theoretically avoidable if noninvasive growers were used

Coronal plane fractures of the posterior femoral condyle, also known as Hoffa fractures, are rare. Lateral fractures are three times more common than medial fractures, although the reason for this is not clear. The exact mechanism of injury is likely to be a vertical shear force on the posterior femoral condyle with varying degrees of knee flexion. These fractures are commonly associated with high-energy trauma and are a diagnostic and surgical challenge. Hoffa fractures are often associated with inter- or supracondylar distal femoral fractures and CT scans are useful in delineating the coronal shear component, which can easily be missed. There are few recommendations in the literature regarding the surgical approach and methods of fixation that may be used for this injury. Non-operative treatment has been associated with poor outcomes. The goals of treatment are anatomical reduction of the articular surface with rigid, stable fixation to allow early mobilisation in order to restore function. A surgical approach that allows access to the posterior aspect of the femoral condyle is described and the use of postero-anterior lag screws with or without an additional buttress plate for fixation of these difficult fractures.

Cite this article: Bone Joint J 2013;95-B:1165–71.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Cite this article: Bone Joint J 2014;96-B:1252–7.

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5).

All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly.

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing.

The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy.

Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.

Four men who presented with chronic dislocation of the radial head and nonunion or malunion of the ulna were reviewed after open reduction of the radial head and internal fixation of the ulna in attempted overcorrection. Their mean age was 37 years (28 to 46) and the mean interval between injury and reconstruction was nine months (4 to 18).

The mean follow-up was 24 months (15 to 36). One patient who had undergone secondary excision of the radial head was also followed up for comparison.

The three patients who had followed the treatment protocol had nearly normal flexion, extension and supination and only very occasional pain. All had considerable loss of pronation which did not affect patient satisfaction.

Preservation of the radial head in chronic adult Monteggia fractures appears to be a promising mode of treatment.

Between 1996 and 2003 six institutions in the United States and France contributed a consecutive series of 234 fractures of the femur in 229 children which were treated by titanium elastic nailing. Minor or major complications occurred in 80 fractures. Full information was available concerning 230 fractures, of which the outcome was excellent in 150 (65%), satisfactory in 57 (25%), and poor in 23 (10%). Poor outcomes were due to leg-length discrepancy in five fractures, unacceptable angulation in 17, and failure of fixation in one. There was a statistically significant relationship (p = 0.003) between age and outcome, and the odds ratio for poor outcome was 3.86 for children aged 11 years and older compared with those below this age. The difference between the weight of children with a poor outcome and those with an excellent or satisfactory outcome was statistically significant (54 kg vs 39 kg; p = 0.003). A poor outcome was five times more likely in children who weighed more than 49 kg.