Introduction. Up to 16% of scaphoid fractures are radiologically occult; failure to diagnose scaphoid fractures may lead to delayed union, nonunion or avascular necrosis. Fractures may take weeks to be excluded and many patients are unnecessarily immobilised increasing work absence, clinical reviews and cost. The use of CT early in the management of suspected occult scaphoid fractures has been evaluated. Methods. The radiology and clinical notes of all patients that had scaphoid CT scans over the preceding 3 years were retrospectively reviewed. 84 patients that had CT scans within 14 days from injury were identified. Results. 64% of CTs excluded fracture (N=54) and these patients were mobilised promptly and reviewed within six weeks. No patients returned with any complications, such as carpal instability, from this management strategy. Mean number of clinic appointments for this group was 2.34 (range 2–6). 36% of CTs were abnormal (N=30). 7% revealed occult scaphoid fractures; 18% revealed occult carpal fractures of the triquetrum, capitate and lunate respectively and 5% distal radius fractures. All patients diagnosed with fractures were successfully managed with plaster immobilisation, with one case of regional pain syndrome. Conclusions. Early CT immediately alters therapeutic decision making in suspected occult fractures preventing unnecessary immobilisation. Early CT also reduces clinic attendances for clinical and radiological review without increase in cost

Introduction. Fracture non-union is a devastating cause of patient morbidity. The cost of NU treatment ranges from £7,000 to £79,000. With an estimated 11,700 cases in the UK pa the financial implications are huge, potentially costing several hundreds of million of pounds annually. Successful outcome in the management of non-union is based upon correctly identifying the underlying cause(s) and addressing them appropriately. Aim. The aim of this study was to assess the causative factors in non-union in order to optimize the management of non-union. The causes of NU were categorized into 4 groups (infection, dead bone/gap, host factors, mechanical). Method. 100 consecutive patients who had surgery for long bone non-union were analysed. Information was obtained from the patient clinic visits, notes, radiographs and laboratory results. The cause(s) of the non-union were identified, recorded and divided into 4 groups; host, mechanical, dead bone/gap at NU site and infection. Results. The mean age at time of injury was 41.4(±16.7)years; male/female ratio was 3:1, 80% were lower limb (52% of all cases were tibial). 69% were high energy, 38% were open. 26% of patients had a single attributable cause, 59% had two causes, 14% had three causes and one had all four. Mechanical causation was found in 56% of cases, dead bone/gap in 50%, host factors in 44%, infection in 40% of patients. 5.7% of the infections were unexpected new/occult positive findings. 73% of patients with previously treated infection but without ongoing infection had multiple positive cultures. Conclusion/discussion. Surgical procedures for non-union often address a single aspect yet 74% had more than one attributable cause. With a 6% occult infection rate multiple tissue samples for microbiology and pathology investigation should be carried out routinely in every patient with non-union. The multi-factorial nature of non-union makes meticulous patient assessment vital to maximise the chance of treatment success

It has been suggested that occult infection of joint prostheses contributes to a proportion of aseptic loosening. The aims of the study were to determine the incidence of occult infection in a sample of patients undergoing revision surgery for aseptic loosening and examine the role of ultrasound sonication in its detection. A prospective trial was conducted at Christchurch and Burwood Hospitals. At the time of revision surgery, intra-operative tissue and fluid samples were taken. The removed prosthesis was immersed in saline solution in a sterile plastic container, and then sonicated. The sonicate fluid underwent prolonged routine cultures (14 days) to increase the rate of detection of slow growing organisms. The cases were patients undergoing revision surgery for aseptic loosening or infection. The control group was comprised of patients having revision surgery for any other indication. These implants were subjected to the same protocol as the study group. A total of 122 patients were included in the study; 54 in the Aseptic Loosening [AL] group, 15 Infections and 53 controls. There were significantly more smokers in the AL group and less smokers in the control group (p=0.04 and p=0.04 respectively). The mean age for revision in the Infection and Periprosthetic fracture groups was less than those of other groups (p=0.007 and p=0.02) respectively. There were 18 cases with positive intra-operative cultures. Eight of those were in the aseptic group (i.e. 14.8% of the group). Conventional sampling techniques were positive in 17 of 18 cultures (94%). Sonication was only positive in 10 out of the 18 cultures (56%). Sonication was concordant with the conventional sampling techniques in half of the positive cultures in the AL group and overall. The only bacteria to be isolated from sonicate cultures were Staphylococcus Aureus and Coagulase Negative Staphylococci. Diabetes Mellitus was the only risk factor to have a significant association with having a positive culture result (p=0.03). There was also a significant association with having raised pre-operative Neutrophil differential count or inflammatory markers with having a positive culture (p=0.0001). However this association was not present when the AL group was examined separately. There was a significant rate of positive culture results in the aseptic loosening group of around 15%. Ultrasound sonication was less sensitive than current sampling techniques with no apparent added benefit. This paper does not support the hypothesis that occult infection is a significant driver of aseptic loosening

Introduction. Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Studies have demonstrated a high proportion have ipsilateral occult posterior malleolus fractures. We hypothesize that this rotational element will be highlighted using the Mason & Molloy Classification. Materials and Methods. A retrospective review of a prospectively collected database was performed at Liverpool University Hospitals NHS Foundation Trust between 1/1/2013 and 9/11/2020. The inclusion criteria were patients over 16, with a diaphyseal tibial fracture, who underwent a CT. The Mason and Molloy posterior malleolus fracture classification system was used. Results. 764 diaphyseal tibial fractures were analysed, 300 had a CT. 127 were intra-articular fractures. 83 (27.7%) were classifiable using Mason and Molloy classification. There were 8 type 1 (9.6%), 43 type 2 (51.8%), 5 type 2B (6.0%) and 27 type 3 (32.5%). 90.4% (n=75) of the posterior malleolar fractures, were undisplaced. The majority of PM fractures occurred in type 42A1 (65 of 142 tibia fractures) and 42B1 (11 of 16). Conclusions. Most PM fractures occurred after a rotational mechanism. Unlike, the PM fractures of the ankle, the majority of PM fractures associated with tibia fractures are undisplaced. We theorise that unlike the force transmission in ankle fractures where the rotational force is in the axial plane in a distal-proximal direction, in the PM fractures related to fractures of the tibia, the rotational force in the axial plane progresses from proximal-distal. Therefore, the force transmission which exits posteriorly, finally dissipates the force and thus unlikely to displace

Introduction. Diaphyseal tibial fractures account for approximately 1.9% of adult fractures. Several studies demonstrate a high proportion of diaphyseal tibial fractures have ipsilateral occult posterior malleolus fractures, this ranges from 22–92.3%. Materials and Methods. A retrospective review of a prospectively collected database was performed at Liverpool University Hospitals NHS Foundation Trust between 1/1/2013 and 9/11/2020. The inclusion criteria were patients over 16, with a diaphyseal tibial fracture and who underwent a CT. The articular fracture extension was categorised into either posterior malleolar (PM) or other fracture. Results. 764 fractures were analysed, 300 had a CT. There were 127 intra-articular fractures. 83 (65.4%) cases were PM and 44 were other fractures. On univariate analysis for PM fractures, fibular spiral (p=.016) fractures, no fibular fracture(p=.003), lateral direction of the tibial fracture (p=.04), female gender (p=.002), AO 42B1 (p=.033) and an increasing angle of tibial fracture. On multivariate regression analysis a high angle of tibia fracture was significant. Other fracture extensions were associated with no fibular fracture (p=.002), medial direction of tibia fracture (p=.004), female gender (p=.000), and AO 42A1 (p=.004), 42A2 (p=.029), 42B3 (p=.035) and 42C2 (p=.032). On multivariate analysis, the lateral direction of tibia fracture, and AO classification 42A1 and 42A2 were significant. Conclusions. Articular extension happened in 42.3%. A number of factors were associated with the extension, however multivariate analysis did not create a suitable prediction model. Nevertheless, rotational tibia fractures with a high angle of fracture should have further investigation with a CT

Aim. Aseptic loosening is the leading cause of revision of total hip arthroplasty (THA). It is well recognized that an occult infection is the underlying cause of some aseptic revisions. Intraoperative cultures are central to the diagnosis of prosthetic joint infection (PJI). However, the diagnostic and prognostic value of unexpected positive intraoperative cultures remains unclear. The aim was to study whether first-time aseptic revision of a total hip arthroplasty with unexpected bacterial growth in cultures of intraoperatively taken biopsies have an increased risk of secondary revision due to all causes and increased risk of PJI revision, specifically. Method. Cases reported as first-time aseptic loosening revisions to the Danish Hip Arthroplasty Register (DHR) performed during January 1. st. , 2010, to May 15. th. , 2016, were included. DHR data were merged with the Danish Microbiology Database, which contains data from all intraoperatively obtained cultures in Denmark. Included first-time revisions were grouped based on the number of positive cultures growing the same bacteria genus: ≥2, 1 and 0 cultures. Revisions were followed until secondary revision, death, or end of follow-up period after one year. Relative risk for secondary revision due to all causes and PJI was estimated. Results. We included 2,305 first-time aseptic revisions. Unexpected growth was found in 282 (12%) of which 170 (60%) cases showed growth of the same bacteria in only one culture. Coagulase-negative staphylococcus accounted for 121 (71%). Secondary revision was performed in 163 (7%) cases, with PJI being the indication for revision in 43 (26%) cases. The relative risk of secondary revision was significantly higher for cases of one positive culture growing the same bacteria compared to culture negative cases, both for revision due to all causes; 1.73 (95%CI 1.07; 2.80) and PJI exclusively; 2.63 (1.16; 5.96). Cases of 2 or more biopsies culturing the same bacteria had a relative risk of all cause revision of 1.52 (0.82; 2.80). Conclusions. First-time aseptic loosening THA revisions with unexpected growth in only one biopsy culture had an increased risk of secondary revision, both due to all causes and PJI. Our findings indicate that some cases of unexpected growth of bacteria should likely be regarded as clinically significant and not sample contamination, underlining the need for more awareness and better strategies when treating patients with unexpected positive intraoperative cultures. The improved diagnosis of occult PJI in clinically aseptic THA is of great importance for future care of this large and growing patient group

Introduction. Scaphoid fracture is the most common undiagnosed fracture. Occult scaphoid fractures occur in 20-25 percent of cases where the initial X-rays are negative. Currently, there is no consensus as to the most appropriate investigation to diagnose these occult frctures. At our institution MRI has been used for this purpose for over 3 years. We report on our experience and discuss the results. Materials and methods. All patients with occult scaphoid fractures who underwent MRI scans over a 3 year period were included in the study. There was a total of 619 patients. From the original cohort 611 (98.7%) agreed to have a scan, 6 (0.97%) were claustrophobic and did not undergo the investigation and 2 (0.34%) refused an examination. 86 percent of the cases were less than 30 years of age. Imaging was performed on a one Tiesla Siemen's scanner using a dedicated wrist coil. Coronal 3mm T1 and STIR images were obtained using a 12cm field of view as standard. Average scanning time was 7 minutes. Results. The majority of the scans were performed within 2 weeks of the request. The breakdown of results is as follows: Normal 45%; Scaphoid bruise 10%; Scaphoid fracture 9%; Distal radius fracture 8%; Distal radius bruise 7%; TFCC tear 4%; Wrist ganglion 3%; Basal thumb arthritis 3%; Miscellaneous 12%. We did not have any missed scaphoid fractures during this period. Conclusions. Patients with a clinically suspected scaphoid fracture could have a wide range of possible diagnoses. Almost half the patients had a negative scan and therefore did not require further immobilisation/activity restriction. It is possible to perform MRIs within a reasonable timeframe in a DGH setting. Patient acceptance was very high (99%). There were no missed diagnoses. Scaphoid bruising could be picked up and consequently unnecessary immobilisation avoided. In patients with other diagnoses a reliable prognosis could be given

Background. High velocity vertical aircraft ejection seat systems are credited with aircrew survival of 80-95% in modern times. Use of these systems is associated with exposure of the aircrew to vertical acceleration forces in the order of 15-25G. The rate of application of these forces may be up to 250G per sceond. Up to 85% of crew ejecting suffer skeletal injury and vertebral fracture is relatively common (20-30%) when diagnosed by plain radiograph. The incidence of subtle spinal injury may not be as apparent. Aim. A prospective study to evaluate spinal injury following high velocity aircraft ejection. Methods. A prospective case series from 1996 to 2006 was evaluated. During this interval 26 ejectees from 20 aircraft were admitted to the spinal studies unit for comprehensive examination, evaluation and management. The investigations included radiographs of the whole spine and Magnetic Resonance Imaging (incorporating T1, T2 weighted and STIR sagittal sequences). All ejections occurred within the ejection envelope and occurred at an altitude under 2000 feet (mean 460 feet) and at an airspeed less than 500 knots (mean 275 knots). Results. in this series 6 ejectees (24%) had clinical and radiographic evidence of vetebral compression fractures. These injuries were located in the thoracic and thoracolumbar spine. 4 cases required surgery (indicated for angular kyphosis greater than 30 degrees, significant spinal canal compromise, greater than 50% or neurological injury. 1 patient had significant neurological compromise, following an AO A3.3 injury involving the L2 vertebra. 11 ejectees (45 %) had MRI evidence of a combined total of 22 occult thoracic and lumbar fractures. The majority of these ejectees with occult injury had multilevel injuries. Conclusion. This study confirms a high incidence of spinal fracture and particularly occult spinal injury

Although there is strong evidence that bisphosphonates prevent certain types of osteoporotic fractures, there are concerns that they may be associated with rare atypical femoral fractures. 1480 patients of proximal femur and shaft fractures over a period of 2 years from Jan 2014 to Jan 2016 were retrospectively reviewed in Gloucestershire Hospitals NHS trust. Hospital trauma database was used.195 patients had fractures in subtrochancteric and femoral shaft area. 11 patients had atypical femur fractures as defined by American society for bone and mineral research (ASBMR) task force 2013, revised criteria. Ten were female, one was male. Patients were aged from 68 to 97. In 6 patients, fractures were in the shaft, 5 in subtrochancteric area and 4 patients out of these had bilateral fractures. 10 out of 11 patients were on bisphosphonates. 4 patients had delayed diagnosis. 5 out of 11 patients did not have contralateral femoral x-rays. Treatment, 9 patients had intramedullary nail, one blade plate, and one treated conservatively. One patient in the IM group, had bilateral nailing. Average follow up was 7.6 months (range 1 to 16 months). At the end of the study, only 4 had united, 6 had not united and one not followed up. 4 out of 7 had low Vitamin D levels, 3 out of 7 had their bisphosphonate treatment stopped and 2 had histology which showed necrotic bone with trabeculae surrounded by fibrosis. Increasing number of patients are on bisphosphonates for osteoporosis. Atypical femur fractures from bisphosphonates are often occult, often bilateral, with delayed healing. Patients on bisphosphonatetreatment should be advised to report any thigh or groin pain. Painful incomplete fractures need treatment with cephalomedullary nailing. Bone biology needs correcting by stopping bisphosphonatesand administering calcium & vitamin D supplements. Implications: We need to raise awareness amongst treating clinicians and have national guidelines

The insidious and occult characteristics of psoas abscess and clinical features similar to conditions like lumbar strain, abdominal/urologic disorders sometimes cause diagnostic delays; resulting in considerably high morbidity and mortality. Chronic inflammatory conditions of the digestive tract and tuberculosis of spine are the commonest source of secondary abscess in the developed and developing countries, respectively [1]. We report a case of an 86 year with a psoas abscess secondary to mucinous adenocarcinoma of colon. 86 year old female presented with right thigh pain in February 2014. CT scan confirmed the clinical suspicion of right psoas abscess which was drained surgically. Intraoperatively, we found pus mixed with mucinous material coming from a small opening in a rounded structure lateral to psoas which could not be identified. The abscess recurred within 2 days. Culture grew Pseudomonas aerugenosa and streptococcus viridans and histopathology showed metastatsis of mucin secreting adenocarcinoma infiltrating the muscle with pyogenic abscess. Repeat CT scan showed abscess communicating with tumor in the colon(Fig 1). Abscess was drained, but tumor was not addressed considering patients age. The infection resolved with 6 weeks of oral linezolid, however the patient expired after 8 months. Cultures in secondary psoas abscess are often mixed, with E. coli and Bacteroides spp predominating. One must rule out gastrointestinal/genitourinary pathology in cases where the CT/ USG guided culture reports are suggestive of gram negative infection. The fact that carcinoma of the colon could be a cause of psoas abscess should be considered when an unexplained psoas abscess is diagnosed [2]. Acknowledgements. None of the authors received payments or services, either directly or indirectly from a third party in support of any aspect of this work that could be perceived to influence what is written

Purpose of study:. The question of prolonged bracing following injury in patients diagnosed with SCIWORA remains controversial. Proponents of the ‘Segmental Spinal Instability’ hypothesis claim that there is occult ligamentous injury leading to instability and a risk of recurrent injury. Published reports of recurrent SCIWORA involve patients with minor, transient neurological symptoms and normal MRI findings. The contradicting ‘differential stretch hypothesis’ is based on the premise that the spinal column will deform elastically, exceeding the elastic deforming potential of the more fragile spinal cord, but will return to its baseline stability. The purpose of this study is to evaluate the need for bracing in patients with SCIWORA based on MRI evidence of instability. Methods:. A retrospective chart review was performed for a series of eleven patients with documented SCIWORA that presented to Red Cross Children's Hospital over the past 8 years. Details regarding mode of injury, age at presentation, neurological deficit at presentation, MRI findings and long term prognosis were documented. MRI's were reviewed by the authors as well as a consultant radiologist. Results:. There were 9 males and 2 females. The average age was 4.5 years. All patients were victims of motor vehicle accidents and had multiple injuries. Five patients had cervical, five thoracic and one had both cervical and thoracic injuries. There were 1 monoplegia, 4 hemiplegias, 3 paraplegias and 3 triplegias. None of the MRIs performed on these patients demonstrated ligamentous or bony injury. Patients with only T2 changes demonstrated progressive neurological recovery within a few months following injury. There were no recurrences and none of the patients were braced following the diagnosis of SCIWORA. Conclusion:. Our results from this small series support the ‘differential stretch hypothesis’ and we maintain that patient's with SCIWORA does not demonstrate spinal instability and therefore does not require bracing following injury

MRI has been little utilised in the post-operative assessment of joint replacement due to the problem of artifact. With modern machines and sequencing, artifact can be minimised in small joints with titanium prostheses. Twenty four consecutive patients implanted with a Buechel-Pappas Total Ankle Replacement underwent MRI examination at an average of 583 days post surgery to determine its usefulness as an adjunct to x-ray and bone scan in assessing prosthetic integrity and the source of post-operative symptoms. The purpose of the study was to evaluate the use of modified MRI techniques in the assessment of bone-implant interface, soft tissue changes, bone oedema and extent of osteolysis in setting of total ankle joint replacement and propose a descriptive classification to document the changes. We found MRI was extremely useful in identifying abnormalities in structures apart from the prosthesis such as occult degeneration in the subtalar joint and ligament pathology. Despite the new techniques, artifact remains a problem when assessing the bone prosthesis interface although adjacent bone oedema is well seen. MRI has a role in the identification of pathology in the tissues surrounding a TAJR especially with unexplained pain in an otherwise well functioning prosthesis. It's role in the assessment of prosthetic integrity remains qualitative but further work will be required to correlate MRI findings with clinical examination

Background. Tapered cementless femoral components have been used in total hip arthroplasty (THA) constructs for more than 20 years. The Synergy femoral component was introduced in 1996 as a second generation titanium proximally porous-coated tapered stem with dual offsets to better restore femoral offset at THA (Figure 1). The purpose of this study was to evaluate the outcome of the authors' experience using the Synergy stem at minimum 15 years of follow-up. Material and methods. We retrospectively reviewed a consecutive series of 102 patients (112 hips) who underwent surgery between November 1996 and October 1998 for primary THA using cementless Synergy stem with a minimum 15-years follow-up. The mean age at the time of surgery was 61 years, and the mean duration of follow-up was 16.3 years. Seventeen patients were lost at FU (8 died before the 15 years mark, 8 changed residency, 1 not willing to be seen) with no problems related to the replaced hip. Ninety-four hips in 85 patients were available for clinical and radiologic analysis. Clinical results of the 94 THAs with more than 15 years of follow-up were assessed preoperatively and postoperatively at 5, 10 and 15 years by means of standard evaluation tools: SF12, WOMAC and Harris Hip Score. Thigh pain frequency and intensity were also recorded. Radiographic analysis (Figure 2) was focused on stem alignment, bone ingrowth, radiolucent lines presence, width and progression, stress-shielding and heterotopic ossification (HTO). Student paired test and Kaplan-Meier survival analysis were used for statistical analysis. Results. All clinical evaluation tools showed at 5-year FU, 10-year FU and at latest FU (15–17 years) a statistically significant improvement compared to the preoperative scores. We observed a not constant thigh pain in 5 hips (4.75%). Nine stems were revised due to polyethylene wear (3 cases), late periprosthetic fracture (2 cases), infection (2 cases), subsidence (1 case) and instability (1 case). Stem related revision was a case of subsidence, related to occult intraoperative calcar crack and early revised (within 1 year); cumulative stem-related survival rate at 15 years was 99%. Alignment was varus in 5 cases and valgus in 1. Bone in-growth was observed in 93 hips (98%). Radiolucent lines were uncommon, non progressive, less than 2 mm, in Gruen zones 2 and 6. Stress-shielding was present as cortical reaction in 5 femurs in Gruen zones 3 and 5. Fifteen cases of HTO (grade I and II in 12 case and grade III in 3 cases) were observed. Conclusions. The Synergy stem demonstrated excellent clinical and radiographic results at 15–17 years FU in 85 patients. Survivorship (with stem revision as end point) was 99% at 15 years. Thigh pain was uncommon and the level of activity and autonomy is excellent. Radiographically bone ingrowth is evident in all stems and radiolucent lines are “benign” with no aseptic loosening

Introduction:. Measurement of ankle brachial pressure index is an easy screening test to perform in patients presenting with an acute knee injury. According to Nicardi et al recognition of vascular injury is particularly challenging because vascular compromise may not be immediately associated with clinical signs of ischemia. The aim of the study is to correlate the values of ABPI measurements to CT angiograms and clinical outcome in high energy knee trauma. Materials and Methods:. We reviewed the records of patients admitted to our unit following high energy knee trauma during the period Nov 2012 to Dec 2013. The orthopaedic injuries sustained were 11 knee dislocations, 5 supracondylar femur fractures, 3 high energy tibia plateau fractures (Schatzker 5 and 6) and 4 gunshot injuries. From the records we recorded the nature of the orthopaedic injury, the ABPI, the CT angiogram and the clinical outcome. We excluded all patients with insufficient records and previous vasculopathy. After these exclusions, 23 patients were enrolled for the study. Analysis of the data involved calculating of basic descriptive statistics, including proportional and descriptive measures. T-tests (one-sample and independent) and chi-square tests of independence were employed to investigate the relationship between ABPI and CT angiogram and clinical outcomes. Throughout the statistical analysis cognisance is taken of the relative small sample, and relevant test adjustments made. Results:. A total of 5 of the 23 patients had a significant vascular injury that required vascular intervention. Three patients underwent vascular repair and orthopaedic fixation. One patient had an occult vascular injury and presented with a necrotic limb three days after admission. His delayed CT demonstrated arterial cut off. This patient later went on to have an amputation. The fifth patient presented 12 days post knee dislocation with reduced pulses but the leg was still viable. In these five patients the ABPI value ranged from 0.3 to 0.65. In the remainder the ABPI ranged from 0.91 to 1.4. These 18 patients had a CT angiogram with normal flow and no intimal tears. Conclusion:. In all the patients with vascular sequelae from high energy knee injuries and dislocation the initial ABPI measurement performed well as a screening test for vascular injuries. It can therefore be recommended as a practical investigation in the initial evaluation of knee injuries that has cost and time saving benefits

INTRODUCTION. Venous thromboembolism (VTE), especially, deep vein thrombosis (DVT) in lower extremities, often seriously combined with pulmonary embolism (PE), is a major and critical complication after total hip arthroplasty (THA). For better disgonsis of VTEs, D-dimer test is one of the useful methods. The aim of this study was to evaluate the efficacy of D-dimer levels before THA. MATERIALS AND METHODS. Medical records of patients with osteoarthritis who received THA between April 2009 and March 2010 were reviewed. Value of D-dimer at preoperative day 1, postoperative day 3 and 14 was examined in those patients. D-dimer levels were examined by Latex Immunity Nephelometry Measurement Method and the Kit (Sysmex Corporation, Kobe, Japan). A total of 327 patients with D-dimer values were examined. The values D-dimer of the available patients were under 1.0 μg/ml. Ninety-nine patients (30%) had a high D-dimer level. DVT was diagnosed by doppler ultrasonography at preoperative day 1, postoperative day 3 and 14. The sensitivity and specificity of D-dimer in different cutoffs were verified by Receiver Operating Characteristic (ROC) curve. The ROC curve was constructed to describe the relationship between the sensitivity and the false positive rate for different values of D-dimer to patients suspected of VTEs. The study protocol was approved by the institutional ethics committee. RESULTS. Eighty-two patients (83%) were females and 17 (18%) were males. Mean age was 67.3 (51–88) years. Mean value of D-dimer was 2.6 (1.1–10.3) μg/mL. DVT was detected in 21 patients (21%) at the preoperative day 1 (DVT positive group). Average of age of this (or DVT positive) group was 71.9 (52–88) years. There was significant difference in D-dimer level between DVT negative group, DVT was not detected at the preoperative day 1, and DVT positive group (p<0.05). The areas under the receiver operating characteristic curve of D-dimer were larger than those of other parameters in the ROC curve (p=0.76). The cutoff value from the Youden index was 1.95 μg/mL, and the sensitivity and specificity values were 84.2% and 62.7%, respectively. The incidence of DVT in the positive group was 19% and 16%, respectively. DISCUSSION AND CONCLUSION. Even DVT in the calf has the potential to propagate proximally, which led to a risk of PE. Therefore, screening for detection of DVT is important, even if the DVT was asymptomatic distal DVT. In some countries, it is thought that if the value of D-dimer is less than 0.5 μg/mL, VTEs are excluded in patients without surgeries, but some D-dimer kits, frequently used in Japan, have different cutoff values for the exclusion of DVT. Assessment of D-dimer is simple and reliable, as to be one of the beneficial methods to detect high-risk patients of VT and/or occult DVT before THA. In conclusion, it is important to evaluate preoperative screening of VTE before THA, as the existence of pre-operative DVT has high risk of postoperative DVT occurrences. The D-dimer test is one of useful methods to evaluate the perioperative state of the patients with VTE risk

The aim of tissue sparing surgery in total knee arthroplasty is to reduce surgical invasivity to the entire knee joint. Surgical invasion should not be limited only toward soft tissues but also toward bone. The classic technique for total knee arthroplasty implies intramedullary canal invasion for proper femoral component positioning. This phase is associated to fat embolism, activation of coagulation, and occult bleeding from the reamed canal. The purpose of our study was to validate a new extramedullary device which relies on templated data. Two-hundred patients in four different orthopaedics centres were randomized to undergo primary total knee arthroplasty either using standard intramedullary femoral instruments (IM group) or using a new extramedullary device (EM group). A new set of instruments was developed to control the sagittal and coranl plane of the distal femoral resection. The extramedullary instrument was calibrated referencing to templated data obtained from the preoperative long-limb radiograph (Fig 1, 2). Varus-valgus orientation of the resection were established by moving the two paddles according to templated data. An L-shaped sliding tool (5 centimetres long) over the anterior cortex controls the flexion-extension parameter of the resection and is intended to allow a cut flush with the anterior cortex at 0° of angulation with the distal aspect of the femoral diaphysis on the sagittal plane. Femoral component coronal alignment was within 0±3° of the mechanical axis in 86% of the IM group and 88% of the EM group. Sagittal alignment of the femoral component was 0±3° in 80% of the IM group and 94% of the EM group. There was no difference in the average operative time between the two groups. The EM group showed a trend toward less postoperative blood loss. Extramedullary reference with careful preoperative templating can be safely utilized during total knee arthroplasty

Aim. This study reviewed the efficacy of a CT arthrogram in clinical decision making for wrist disorders. Methods. Sixty four consecutive CT arthrograms done in a three year period at Glenfield Hospital were selected. All patients were referred by hand consultants at the Glenfield Hospital and all investigations were performed by a single senior musculoskeletal radiologist. CT arthrograms focussed on the following areas: scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL), peripheral and central triangular fibrocartilage complex (TFCC) tears, and articular surface disorders. Referral and clinic letters for all patients were obtained. We collected patient demographic detail, prescan diagnosis and clinical plan, CT arthrogram findings, postscan diagnosis and clinical plan and the final outcome. A decision was made whether the scan helped in the clinician's management plan and if so how it helped. Results. There were 35 male and 29 female patients with a mean age of 44.1 years. The right wrist was involved in 42 and the left in 22 patients. Sixty three of the 64 patients had their management based on the CT scan. In 54 of these the CT arthrogram either confirmed and calibrated the diagnosis or identified a new diagnosis. In 10 patients the scan was normal and allowed patient reassurance. Thirty six patients had ulnar sided problems, 20 had radial sided disorders and eight had midcarpal abnormality. The most common abnormality noted was a TFCC tear (24). The next most common was chondral damage/arthritis (14) followed by scapholunate interosseous ligament tear (12). The diagnosis was either confirmed and its extent established (31) or identified in addition to the primary diagnosis (19). Conclusions. The CT arthrogram is a helpful tool in the management of intra-articular wrist pathology. We found it to be useful in both confirming and calibrating the diagnosis and also diagnosing occult patho

Background. In suspected scaphoid fracture the initial scaphoid series plain radiographs are 84-94% sensitive for scaphoid fractures. Patients are immobilised awaiting diagnosis. Unnecessary lengthy immobilisation leads to lost productivity and may leave the wrist stiff. Early accurate diagnosis would improve patient management. Although Magnetic Resonance Imaging (MRI) has come to be regarded as the gold standard in identifying occult scaphoid injury, recent evidence suggests Computer Tomography (CT) to be more accurate in identifying scaphoid cortical fracture. Additionally CT and USS are frequently a more available resource than MRI. We hypothesised that 16 slice CT is superior to high spatial resolution Ultrasonography (USS) in the diagnosis of radiograph negative suspected cortical scaphoid fracture and that a 5 point clinical examination will help to identify patients most likely to have sustained a fracture within this group. Methods. 100 patients with two negative scaphoid series and at least two out of five established clinical signs of scaphoid injury (anatomical snuffbox tenderness (AST), scaphoid tubercle tenderness (STT), effusion, pain on circumduction and pain on axial loading) were prospectively investigated with CT and USS. MRI was arranged for patient with persistent symptoms but negative CT/USS. Results. CT demonstrated 8 scaphoid fractures. 17 other fractures (1st metacarpal, trapezium, trapezoid, distal radius, hook of hammate and triquetral) were also found. USS diagnosed 2/8 scaphoid fractures, raised suspicion in 5/8 and completely missed 1/8. Combining AST, STT with pain on circumduction improved accuracy (sensitivity 87.5% and Specificity 36%). No further fractures were identified on MRI. Conclusions. - CT remains superior to USS for the exclusion of cortical scaphoid fracture. There remains a role for USS if resources are limited. - Combining signs of ASB and tubercle tenderness with pain on circumduction assists in the identification of a ‘fracture likely’ subgroup

Fracture of the acetabulum can result in damage to the articular surface that ranges from minimal to catastrophic. Hip arthroplasty may be required for more severe injuries due to marked articular surface damage, post traumatic degenerative changes, persistent malunion or nonunion, or occasionally avascular necrosis and destruction of the femoral head. These problems may be seen following both closed and open fracture treatment, but prior open reduction and internal fixation often makes subsequent THA more difficult due to soft tissue scarring and retained hardware. In select acute acetabular fracture cases with severe initial comminution of the joint, open reduction and fixation can be technically impossible or so clearly destined to early failure that initial fracture treatment with combined limited fixation and simultaneous THA is the best option, especially in osteoporotic elderly fracture patients. Problems which may be encountered during any THA in a patient with a prior acetabular fracture include: difficult exposure due to soft tissue defects and scarring, presence of heterotopic ossification, and nerve palsy from the original fracture or subsequent osteosynthesis. Retained hardware can present significant challenges and frequently is left in place or removed in part or completely, when intraarticular in location or blocking preparation of the acetabular cavity and placement of the cup. Additional potential problems include residual deformity and malunion, persistent pelvic dissociation or nonunion of fracture fragments, cavitary or segmental bone loss from displaced or resorbed bone fragments, and occasionally occult deep infection. Preoperative assessment and planning should include careful consideration of the most appropriate surgical approach, which may be impacted by the need for hardware removal. Screening laboratory studies and aspiration of the hip may prove helpful in excluding associated deep infection. Intraoperative sciatic nerve monitoring may be of assistance in patients with partial residual nerve deficits or where extensive posterior exposure and mobilization of the sciatic nerve is needed for hardware removal or excision of heterotopic ossification. Metal cutting tools to allow partial removal of long plates and adjunctive equipment for removal of broken or stripped screws should be routinely available during these cases. Careful preoperative planning regarding implant and reconstructive options can also ensure availability of proper components and equipment. Often implants and techniques developed for revision surgery for management of major bone deficiencies are needed. Reported results suggest that surgery is frequently prolonged, can be associated with greater blood loss and may result in increased risk of post-arthroplasty heterotopic ossification when compared to routine primary procedures. Bone stock and fracture union may be better in patients with prior internal fixation than in those with nonoperative treatment of major displaced acetabular fractures. Available long-term results document more durable results with lower rates of aseptic loosening with uncemented acetabular fixation compared to cemented acetabular components. These patients are at higher risk of revision and failure than patients undergoing THA for simple osteoarthritis, though initial short-term results are comparable to conventional hip arthroplasty patients, as long as early wound healing problems and deep infection can be avoided, which is a greater risk for acute THA for initial fracture care. The application of newer implant designs, highly porous ingrowth materials, and methods for management of acetabular bone deficiency developed for revision THA have helped improve results in this challenging subset of primary THA patients

Aims

Elective operating was halted during the COVID-19 pandemic to increase the capacity to provide care to an unprecedented volume of critically unwell patients. During the pandemic, the orthopaedic department at the Aneurin Bevan University Health Board restructured the trauma service, relocating semi-urgent ambulatory trauma operating to the isolated clean elective centre (St. Woolos’ Hospital) from the main hospital receiving COVID-19 patients (Royal Gwent Hospital). This study presents our experience of providing semi-urgent trauma care in a COVID-19-free surgical unit as a safe way to treat trauma patients during the pandemic and a potential model for restarting an elective orthopaedic service.