Introduction. In orthopaedics, clinical outcome assessment (COA) is mostly performed by questionnaires which suffer from subjectivity, a ceiling effect and pain dominance. Real life activity monitoring (AM) can objectively assess function and becomes now feasible as technology has become smaller, lighter, cheaper and easier to use. In this study we validated a custom made algorithm based on accelerometry using different orthopaedic patients with the aim to use AM in orthopaedic COA. Methods. A small, lightweight 3D-accelerometer taped to the lateral side of the affected upper leg served as the activity monitor. AM algorithms were programmed in Matlab to classify standing, sitting, and walking. For validation a common protocol was used; subjects were asked to perform several tasks for 5 or 10 seconds in a fixed order. An observer noted the starting time of each task using a stopwatch. Accuracy was calculated for the number of bouts per activity as well as total time per activity. 10 Subjects were chosen with different pathologies (e.g. post total knee/hip arthroplasty, osteoarthritis) since the difference in movement dynamics in each pathology poses a challenge to the algorithm. Results. In total the subjects performed 267 activities (99 standing, 80 sitting, 88 walking), 258 of which (99, 73, 87 resp.) were classified correctly by the algorithm, corresponding to a sensitivity of 97%. Sensor misplacement in 1 subject caused all missed instances in sitting, and exclusion of this subject increased sensitivity to 99.9%. 5 Instances of standing were incorrectly added by the algorithm, giving a specificity of 95% for standing. In total 80 sit-stand, and 78 stand-sit transitions were performed. Subjects were standing for 792 seconds, sitting for 764 s, and walking for 905 s. The algorithm found a total duration of 739, 583 and 1056 seconds for those activities respectively, and 83 seconds of lying (misclassification of sitting). Discussion. Sensor placement is an important factor to obtain reliable results. Even so sensitivity and specificity are comparable to values found in literature [85–99%]. The added instances of standing occurred when a subject did not immediately sit after a period of walking. It is doubtful if these instances should be considered false positives. The main difference in duration is also found in sitting, which is caused by the missed instances previously described, in combination with the fact that the duration of transitions are added to the walking period in the algorithm, whereas it is divided over sitting and walking by the observer. This corresponds to a difference of less than one second per transition. The algorithm produces reliable results when challenged with different movement patterns common with orthpaedic pathologies. The device may be used as as AM in objective assessment of clinical outcome after orthopaedic procedures

Over the last few decades, the All-Poly Monoblock Tibia has been relegated to a minimum use in the major healthcare systems of the western world. The main reason for this has been the perception that this tibial component is inferior in its ability to withstand stresses. This perception originated and subsequently gained ground, due to certain historical reasons, leading to the widespread use of the modular metal-backed tibial component despite a higher cost. The recent economic downturn has enforced even the rich western healthcare systems to look for cost-effective solutions. The author works in India, where the society is still highly price-sensitive and takes value for money very seriously. Further, the routine ADL of the Indian population requires them to adopt high flexion postures such as cross-legged sitting and squatting. The author has used the All-Poly Tibia extensively, which is the most economical of tibial components. Further, he has developed a surgical technique which has resulted in his patients achieving high flexion (greater than 135 degrees) in more than 75% cases. This paper presents the 10 year results of a series of 500 cases of Primary TKR in which the All-Poly Monoblock Tibia had been used. All the patients had cross-legged sitting activity as part of their ADL, thus presumably generating significant pressures on the joint surfaces. Of the original 500 cases, we could follow up 434 cases. We report a 96% survival rate of the implant in this series. There was not a single aseptic plastic failure. The revisions required were due to infection, peri-prosthetic fracture, and instability. The message being conveyed in this paper is that the All-Poly Tibia is a very cost-effective solution in routine Primary TKRs, and is able to deliver excellent long-term results even in high stress situations like cross-legged sitting activity. It would offer a huge cost savings to the healthcare system if the Orthopaedic Surgeons start using this implant more frequently

Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

AIM. Chronic osteomyelitis still remains challenging and expensive to treat inspite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure. METHODS. We retrospectively identified eight patients (5 Females) with mean age of 63 yrs (Range40–71 yrs) Case notes were reviewed for co morbidities, Pre and post treatment inflammatory markers (plasma viscosity and CRP) and clinical staging. Mean follow up was 3 yrs (Range 1–6 yrs) All the patients were jointly operated by orthopaedic and plastic surgeons and underwent thorough debridement and muscle flap (Seven free flaps and one rotational flap) in the same sitting. All the patients were reviewed regularly by plastic and orthopaedic surgeons. Seven patients had free Gracilis flap and one had Triceps flap. Clinical assessment of reinfection was made on presence of erythema, wound discharge, pain and swelling. Primary outcome measure was resolution of infection. RESULTS. Seven patients had full resolution of osteomyelitis as evident by clinical examination and inflammatory markers. Three patients had graft problems to start with, but theses settled within six months One patient had minor wound discharge at three years which settled with conservative management. One further patient developed eczematous dermatitis around the flap which was managed successfully by the dermatologist. CONCLUSIONS. We believe this to be the only study in which both the procedures (debridement and muscle flap) are performed in one sitting. This technique is a successful and useful addition to the armamentarium of surgeons in the management of chronic osteomyelitis. Though our study is small but our results are encouraging

Aims

Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters.

Background:. Little is known about the forces carried by the Taylor Spatial Frame (TSF) hexapod fixator. Our aim was to measure the TSF resultant force and how this changed during the consolidation phase. Method:. Five patients undergoing correction of tibial deformities were recruited. Measurements were taken at 2, 4, 8 and 12 weeks post-correction during various activities. Instrumented struts incorporating strain gauges measuring axial force were temporarily used each time. Strut forces and lengths were used to determine frame kinetics. The resultant axial fixator forces and moments were calculated relative to sitting. Ground reaction forces (GRF) were measured using the treadmill force plates. Results & Discussion:. Due to the subjects' varying confidence in weight bearing the forces varied both inter- and intra-activity and over post-corrective time. Variation in individual strut forces produced a resultant force and bending moment across the fixation. As the healing bone assumed more load over time there was a reduction in the force and bending excursions across the frame as a percentage of GRF, achieving a minimum by 8 weeks. Conclusion:. Instrumented TSFs are a useful means of assessing the forces acting during healing. Monitoring of these forces can determine optimal removal

Single focal grade IV cartilage lesion in the knee has a poor healing capacity. Instead these lesions often progress to severe and generalized osteoarthritis that may result in total knee replacement. Current treatment modalities aim at biological repair and, although theoretically appealing, the newly formed tissue is at the best cartilage-like, often fibrous or fibrocartilaginous. This at the expense of sophisticated laboratory resources, delicate surgery and strict compliance from patients. An alternative may be small implants of biomaterial inserted to replace the damaged cartilage. We investigated the response of the opposing tibia cartilage to a metallic implant inserted at different depth into the surrounding cartilage level. Methods. The medial femoral condyle of both knees of 12 sheep, 70–90kg, 2 year of age and from the same breeder, was operated. A metallic implant with an articulating surface of 316L stainless steel, diameter of 7mm, HA plasma sprayed press-fit peg and a tailored radius and contour to the sheep femoral condyle was placed at the most weight-bearing position. The level of the implant was aimed flush, 0,3 and 0,8 mm below surrounding cartilage. The animals were stabled indoors, allowed to move freely and euthanized after 6 and 12 weeks. Postoperatively the knees were high resolution photographed for macroscopic evaluation. The position and depth of the implant were analysed using a laser scan device. Tibial and femoral condyles specimen were decalcified and slices were prepared for microscopic evaluation. Implant position and cartilage damage was assessed from two independent observers using a macroscopic ICRS score and a modified histologic score according to Mankin. Results. 22 tibia condyles showed a variety of cartilage damage ranging from severe damage down to subchondral bone to an almost pristine condition. There was a strong correlation between implant position and damage to opposing cartilage surface. Mankin score correlated significantly with implant position (p<0.001 regression analysis, r. 2. =.45) as did the ICRS score (p<0.001, regression analysis, r. 2. =.67). Implants sitting proud were associated with poor Mankin score. There was no difference between 6-week and 3-months knees. Conclusion. By precise postoperative measurement we have shown that significant imprecision occur; this has never before been studied. We found a distinct correlation between implant position and cartilage damage. These results suggest that further studies of metallic implants, inserted into cartilage defects with the utmost precision regarding the surrounding cartilage, may be warranted

Purpose. Clinicians need knowledge about early and valid predictors of short-term outcome of patients with hip fracture, to adjust and plan rehabilitation. The concept of multimodal rehabilitation has proven effective. Still, some patients do not regain basic mobility independency in the acute orthopaedic setting. The aim was to examine the predictive value of age, sex, prefracture functional level, mental and health status, and fracture type of in-hospital basic mobility outcome, and discharge destination after hip fracture surgery. Subjects. A total of 213 consecutive patients (157 women and 56 men) with a median age of 82 (25–75% quartile, 75–88) years, admitted from their own home, and following a multimodal rehabilitation concept, were included. Fifty percent of patients had a high prefracture functional level, evaluated by the New Mobility Score (NMS), 77 and 62% had respectively, a high mental and health status, and the distribution of cervical versus intertrochanteric fractures were equally divided. Methods. Outcome variables were the regain of independency in basic mobility during admittance and discharge destination. The Cumulated Ambulation Score was used to evaluate basic mobility defined as, independency in getting in and out of bed, sitting down and standing up from a chair, and walking. Discharge destination was classified as own home or further inpatient rehabilitation facilities in the community. Results. A total of 50 (24%) patients did not regain their basic mobility independence during admittance, and 51 patients (24%) were not discharged to their own home. Simple regression analysis showed that age, the prefracture NMS functional level, mental status and fracture type (P<0.01), significantly influenced basic mobility outcome, while sex (P=0.06) and health status (P=0.08), did not. Multiple logistic regression analysis, revealed the prefracture NMS level, age and fracture types as the only independent predictors, when adjusted for sex, mental and health status. Thus, a patient with a low prefracture NMS and/or an intertrochanteric fracture was respectively, 6 and 4 times more likely not to regain independency in basic mobility during admittance, and 4 and 3 times more likely not being discharged to own home, compared to a patient with a high prefracture NMS level and a cervical fracture, respectively. Further, odds of not being discharged directly to own home increased with 9% per each additional year the patient got older. Conclusion. The prefracture NMS functional level, age and fracture type were strong and independent predictors of in-hospital outcome in patients with hip fracture who followed a multimodal rehabilitation concept. Clinicians using these three easily available variables, have the possibility to identify patients who may benefit from special attention

Purpose. The purpose of this study was to prospectively evaluate the rehabilitation outcome of children following operative and non-operative stabilisation of long bone fractures sustained in conjunction with an acquired brain injury (ABI). Materials and Methods. Between 1996 and 2002, children up to 16 years of age who were admitted to the Paediatric Intensive Care Unit (PICU) with an ABI and concomitant tibial or femoral shaft fractures were considered eligible for inclusion. Children who died or were unable to walk before the accident were excluded. All data relating to the sustained injuries, the duration of PICU inpatient stay, the fracture treatment and the functional outcome were collected prospectively. The severity of the injuries was assessed using the Injury Severity Score (ISS) and the Glasgow Coma Score (GCS). The duration of time was taken from admission to reaching rehabilitation milestones; the ability to sit, stand and walk was then assessed. Total duration of hospital inpatient stay and mobility on discharge were also recorded. Operative skeletal stabilisation included external or internal fixation, as well as flexible intramedullary nailing. Statistical analysis was performed using the Mann-Whitney U Test. Results. From 300 children admitted to the PICU for treatment of ABI, thirty-seven fulfilled the criteria for inclusion into the study. For both groups (operative vs nonoperative treatment) the mean age of patients was 9 years (range 1–15yrs) and the ISS, GCS scores and the mean stay in PICU were similar. There was a total of 21 femoral fractures (11 treated conservatively and 10 operatively) and 16 tibial fractures (7 conservatively and 9 operatively). Overall, the results showed a reduction in the mean time taken to reach all rehabilitation milestones following operative fracture stabilisation when compared to those treated non-operatively. The mean time to sitting was reduced from 27.1 days to 17.8. The mean time to standing was reduced from 50.1 to 35.6 and to walking, from 67.1 to 45.7 days. The Mann-Whitney U Test demonstrated a statistically significant reduced time to walk in the operatively treated group (p<0.05). Due to the small size of the sample group, significant statistical data for the other parameters measured was not evident. Conclusion. This study was specifically aimed at the short to medium term gains of operative treatment of tibial and femoral fractures in association with ABI. It has been shown that a co-ordinated rehabilitation programme plus operative stabilisation of children's tibial and femoral shaft fractures sustained in association with ABI, hastens rehabilitation, as it allowed aggressive rehabilitation programme to commence at a much earlier stage without risk of loss of fracture reduction

The purpose of the study is to evaluate the retrospective results of 92 surgically treated spastic hips. Twenty-one patients were able to walk in the community with aids, 19 were able to walk about the house, and 13 were wheelchair bound. The mean age at the time of the operation was 7 yrs (3–18) and the average follow-up was 5. The cohort of the study included 45 tetraplegic patients, 6 diplegic, and 2 hemiplegic. The dislocated hips were 25 and the subluxated ones 67. The surgical treatment included soft tissue and bone procedures. The 53 patients were divided into two age groups: those less than 7yrs old and those older than 7yrs. The cohort was also divided into 39 patients operated in one setting, and 14 operated in more than one. Clinical evaluation was based on the joint range of motion, the ambulatory status and the pain. The radiological evaluation criteria were based on Reimer's migration index, the center-edge angle, Sharp's angle, and neck-femoral angle. We used the interclass correlation coefficient to measure our interobserver reliability for MI 0,93, for CE angle 0,95 and for Sharp's angle 0,81, as the interobserver difference for MI averaged 9% for CE angle 7and for Sharp's angle 3. Statistical analysis of continuous variables was done by Student's t-test or the Wilcoxon rank sum test. Categorical variables were evaluated by Fisher's test. Concerning the walking ability, from the 13 severe quadriplegic patients, none improved his functional level but they achieved better sitting balance. The walking ability of the rest of the patients improved one level in 78% of the cases. The mean preoperative abduction was improved from 24,7 to 33,5, the mean flexion was slightly reduced from 123 preoperatively to 114 postoperatively and the mean extension reduced from −20 preoperatively to −8 postoperatively. Reimer's index reduced from 67,2 to 21,7 postoperatively, the CE angle increased from −10,6 to 20,5, the Sharp's angle increased from 36,9 to 40,5 and the neck-shaft angle increased from 119,7 to 157,5post-operatively. Of greater significance were MI and CE at p<0.05. A migration index of >50% at final follow-up was associated with a worse migration index and a worse CE angle at 1 year post-operatively. 46 hips were evaluated as good, 30 as satisfactory, and 16 as poor. The severe tetraplegic with small-negative CE angle and Reimer's migration index > 50%, as well as the small age of the patients (<7 yrs) were negative prognostic factors. Better results were observed when patients were operated at age <7yrs by soft tissue procedures and MI<30%, while patients >7yrs had satisfactory results only after combined bony and soft tissue procedures and MI <50%. A migration index of >50% at final follow-up was associated with a worse migration index and a worse CE angle at 1 year postoperatively

Aims

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

Patients with transfemoral amputation (TFA) often experience problems related to the use of socket-suspended prostheses. The clinical development of osseointegrated percutaneous prostheses for patients with a TFA started in 1990, based on the long-term successful results of osseointegrated dental implants.

Between1999 and 2007, 51 patients with 55 TFAs were consecutively enrolled in a prospective, single-centre non-randomised study and followed for two years. The indication for amputation was trauma in 33 patients (65%) and tumour in 12 (24%). A two-stage surgical procedure was used to introduce a percutaneous implant to which an external amputation prosthesis was attached. The assessment of outcome included the use of two self-report questionnaires, the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) and the Short-Form (SF)-36.

The cumulative survival at two years’ follow-up was 92%. The Q-TFA showed improved prosthetic use, mobility, global situation and fewer problems (all p < 0.001). The physical function SF-36 scores were also improved (p < 0.001). Superficial infection was the most frequent complication, occurring 41 times in 28 patients (rate of infection 54.9%). Most were treated effectively with oral antibiotics. The implant was removed in four patients because of loosening (three aseptic, one infection).

Osseointegrated percutaneous implants constitute a novel form of treatment for patients with TFA. The high cumulative survival rate at two years (92%) combined with enhanced prosthetic use and mobility, fewer problems and improved quality of life, supports the ‘revolutionary change’ that patients with TFA have reported following treatment with osseointegrated percutaneous prostheses.

Cite this article: Bone Joint J 2014;96-B:106–13.

We performed a systematic review of the literature to evaluate the use and interpretation of generic and disease-specific functional outcome instruments in the reporting of outcome after the surgical treatment of disruptions of the pelvic ring. A total of 28 papers met our inclusion criteria, with eight reporting only generic outcome instruments, 13 reporting only pelvis-specific outcome instruments, and six reporting both. The Short-Form 36 (SF-36) was by far the most commonly used generic outcome instrument, used in 12 papers, with widely variable reporting of scores. The pelvis-specific outcome instruments were used in 19 studies; the Majeed score in ten, Iowa pelvic score in six, Hannover pelvic score in two and the Orlando pelvic score in one. Four sets of authors, all testing construct validity based on correlation with the SF-36, performed psychometric testing of three pelvis-specific instruments (Majeed, IPS and Orlando scores). No testing of responsiveness, content validity, criterion validity, internal consistency or reproducibility was performed.

The existing literature in this area is inadequate to inform surgeons or patients in a meaningful way about the functional outcomes of these fractures after fixation.

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year.

In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group.

We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.