Aims

We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue.

Background:

Acute deformity correction with the help of osteotomies and stabilisation with intramedullary (IM) nail is a recognised technique. We present our case series of long bong deformity correction using an innovative technique that aids accurate correction after osteotomy and insertion of IM nail.

Aim

To determine the rate of recurrence of coronal plane deformity in children treated with ‘guided growth’ using 8-plates, from the time of implant removal to skeletal maturity.

Purposes of the Study

To study the incidence of delayed consolidation of regenerate in children undergoing correction or lengthening of lower limb deformities using an external fixator.

Background

The management of non-unions of subtrochanteric femoral fractures with associated implant failure is challenging. This study assessed the outcome of a cohort of patients treated according to the diamond concept.

Background

Distal tibial metaphyseal fractures pose many complexities. This study assessed the outcomes of distal tibial fractures treated with percutaneously inserted medial locking plates.

Background

Despite interest, the current rate of day-case anterior cruciate ligament reconstruction (ACLR) in the UK remains low. Although specialised care pathways with standard operating procedures (SOPs) have been effective in reducing length of stay following some surgical procedures, this has not been previously reported for ACLR. We evaluate the effectiveness of SOPs for establishing day-case ACLR in a specialist unit.

Introduction

The aim of this study was to evaluate the health quality of life and return to sports activities following pelvic ring injuries.

Aim

(1) To determine whether any difference exists in AVN risk between surgical reduction [Fish] or pinning-in-situ [PIS] of severe slips. (2) To review the different classifications of SUFE in relation to AVN.

Introduction: To quantify the magnitude and incidence of haemodynamic changes that occurs during the fixation of extracapsular proximal femoral fractures when using either intra-medullary or extra-medullary fixation device.

Methods: A prospective group of 31 patients with extra-capsular proximal femoral fractures were randomised to either fixation using an extra-medullary compression hip screw or an intra-medullary hip screw. All patients received a general anaesthetic adhering to a standardised anaesthetic protocol including invasive blood pressure monitoring and arterial blood gas sampling. Trans-oesophageal Doppler probe and monitor was used to record pre-operative hypovolaemia and peri-operative changes in cardiac output, stroke volume and corrected flow time (FTc – a reflection of left ventricular end diastolic pressure) during placement of implants.

Results: 77% of patients were hypovolaemic preoperatively, which was corrected with an average of 439 mls of colloid replacement fluid. Application of the extra-medullary CHS produced no change in haemodynamic function. However on insertion of the IMHS we found a statistically significant reduction in stroke volume, cardiac output and FTc without changes in pulse rate or mean arterial pressure. The changes were transient with normal cardiac function returning by 5 mins post operatively.

Conclusion: The transient fall in cardiac function during insertion of the intramedullary hip screw may be caused by fat embolism entering the venous circulation. As these changes are not detected with standard non-invasive monitoring we would recommend that intramedullary devices be used with caution in elderly patients who tend to have poor physiological reserve.

Background: Tranexamic acid has been shown to be effective in reducing blood loss and transfusion requirement in cardiac surgery and total knee replacement surgery. The most effective dose of tranexamic acid in hip arthroplasty surgery is not yet known. We investigated the effect of a pre-operative bolus 1g intravenous tranexamic acid on intra- and post-operative blood loss, transfusion requirement, and risk of venous thromboembolism following total hip arthroplasty.

Results: We report a cohort comparison study of 73 patients who underwent primary hip arthroplasty. Thirty-six patients received tranexamic acid (TA group), and thirty-seven received no tranexamic acid (control group). Blood loss was measured directly intra-operatively, and indirectly post-operatively by haemoglobin and haematocrit measurement. Deep vein thrombosis (DVT) was investigated by venography.

Patient demographics were similar between both groups. There was no significant difference in intra-operative blood loss between both groups. The early post-operative blood loss and total blood loss were significantly less in the tranexamic acid group. This effect of tranexamic acid was more significant in females who showed a dose-related relationship between tranexamic acid dose and blood loss. Fewer patients in the tranexamic acid group required blood transfusion. There was no increased incidence of DVT in the tranexamic acid group.

The use of a single pre-operative 1g bolus of tranexamic acid administered before surgery is a safe, cost-effective method of reducing post-operative blood loss following total hip arthroplasty. The effect is more significant in females at this dose.

Tranexamic acid is a fibrinolytic inhibitor which reduces blood loss in total knee replacement. We examined the effect on blood loss of a standardised intravenous bolus dose of 1 g of tranexamic acid, given at the induction of anaesthesia in patients undergoing total hip replacement and tested the potential prothrombotic effect by undertaking routine venography. In all, 36 patients received 1 g of tranexamic acid, and 37 no tranexamic acid. Blood loss was measured directly per-operatively and indirectly post-operatively.

Tranexamic acid reduced the early post-operative blood loss and total blood loss (p = 0.03 and p = 0.008, respectively) but not the intraoperative blood loss. The tranexamic acid group required fewer transfusions (p = 0.03) and had no increased incidence of deep-vein thrombosis. The reduction in early post-operative blood loss was more marked in women (p = 0.05), in whom this effect was dose-related (r = −0.793).

Our study showed that the administration of a standardised pre-operative bolus of 1 g of tranexamic acid was cost-effective in reducing the blood loss and transfusion requirements after total hip replacement, especially in women.

Aim: To compare of strength of constructs using the newer and part specific nail systems: Polarus and European Humeral Nail with that using PHILOS and Conventional plate systems in a simulated 2-part fracture of proximal humerus, in an osteoporotic bone model.

Materials and Methods: A Biomechanical laboratory study was undertaken. Third generation composite Humerus model was used, with short e-glass epoxy fibres forming cortex and polyurethane cancellous core. Low-density polyurethane core (1.2gm/cc) was used to simulate an osteoporotic model. Osteotomy at surgical neck of humerus was carried out to create 2-part fracture of proximal humerus. Samples were fixed using one of the implants- the Polarus nail, the European Humeral Nail, PHILOS Plate, Clover Leaf Plate or T-Plate. Following fixation samples were placed in a custom made jig to fix proximal and distal ends without interfering with implants and osteotomy site. All samples were subjected to cyclical torque, torque to failure, cyclical compression and Compression loading to failure.

Results: The two Nail systems that are specifically designed for fixation of proximal humerus fracture provided significantly better fixation in all the test modalities. PHILOS construct shows less plastic deformation in cyclical torque and cyclical compression when compared to the other plates but the 2 nail systems were far superior. Locking screws did not ‘back off’ in any of the experiments involving the Polarus, European Humeral Nail and PHILOS construct, however ordinary screws used with the conventional plates did back off both in ‘torque and compression’ testing.

Conclusions: Polarus and European Humeral Nail constructs provide better stability in torque and compression as compared to PHILOS, which in turn is a more stable construct in comparison to conventional plating devices.

Aim: A study was done to investigate the range in size and morphological features of a series of human clavicles.

Method: A Phillips CT scanner was used to examine morphometric properties of 42 right and 36 left adult cadaveric clavicles. The resulting data was analysed with Voxar 3D software. The length of the s-shaped clavicle was measured and the planar cross-sectional geometry of the intramedullary canal and cortical thickness assessed at 10% increments along the length of the bone. MPR (multi-plane reformat) imaging allowed ‘fly-through’ reconstruction of cross-sectional morphology as one travels along the length of the bone.

Results: The sample studied followed a normal distribution with mean size= 136.2mm (range: 112.6– 172.0 mm). In general the sternal portion of the clavicle is circular or prismatic in cross-section where as the acromial portion is flatter on its superior and inferior surfaces. A spacious, variably shaped canal is observed at the sternal and acromial thirds in contrast to the denser, smaller, more circular shaped canal in the central third of the bone. Unlike most long bones, the clavicle was observed to have an extensive network of trabeculae along the entire length of the intramedullary canal. The central third of the clavicle has the thickest cortex. The mean cortical thickness (3.37mm; range: 1.8– 7.9mm) was greatest at a point 60% from the sternal end with the mean thinnest cortex (1.37 & 1.15mm) found at the extreme sternal and acromial ends of the bone respectively.

Conclusion: The clavicle is highly variable in shape and exhibits dramatic variations in both curvature and cross-sectional geometry along its length. Contrary to previous teaching, MPR reconstruction accurately demonstrates clear visualization of a distinct intra-medullary canal.

Aim: To investigate in vitro the mechanical stability of a locking compression plate (LCP) construct in a simulated diaphyseal fracture of the humerus at increasing distances between the plate and bone.

Materials & Method: A series of biomechanical in vitro experiments were performed using Composite Humerus Sawbone as the bone model. Osteotomy created in the mid-diaphyseal region. A 10mm osteotomy gap was bridged with a 7-hole 4.5 stainless steel plate with one of four methods: a control group consisted of a Dynamic Compression Plate applied flush to the bone and three study groups which comprised of a LCP applied flush to the bone, at 2mm and at 5mm from the bone. Standard AO technique used with locking head screws used for LCP fixation. Static and dynamic loading tests performed in a jig with the bone model fixed both proximally and distally. Samples were subjected to cyclical compression, compression load to failure, cyclical torque and torque to failure. Plastic deformation and failure was assessed. Scanning electron microscopy of the plate and screw surface allowed detailed inspection of micro-fracture in areas of fatigue.

Results: Consistent results were achieved in LCP constructs in which the plate was applied at or less than 2mm from the bone. When applied 5mm from the bone the LCP demonstrated significantly increased plastic deformation during cyclical compression and required lower loads to induce construct failure.

Conclusion: In our laboratory model a significant decrease in axial stiffness and torsional rigidity becomes evident at a distance of 5mm between plate and bone.

Aim: To test the hypothesis that the number of admissions in an orthopaedic trauma ward are related to weather conditions.

Materials and Methods: Details of all admissions to the orthopaedic trauma ward over one complete year were retrieved from a computerised data base. Fractures were classified according to the AO classification.

Meteorological data correlated with trauma admissions and data analysis using SPSS version 10.1

Results: Total number of admissions = 1390 [mean age: male=44.2, female=67.6 years]. Commonest fractures in descending order: neck of femur, distal tibia and distal humerus. Overall correlation: significantly +ve (p=0.013) with sunshine (more sunshine = more fractures) and significantly –ve (p=0.001) with rain (less rain = more fractures). 34.5% of admissions were non trauma related.

Conclusion: Females were significantly older than men probably reflecting hazardous activities by younger males and the presence of osteopaenia in females. No significant monthly (seasonal) variations were seen. Influence of weather conditions:

Proximal femoral fracture incidence increase with fall in temperature (freezing conditions does NOT further increase the risk) and rain (but NOT dependent on the amount of rain).

A long term prospective study is required to further support the above findings if clinical trauma resources are to be planned based on predicted weather forecast.

Aim: A case report: Symptomatic Osteochondroma of the Coracoid

Introduction: An osteochondroma is a common developmental tumour of bone characterized by abnormal periphyseal ectopic endochondral ossification. This results in a cartilage-capped subperiosteal bony projection. A solitary osteochondroma is encountered more frequently than are multiple hereditary osteochondromas. They are usually appreciated in the first decades of life and are most commonly located in the long bones, especially the femur, humerus and the tibia. Clinical presentations generally relate to the mass effect of the lesion. These lesions are said to grow to skeletal maturity. Continuous slow growth of the osteochondroma in adults should alert the clinician to the possibility of secondary malignant transformation, usually to a chondroma.

Method: We present an unusual case of shoulder pain in a 36-year-old man with a painful solitary osteochondroma of the coracoid process. Plain radiographs, computed tomographic and magnetic resonance imaging of the lesion showed a solitary osteochondroma with a visible cartilage cap eroding the under surface of the clavicle. The lesion was surgically explored and excised. Histological examination showed a benign osteochondroma. Removal of the tumour resulted in resolution of all signs and symptoms.

Conclusion: We are aware of no reported cases in the literature of osteochondroma of the coracoid process. This case was unusual in terms of age at clinical presentation and location, suggesting a continuous growth of the tumour beyond skeletal maturity.