Lag screw cut-out is a serious complication of dynamic hip screw fixation in trochanteric hip fractures. Lag screw position is recognised as a crucial factor influencing the occurrence of lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesize that it could enhance the reliability of predicting lag screw cut-out in these injuries.

A retrospective study of hip fracture cases was conducted from January 2018 to July 2022. A total of 109 patients were eligible for the final analysis. The modified TAD was measured in millimetres, based on the sum of the traditional TAD in the lateral view and the net value of two distances in the anteroposterior (AP) view. The first distance is from the lag screw tip to the opposite point on the femoral head along the lag screw axis, while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if it is inferior. Receiver operating characteristic (ROC) curve analysis was used to assess the reliability of various parameters for evaluating the lag screw position within the femoral head.

Factors such as reduction quality, fracture pattern according to the AO/OTA classification, TAD, Calcar-Referenced TAD, Axis Blade Angle, Parker’s ratio in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the novel parameter exhibited 90.1% sensitivity and 90.9% specificity for predicting lag screw cut-out at a cut-off value of 25 mm, with a p-value < 0.001.

The modified TAD demonstrated the highest reliability in predicting lag screw cut-out. A value of 25 mm may potentially reduce the risk of lag screw cut-out in trochanteric hip fractures.

Abstract

Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility.

IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm.

We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime.

IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation.

Abstract

Abstract

Growth factors are reported to play an important role in healing after acute Achilles tendon rupture (ATR). However, the association between growth factors and patient outcome has not been investigated previously. The aim of this retrospective study is to identify growth factors and related proteins which can be used as predictors of healing after ATR, ethical approval was obtained from the Regional Ethical Review Committees in Sweden and followed the guidelines of the Declaration of Helsinki. The study included 28 surgically treated patients (mean age 39.11 ± 8.38 yrs) with acute ATR. Healing was assessed by microdialysate two weeks after the surgery and performed on both injured and contralateral un-injured leg. The microdialysates were analyzed by proteomics based on mass spectrometry (MS) to detect growth factor expressions in ATR patients. One year after the surgery, healing outcomes were evaluated by patient-reported Achilles tendon Total Rupture Score (ATRS), Foot and Ankle Outcome Score (FAOS), and functional outcomes by heel-rise test.

A total of 1549 proteins were detected in the microdialysates of which 20 growth factor/ related proteins were identified. 7 of these were significantly up-regulated (IGFBP2, Fold change (FC) = 4.07, P = 0.0036; IGFBP4, FC = 3.06, P = 0.009; CTGF, FC = 15.83, P = 0.003; HDGF, FC = 4.58, P = 0.003; GRB2, FC = 14.8, P = 0.0004; LTBP1, FC = 12.08, P = 0.0008; TGFBI, FC = 5.54, P = 0.001) and 1 down-regulated (IGFBP6) in the injured compared to the contralateral healthy side. Linear regression analysis revealed that TGFB1 was positively associated with improved ATRS (r = 0.585, P = 0.04) as well to ATRS subscales: less limitation in running (r = 0.72, P = 0.004), less jumping limitation (r = 0.764, P = 0.001) and less limitation caused by decreased tendon strength (r = 0.665, P = 0.012). Interestingly, all 7 up-regulated proteins were positively associated with less jumping limitations (IGFBP2, r = 0.667, P = 0.015; IGFBP4, r = 0.675, P = 0.013; CTGF, r = 0.668, P = 0.015; HDGF, r = 0.672, P = 0.014; GRB2, r = 0.665, P = 0.016; LTBP1, r = 0.663, P = 0,016). No associations were observed among any of the growth factor and FAOS or patient's functional outcomes.

We conclude that growth factors and related proteins play a crucial role in ATR healing. More specifically, TGFB1 may be used as prognostic biomarker of the patient-reported outcome 1-year post-surgery. These results may be used to develop more specific treatments to improve ATR healing.

Although patient-reported outcomes (PROs) have become increasingly important in the evaluation of spine surgery patients, interpretability may be limited by a patient's ability to recall pre-intervention impairment. The accuracy of patient recall of preoperative back pain, leg pain, and disability after spine surgery remains unknown. We sought to characterise the accuracy of patient recall of preoperative symptoms in a cohort of lumbar spine surgery patients.

We analysed consecutive patients undergoing lumbar decompression or decompression and fusion for lumbar radiculopathy by a single surgeon over a four-year period. Using standardised questionnaires, we recorded back and leg numeric pain scores (NPS) and Oswestry Disability Indices (ODI) preoperatively and asked patients to recall their preoperative status at a minimum of one-year following surgery. We then statistically compared and characterised patient recall of their pre-operative status and their actual pre-operative status. Patients with incomplete follow up or diagnoses other than degenerative lumbar stenosis were excluded.

Sixty-seven patients with a mean age of 66.1 years (55% female) were included in the final analysis. All cases were either posterior or combined anterior/ posterior procedures. Mean levels of surgery was 1.7 and 93.8% of all cases were instrumented. Mean duration of preoperative symptoms was 44.5 months (3.7 years). Preoperative vs postoperative PROs improved with regards to NPS back (5.2 vs 2.2, p= to 2 point difference), exceeding the minimal clinical important difference (MCID) for NPS. This pattern was maintained across age, gender, and duration of preoperative symptoms. We also observed cases of symptom minimisation recall bias, and cases in which back and leg pain predominance were switched in severity during recall bias.

Significant recall bias of preoperative symptoms exists in patients undergoing spine surgery, potentially limiting accurate assessment and interpretation of PROs. An understanding of PROs and their limitations is essential to assess treatment efficacy of spinal procedures.

Background

Wallis implant was developed in 1986 to stiffen unstable operated degenerate lumbar segments while preserving some intervertebral mobility. The long-term results of first-generation Wallis implant from developers were promising. However, documentation pertaining to safety and efficacy of second generation Wallis implant is sparse in literature.

The use of percutaneous Kirschner wires [K-wires] and plaster is a popular method of treatment for displaced distal radius fracture. However, multi-database electronic literature review reveals unsurprisingly different views regarding their use.

From August 2002 till June 2004, 280 distal radial fractures were admitted to our orthopaedic department. They were recorded prospectively in the departmental trauma admissions database. We studied the 87 cases treated with the K-wires and plaster technique. They were classified according to the AO classification system. The mean patient age was 53 [5-88] years. The mean delay before surgery was 7 [0-24] days. We studied the complications reported by the attending orthopaedic surgical team. 48 out of 87 patients [55.1%] were reported to have complications.

We analysed the displacement and the pin tract infection, as they were the main reported complications. 28 out of 87 patients [32%] had displacement [9 had further surgery to correct the displacement, 19 did not have any further surgery as the displacement was accepted]. 11 out of 87 patients [12.6%] had pin tract infection [7 needed early removals of the K-wires and systematic treatment]. Further analysis showed no statistically significant relation between the complications rate and the age of the patients, the delay before surgery or the type of the fractures.

We demonstrate a considerable high displacement and infection rate with the use of K-wires and plaster technique for fixation of distal fracture irrespective of the age of the patients, the delay before surgery or the fracture classification. There are other methods for fixation of the distal radial fracture with proven less morbidity which should be considered.

Aim: To report outcomes of high tibial osteotomies (HTO) in the treatment of patients with symptomatic varus-osteoarthritic knees.

Methods: Fourteen patients had a medial opening wedge HTO between 2001–2008. Twelve were male, mean age 42.2 years (range 33–49). Follow-up range 8–72 (mean 31 months). Six had simultaneous ACL reconstruction (one a revision another part of multiligament reconstruction). X-rays were taken at follow-up at 6, 12, 24, 36 and 52 weeks. Patients had pre- and post-operative KOOS assessment.

Results: All patients achieved a pain free leg with radiological evidence of union at mean 4.7 months (range 3–9). Two major complications occurred in one patient (PE and sensory neuropraxia). Minor complications in three patients: cellulitis, donor site infection, 1cm limb length discrepancy. Six patients required 7 further procedures: 2 arthroscopic chondral debridements, 2 microfractures and 3 arthroplasties. Tibial knee varus angles improved from mean 4.7° to 0.28°. KOOS scores improved in all domains: pain 28.5 to 52.8 (P< 0.01), symptoms 30.4 to 48.2 (P< 0.01), ADL 31.3 to 54.4 (P< 0.05), sport and recreation 2.5 to 7.5 P=0.125 and QOL 4.69 to 17.2 (P< 0.05). Kaplan-Meier survival analysis with failure defined as conversion to TKR shows a survivorship of 78.8% at 3 years.

Conclusions: Young patients with medial compartment osteoarthritis can have improved pain and function after HTO.

Better results are reported in the literature. However, some papers suggest osteotomies have been carried out in relatively asymptomatic patients and others accept significant pain in longer follow-up intervals without their patient cohorts having been offered alternative pain relieving strategies, such as chondral resurfacing or arthroplasty.

Patients require careful counselling that they will not achieve normal function and have a high incidence of need for further intervention.

Introduction: Ankle fractures are one of the most common injuries treated by the orthopaedic surgeon. The general recommendation is if surgical treatment is not carried out within the first 24 hours from injury, then it should be delayed for about 5–7 days to reduce the risk of wound complications associated with limb swelling. The aim of our study was to see whether timing of surgery affects the relative risk of skin complications following internal fixation of ankle fractures.

Method: We analysed medical records of 102 patients with closed ankle fractures admitted to the orthopaedic department at our hospital between May 2003 and May 2005. The fractures were classified according to the Weber-AO classification. Open reduction and internal fixation was performed according to the techniques of the AO Group.

Results: The mean age of patients was 43 years(range 13–87). According to the AO classification, 3 were type A(A1–3), 77 were type B(B1-16, B2-42, B3-16), 17 were type C(C1-2, C2-11, C3-4), 4 were isolated medial malleolus and 1 was Salter-Harris type 2 fractures. The mean delay before surgery was 3(0–18) days. The mean length of hospital stay was 6(1–44) days. Out of 102 patients, 53 of the patients were operated within 24 hours, 22 were operated from 24–72 hours, 15 within 4 to 7 days and the rest were operated within 7–18 days. The main reasons for delay were either failed initial conservative management or late presentation.

There was one case of superficial wound infection, deep vein thrombosis, neuroma and delayed union of medial malleolus each.

Conclusion: We conclude that for ankle fractures that are not operated on within the initial 24 hours from the injury, delayed treatment could be instituted as soon as patient and limb factors permit and rigid adherence to waiting times of 5–7 days is not necessary.

Background: Non-rigid fixation clearly appears to be a useful technique in the management of degenerative intervertebral lumbar disc disease. A mobile, dynamic stabilization restricting segmental motion is possible to be advantageous in various indications, allowing greater physiological function and reducing the inherent disadvantages of rigid instrumentation and fusion.

Aim: This study is a prospective analysis of the early results of second generation Wallis implant for degenerative disc disease.

Methods and Materials: Twenty-five patients with leg and back pain that was not responsive to conservative treatment underwent discectomy and implantation of second generation device. There were 22 one-level and 3 two-level cases. The preoperative radiological work-up included conventional X-rays, computed tomography and magnetic resonance imaging (MRI). All patients underwent neurological examination, assessment of pain on a visual analog scale, and a functional evaluation using the Revised Oswestry disability index before surgery, 3 months after surgery and at follow- up.

Results: A total of 25 patients (13 men, 12 women) with a mean age of 51.9 years (range, 34 to 69 years) were evaluated with a mean follow-up of 1.4 year after the intervention. Mean pain and function scores improved significantly from baseline to follow up as follows: – back pain scale from 7.2 to 2.9, leg pain scale from 6.8 to 2.5 and Oswestry Disability Index from 59.1% to 22.6%. No cases of infection or worsening of neurological deficit occurred. One patient had revision surgery for persistent pain as a result of granulation tissue underneath the implant. No mechanical failure of the implants or loosening was observed and the process retained motion.

Conclusion: Clinical results are satisfactory and compare well with those obtained by conventional procedures in addition to which mobile stabilisation are less invasive then fusion. Wallis neutralisation proves to be a safe and effective in the treatment of unstable lumbar condition.

Aim: To determine the effectiveness of therapeutic lumbar facet joint injections in patients with chronic low back pain.

Methods: Eighty-six patients with refractory chronic low back pain were randomly assigned to receive facet joint injection using local anaesthetic and corticosteroid suspension under fluoroscopic guidance after clinical and radiological assessment. The main parameter for the success or failure of this treatment was the relief of the pain. Pain intensity was assessed with a visual analog scale (VAS) and changes in function and quality of life were assessed by the revised Oswestry Disability Questionnaire (ODQ) at baseline and during follow-up after injection.

Results: Patients reported lasting pain relief, better function, and improved quality of life following injection. Cumulative significant relief following injection was 91.9% up to 1 to 3 months, 81% for 4 to 6 months, 34% for 7 to 12 months, and 10% after 12 months, with a mean relief of 6.5 +/− 0.76 months. There was significant improvement noted in overall health status with improvement not only in pain relief, but also with physical, functional, and psychological status, as well as return-to-work status. No complications were noted following injection.

Conclusion: The results of this study demonstrate that intra-articular facet joint injection appear to have a beneficial medium-term effect in patients with chronic lower back pain and may therefore be a reasonable adjunct to non-operative treatment.

Background: Patients suffering from hip osteoarthritis (OA) are frequently symptomatic, and the disease can result in significant limitation of patients’ activity and high social costs. Viscosupplementation, which aims to restore physiological and rheological features of the synovial fluid, is a well-accepted therapeutic option in knee OA patients, but limited data exist in the literature about its potential benefit for the treatment of hip OA.

Aim: To evaluate the efficacy and safety of viscosupplementation (VS) with hyaluronic acid (Hylan GF 20) under fluoroscopic guidance in patients with symptomatic hip OA

Methods: Forty six patients (26 men, 20 women, mean age 56.4 years) with symptomatic hip OA were treated with one injection of 2 ml of hylan G-F 20(Synvisc) under fluoroscopic guidance which could be repeated after at least 3 months. Treatment efficacy was assessed by functional index oxford hip score, pain evaluation on a visual analogue scale and NSAID consumption. All such parameters were recorded at baseline as well as 2, 6 and 12 months after the beginning of the treatment.

Results: We observed a statistically significant reduction of all considered parameters at the timepoints 2 and 6 months, when compared to baseline. At 12 months the changes were still statistically significant for all parameters for about 50% of the patients. Three patients reported self-limited mild, local pain post-injection otherwise no systemic adverse events were observed.

Conclusion: Viscosupplementation with hylan G-F20 is feasible, easy to perform as well as safely relieves osteoarthritis hip pain, facilitates an improved activity level, decreases the need for pain medication, physiotherapy, and assistive devices.

Introduction: Ankle fractures are one of the most common injuries treated by the orthopaedic surgeon. The general recommendation is if surgical treatment is not carried out within the first 24 hours from the injury, then it should be delayed for about 5-7 days to reduce the risk of wound complications associated with limb swelling. The aim of our study was to see whether timing of surgery significantly affects the outcome or wound complications following internal fixation of displaced ankle fractures.

METHOD: We retrospectively analysed the medical records of 37 patients with ankle fractures, who were admitted to the orthopaedic department at our Hospital between May 2003 and May 2004. The fractures were classified according to Dennis-Weber classification. Open reduction and rigid internal fixation was performed according to the techniques of the Association for the Study of Internal Fixation (AO Group).

RESULTS: The mean age of the patients was 41.6 years (range 19-70). According to Denis-Weber classification 2 (6%) were type A, 26 (70%) were type B and 9 (24%) were type C fractures. The mean delay before surgery was 2.4 (0-9) days. The mean length of hospital stay was 4.6 (1-13) days. 35% of the fractures were operated between the second and fourth days after the injury without any increase in wound or fracture related complications. There were no cases of wound infection or dehiscence. Although there was one case of delayed union of medial malleolus, the overall union rate was 100%.

CONCLUSION: We conclude that for ankle fractures that are not operated on within the initial 24 hours from the injury, delayed treatment could be instituted as soon as patient and limb factors permit and rigid adherence to waiting times of 5-8 days is not necessary.

Although there have been many studies of the epidemiology of hip fractures in the older population, including the assessment of bone density and the predictive value of a Cole’s fracture in particular for later hip fracture, there has not previously been an analysis of combined presentation of hip and upper limb fractures. We performed this study to examine the incidence and risk factors of such combined injuries and to assess the impact these have on rehabilitation and subsequent treatment in order to formulate a possible clinical pathway or treatment protocol for such patients.

The study was performed retrospectively, with all patients admitted over 3 years with fractured neck of femur being reviewed. Of the 681 patients admitted over this period of time (324 intracapsular and 357 extracapsular fractured necks of femur), 22 were found to have a contemporaneous fracture of the upper limb. The associated upper limb fractures were distal radius (n=11), olecranon (n=5) and neck of humerus (n=6), with the same ratio of intracapsular to extra-capsular fractures as the whole group. The female to male ratio in both isolated hip and combined fracture groups was the same at 3:1. The mean patient age was 77.6 years for isolated hip fractures and 78.4 for the combined group. The usual mechanism of injury in both groups was a fall onto the side, but patients in the combined group also typically described having the arm outstretched for protection. The mean total length of stay in hospital for isolated hip fracture was 10.9 days and for combined fractures was 23.2 days (p< 0.05, ANOVA). Exact details were not retrievable from the nursing homes taking some of these patients, but from the data obtained there was a trend apparent for more of the combined group to require such care and for longer. In summary, it is obvious that patients sustaining combined upper limb and hip fractures can become a significant burden on already busy hospital services. These patients therefore require an even more concerted effort at rehabilitation than those patients with isolated hip fractures. We therefore now recommend the use of a specific clinical pathway or protocol including early fixation, immediate co-ordinated multidisciplinary team involvement and rehabilitation, with everyone involved with the treatment of these patients, doctors, physiotherapists, occupational therapists and others, being aware of these extra requirements. Issues for further analysis in these patients include assessing the contribution of bone density to such double fractures, the associated risk of further fractures and therefore whether such patients require further treatment or protective measures.