Aims

Although infrequent, a fracture of the cuboid can lead to significant disruption of the integrity of the midfoot and its function. The purpose of this study was to classify the pattern of fractures of the cuboid, relate them to the mechanism of injury and suggest methods of managing them.

Introduction:

Failure to adequately treat an injury of the syndesmosis leads to poor functional outcomes and posttraumatic arthritis. Many techniques have been proposed to salvage chronic instability. We report on the largest series of chronic syndesmotic injuries to be managed by syndesmotic arthrodesis from Europe to date.

Introduction

Isolated trochlea fractures are very rare and have only been described previously as case reports.

Introduction

In January 2000, the Bone and Joint Decade was formally launched at the headquarters of the World Health Organization in Geneva, Switzerland. The goal was “to improve the health-related quality of life for people with musculoskeletal disorders throughout the world”. They aimed to do this, in part, by “raising awareness of the growing burden of musculoskeletal disorders on society”. The Bone and Joint Decade has 63 supporting governments, over 700 supporting government and non-government organisations and a budget in the millions. It was the largest musculoskeletal health promotion campaign in history.

Purpose

To determine, for the first time, how back pain is portrayed in the United Kingdom press.

Introduction: The Foundation Programme was implemented across the United Kingdom in 2005 and aims to “bridge the gap between medical school and specialty/general practice training.” Musculoskeletal complaints are the single most common reason for patients seeking medical attention and it is imperative that all clinicians should have at least a basic competency in musculoskeletal medicine.

Aim: To determine if Foundation Programmes give junior doctors sufficient training to deal competently with musculoskeletal complaints.

Methods: We prospectively enrolled junior doctors at the completion of their Foundation Programme. They were assessed using the Freedman and Bernstein musculoskeletal examination tool- the only validated method of assessing musculoskeletal medicine knowledge currently available. Passing this test only implies a basic level of competence in musculoskeletal medicine.

Results: We recruited 112 junior doctors from across the United Kingdom. Only 8.9% of those recruited passed the assessment. Significantly higher mean scores were obtained by those with Foundation Programme exposure to Orthopaedics- 62% vs. 51.6% (p=0.005), an interest in Orthopaedics as a career- 64.8% vs. 52.8% (p=0.026) and those who felt that they had gained adequate Foundation Programme exposure to musculoskeletal medicine- 64% vs. 51.6% (p=0.0014). Those who were interested in General Practice obtained significantly lower scores than the rest of the group- 48.4% vs. 55.6% (p=0.009).

Orthopaedics, internal medicine and general practice were the future specialty interest of 6%, 29% and 36% respectively. Only 15% had any Foundation Programme exposure to Orthopaedics and only 13% felt they had been given adequate exposure to musculoskeletal medicine.

Conclusions: Foundation Programmes are currently failing to ensure junior doctors entering specialty training have a basic competence in musculoskeletal medicine. Given the high prevalence of musculoskeletal conditions encountered by most clinicians this is unacceptable and steps must be taken to improve the quality of Foundation Programme training in musculoskeletal medicine.

This paper could not be resubmitted: The paper was initially presented at the BHS and they have already published it in the JBJS Supplement.

Introduction: Osteoporotic fracture care is on the increase in healthcare systems worldwide. In the UK the British Orthopaedic Association (BOA) recommends all patients > 60 presenting with fragility fracture (FF) should be evaluated for osteoporosis by axial Dual Energy X-ray Absortiometry (DEXA) scan. All patients < 60 should be assessed for osteoporosis risk factors and DEXA scanned if present. The National Institute for Clinical Excellence (NICE) recommends all woman > 75 with FF should be prescribed secondary prevention bisphosphonates for osteoporosis 1st line without the need for DEXA scan.

Aim: To evaluate how often patients with FF were appropriately managed in fracture clinic using BOA and NICE guidelines for the secondary prevention of FF.

Methods: and Results: Over a two month period 18 of 184 new patients admitted to fracture clinic were identified as having FF (16 females, 2 males with age ranges 61–89). They were followed up over six months. According to BOA and NICE guidelines only 33% (6 of 18 patients) and 42% (3 of 7 > 75’s) respectively were appropriately managed for secondary prevention.

Following this a FF prevention strategy was implemented. This consisted of fracture clinic infrastructure changes, a staff awareness teaching programme and the assignment of an osteoporosis nurse specialist.

A re-audit six months later identified 16 of 175 new patients as having FF. According to BOA and NICE guidelines 88% (14 of 16 patients) and 75% (6 of 8 > 75’s) respectively were appropriately managed for secondary prevention. Fisher’s Exact Test showed a significant improvement in secondary prevention management according to BOA guidelines (p< 0.05), but not NICE guidelines (p=0.2), as a consequence of these interventions.

Conclusion: Osteoporosis is an important cause of fracture in elderly patients. Changes to fracture clinic infrastructure, educational teaching initiatives and osteoporotic nurse specialists can improve uptake of secondary prevention measures in fracture clinic aimed at reducing risk of future fragility fractures in elderly patients.

Introduction: MRSA spondylodiscitis is an increasingly common phenomenon. Despite this there is very little reported on it.

Objectives: Our objective was to present relevant demographics, clinical presentations and outcomes for this condition from our institution.

Methods: We performed a retrospective review of patients presenting over a six year period from 2000 to 2005.

Results: 13 cases were identified. The mean age was 65 years (range 36–92), 85% were male. All cases presented with back pain, spinal tenderness and systemic upset. Neurological deficit was present initially in 38% and a further 8% developed neurological deterioration during treatment. The thoracic spine (53%) was most commonly affected followed by the lumbar (33%), thoracolumbar junction (7%) and cervical spine (7%); 16% of cases were multilevel. The WCC, ESR and CRP were elevated in all cases with means of 17.3 ×10-9/L, 102 mm/hr and 236 mg/L respectively. In cases cured of infection, the WCC, ESR and CRP normalised at a mean of 10 weeks, 14 weeks and 19 weeks respectively. Radiological diagnosis was established with MRI in all cases. The most common risk factors were diabetes mellitus (62%), mal-nourishment (54%), cirrhosis (31%), end stage renal failure (15%) and intravenous drug use (15%). Multiple risk factors were present in 76% of cases and 15% had no identifiable risk factors. The main sources of sepsis were intravenous catheters (23%), urinary tract (15%) and intravenous drug use (15%). In cases cured of infection treatment consisted of intravenous vancomycin mono-therapy for a mean period of four weeks followed by oral combination or monotherapy antimicrobials for a mean period of 8 weeks. Operative intervention was required in 38% of cases. At six months 54% of cases were clinically free of infection, 38% had died and 8% required ongoing treatment. Neurological deficit was present in 50% of survivors. At one year 29% of survivors suffered from MRSA bacteraemia and spondylodiscitis recurrence.

Conclusion: This is a devastating condition. Clinical suspicion should remain high and prompt diagnosis and treatment is essential.

Introduction: Septic arthritis of the hip is an Orthopaedic emergency. While common in the paediatric population, it is rare in adults and little is reported on it.

Methods: Retrospective review of cases presenting to Leeds General Infirmary, St James’s University Hospital & York District Hospital over a fourteen year period from 1991–2005.

Results: 46 cases identified. The mean age was 43 years and 80% (37/46) of cases were male. Risk factors for sepsis were present in 87% (40/46) and consisted of IVDU in 48% (22/46), DM in 20% (9/46), liver disease in 22% (10/46) and immunosuppressive drugs in 17% (8/46). Rheumatic joint disease was present in 28% (13/46) consisting of rheumatoid arthritis, gout and psoriatic arthropathy in 13% (6/46), 9% (4/46) and 7% (3/46) respectively. The primary sources of sepsis were IVDU in 48% (22/46), unknown in 39% (18/46), line sepsis in 11% (5/46) and psoas abscess in 2% (1/46). All cases presented with the triad of groin pain, constitutional upset and difficulty or inability to weight bear. Examination revealed pyrexia in 57% (26/46) and a painfully decreased range of joint motion in all cases. Laboratory tests revealed a raised white cell count in 57% (34/46) and raised CRP’s and ESR’s in all cases. The most commonly isolated organism was staphylococcus aureus 78% (36/46). Medical treatment consisted of antimicrobial therapy for a mean length of 49 days. Surgical treatment consisted of a mean of 1.8 arthrotomies or arthroscopic hip washouts and debridements in consenting cases- 89% (41/46). Two stage total hip arthroplasty for symptom control was required in 4% (2/46). Outcomes were good with sepsis related mortality of 4% (2/46) and local recurrence of 9% (4/44).

Discussion: Septic arthritis of the hip is a potentially serious condition. Timely medical and surgical intervention can lead to good outcomes.