Aims

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

Purpose

To elucidate whether there is an advantage in external fixation supplementation of K-wires in comparison to K-wires and plaster, in the treatment of distal radius fractures without metaphyseal comminution.

Limited wrist arthrodesis has been shown to be an effective treatment for the degenerative and unstable wrist, abolishing pain but limiting motion. The aim of the study was to assess the effect of excision of the scaphoid and triquetrum on wrist joint range of motion, in the setting of a limited midcarpal arthrodesis. Twelve cadaveric wrists had the range of motion measured, before and after, ulnar four-corner fusion (lunate, capitate, triquetrum and hamate fusion). This was measured again following sequential scaphoid and triquetral resection.

Scaphoid excision after four-corner arthrodesis resulted in a 12 degrees increase in the radio-ulnar (R-U) arc and 10 degrees increase in the flexion-extension (F-E) arc range of motion. Subsequent excision of the triquetrum, to produce a three-corner fusion, further increased R-U arc by seven degrees and F-E arc by six degrees.

These results demonstrate that three-corner fusion with excision of scaphoid and triquetrum results in improvement in wrist motion when compared to four-corner fusion with scaphoid excision alone. From this we conclude that triquetrum excision should be considered in Scapholunate advanced collapse (SLAC) wrist reconstruction to improve residual wrist range of motion.

Symptomatic isolated scaphotrapeziotrapezoid joint arthritis affects approximately 10% of the population. Involvement of the scaphotrapeziotrapezoid (STT) joint occurs in 15–30% of all degenerate wrists. Investigation of the technique of arthroscopic debridement of this joint was undertaken to assess the symptom relief achieved and record any resulting postoperative morbidity which limits the success of other techniques used for this condition.

Ten consecutive patients with persistent symptoms were assessed prospectively by a research nurse. Measurements of range of motion and grip strength were obtained before and after surgery. Visual analogue scores for pain and satisfaction levels were also recorded and any limitation to activities of daily living was noted. Assessment included clinical examination for local tenderness over the STT joint.

Good or excellent subjective results were achieved in nine patients at final review at an average of 36 (12–65) months after arthroscopic debridement. One patient graded the result as fair due to failure to achieve normal range of motion. All patients described significant reduction in visual analogue pain scores from an average of 86.5 to 14.1 points. The Green and O’Brien wrist scores improved from a mean of 63.2 to 91.2 during the same time frame. Eight of the patients were in employment and returned to work at 3 months post-surgery without the use of any external splints. The wrist scores were maintained in the five patients reviewed at least three years post-operation.

Conclusion: Arthroscopic debridement is simple, safe and effective when compared with other treatment modalities, achieving excellent pain relief and restoration in function in the short term in patients with isolated idiopathic STT arthritis. Longer term follow-up is no doubt required.

To investigate whether radioscapholunate arthrodesis [RSLA] can provide functional wrist movement with satisfactory pain relief. 19 patients with radio-carpal arthritis underwent RSLA. There were 3 diagnostic groups [post-traumatic osteoarthritis, rheumatoid arthritis and Kienbock’s disease].

The total flexion-extension range decreased. There was a decrease in pain post-operatively. Grip strength increased in Kienbock’s but fell-in patients with osteoarthritis. 95% of patients were satisfied with their result.

The normal ‘functional’ arc is 35 degrees. Pain was reduced in all of our patients, whilst maintaining the functional arc. With only one failure and no complications, we feel the procedure is safe and reliable.

Secure fixation of displaced proximal fractures of the humerus is a challenging problem. A total of 32 patients with acutely displaced three- or four-part proximal fractures of the humerus were treated by open reduction and internal fixation using the proximal humeral internal locking system (PHILOS) plate. There were 23 women and nine men with a mean age of 59.9 years (18 to 87). Data were collected prospectively and the outcomes were assessed using the Constant score. The mean follow-up was for 11 months (3 to 24). In 31 patients (97%) the fracture united clinically and radiologically at a mean of 10 weeks (8 to 24). The mean Constant score at final review was 66.5 (30 to 92). There was no significant difference in outcome when comparing patients aged more than 60 years (18 patients) with those aged less than 60 years (14 patients) (t-test, p = 0.8443). There was one case each of nonunion, malunion and a broken screw in the elderly population.

This plate provides an alternative method of fixation for fractures of the proximal humerus. It provides a stable fixation in young patients with good-quality bone sufficient to permit early mobilisation. Failure of the screws to maintain fixation in the elderly remains a problem.

Displaced proximal humeral fractures remain a difficult management problem. There are many treatment methods described in the literature but there is no universally accepted technique.

Materials and Methods We treated 25 patients with displaced fractures of the proximal humerus by internal fixation with a locked Polarus nail at our hospital over a period of 4 years. The male: female ratio was 13:12. The average age was 63 yrs and the average follow-up in the series was 24 months. Fracture union was evaluated by regular clinical and radio graphic examination. The functional outcome was assessed by Constant’s score.

Results In 23 patients, the fracture united while one patient had failure of the proximal fixation due to collapse of the head requiring a shoulder replacement. One patient died post-operatively due to medical conditions. There were no wound infections in our series; two patients had temporary radial nerve palsy. There were three patients in which one of the proximal locking screws was missing the nail. There was backing out of proximal locking screws in four patients which required removal. One patient required removal of the nail due to impingement symptoms. There was no difference in the Constant’s score in the young and the elderly population. 75% of the patient’s were satisfied with their functional outcome.

Discussion In our limited experience, Polarus nail is an effective mechanical device for the treatment of unstable proximal humeral fractures. The proximal locking screws are often seen to back out in elderly population and they may require removal if symptomatic. This appears to be due to poor grip of screws in osteoporotic bone. In order to minimise the risk of proximal screws missing the nail we recommend the nail insertion device should be assembled by the surgeon himself before insertion into the patient and check to make sure the holes in the jig match those in the nail. In our hands we found that the entry point is very critical and we feel that it should be as medial as possible to preserve the lateral metaphysis. Our study shows that Polarus nail is an effective device to treat displaced proximal humeral fractures but the fracture communition and bone quality also plays a role in the outcome of such fractures.

Massive endoprostheses using a cemented intramedullary stem are widely used to allow early resumption of activity after surgery for tumours. The survival of the prosthesis varies with the anatomical site, the type of prosthesis and the mode of fixation. Revision surgery is required in many cases because of aseptic loosening. Insertion of a second cemented endoprosthesis may be difficult because of the poor quality of the remaining bone, and loosening recurs quickly.

We describe a series of 14 patients with triplate fixation in difficult revision or joint-sparing tumour surgery with a minimum follow-up of four years. The triplate design incorporated well within a remodelled cortex to achieve osseomechanical integration with all patients regaining their original level of function within five months.

Our preliminary results suggest that this technique may provide an easy, biomechanically friendly alternative to insertion of a further device with an intramedullary stem, which has a shorter lifespan in revision or joint-sparing tumour surgery. A short segment of bone remaining after resection of a tumour will not accept an intramedullary stem, but may be soundly fixed using this method.

Intraosseous ganglia are typically found in the epiphyses of long bones with the two most common locations being the femoral head and medial malleolus. Almost a fifth of cases reported are found in the carpal bones where the ganglion may be an infrequent cause of chronic wrist pain. Persistence and severity of symptoms rather than radiological findings determine the need for further management. Curettage and bone grafting has been performed for patients with constant symptoms that have severely restricted occupational or recreational activities. Clinically the patients improve but in up to forty percent symptoms persist affecting function.

The authors describe an arthroscopic assisted technique of debridement and bone graft used to treat eight patients with intraosseous ganglions of the lunate. All patients returned to work within four months with significant improvement in function and substantial reductions in pain scores. The modified Green scores increased 33.8 points from 51.2 to 85.0 points (p=0.03) by one year postoperatively. Radiographic analysis showed trabeculation within the lunate at an average of 13.8 months following surgery.

The technique is safe, with minimal morbidity and no re-operations.

Massive cemented endoprosthesis are used to enable early resumption of activity after tumour surgery. The longevity of the prosthesis varies with anatomical site, pros-thesis type, and mode of þxation. Revision surgery will be required in approximately 50% of cases of endopros-thetic replacements around the knee by 10 years because of aseptic loosening. Insertion of a second cemented endoprosthesis is a challenge because of the poor quality of the remaining bone and loosening recurs quickly. The use of extracortical plate þxation in joint sparing surgery where the remaining bone after tumour resection will not accept an intramedullary stem is also described.

The þrst series of 14 patients with extracortical plate þxation in difþcult revision or joint-sparing tumour surgery with a mean follow-up of 5 years are described. The three-plate design incorporates well within a remodelled cortex to achieve osseomechanical integration with all patients regaining their premorbid level of function within 5 months. At 5 years the Enneking scores averaged 27.3.

One revision was required in a femoral replacement because of loosening. It was possible to insert a new endo-prosthesis as the intramedullary bone had reconstituted.

The preliminary results suggest that this technique may provide an easy, biomechanically friendly alternative to a device with an intramedullary stem, which has a shorter lifespan in revision tumour surgery.

MRI is a well-tolerated, short procedure that would provide an early, accurate and cost effective diagnosis in elderly patients with negative plain films and persistent post-traumatic hip pain, thereby facilitating their correct management.

It is 100% sensitive and specific to occult hip fractures and does not involve ionising radiation.

Fractured necks of femur in the elderly population are common. This group of patients are responsible for a significant proportion of health care costs and efforts today. The diagnosis of hip fractures is not always clear-cut and plain radiographs may not show an undisplaced fracture. The management of this patient group is dependant upon the correct diagnosis via imaging and treatment decisions are based on these findings. If these fractures are missed, there is a significant chance of displacement and avascular necrosis presenting at a later date. This would complicate matters and result in more complex surgery. This also increases health care costs due to an extra admission, more expensive and difficult surgery with longer rehabilitation and after care. In our study, the management of the patients reviewed was significantly altered due to the imaging process used.

We performed MRI scans on thirty-six patients who had post-traumatic hip pain and negative plain radiographs (reported as normal or equivocal). Twenty-three (64%) of the patients sustained a fracture, of which sixteen (44%) involved the neck of the femur, all of whom were above the age of 71 years. 100% of the elderly age group scanned were positive for a femoral neck fracture and eleven (31%) received operative intervention. The five patients who did not undergo operative management were deemed too unwell for surgery. Only three patients’ scans were negative.

These results confirm that MRI (in the 71 years and above age group), is indicated in order to diagnose an undisplaced fractured neck of femur not recognised on plain radiographs, which requires operative intervention in the form of dynamic hip screw or cannulated hip screws to prevent further deterioration or displacement.

Skeletal tuberculosis is an indolent disease whose diagnosis is often delayed. Evidence of pulmonary tuberculosis is present in less than 50% of cases. We present our experience from a small inner city district hospital of the difficulties managing patients with skeletal tuberculosis.

During the period 1988 to 1998 a total of 38 patients with tuberculous osteomyelitis confirmed microbiologically by tissue culture or histologically on material gained at biopsy presented to our inner city hospital serving 250 000 patients.

Two groups of patients were identified in our series. There was an acute group that tended to affect the appendicular skeleton and who responded to local treatment plus chemotherapy with restoration of normal function. In contrast the second group, who were difficult to diagnose, had axial skeleton involvement, deteriorated before treatment and had a poor outcome despite treatment. Failure of admitting medical teams to examine the axial skeleton in their confused patients led to a delay in diagnosis of skeletal tuberculosis in this second group with profound consequences.

All health professionals will be encountering skeletal tuberculosis more frequently with the recent resurgence of pulmonary tuberculosis. They may have little experience with the management of this condition and may overlook the diagnosis with consequent catastrophic results. A high index of suspicion is required for prompt diagnosis with early referral to an orthopaedic surgeon improving outcome.

Survival in the wake of hindquarter amputation and oncological treatment is improving; the hindquarter amputee population is increasing. Some amputees function well others do not.

To assess quality of life and function of hindquarter amputees.

21 amputees (10 females and 11 males) consented to take part in the study. Ethics approval was sought. Assessment was performed using postal questionnaires; SF36 for quality of life; TESS (Toronto Extremity Salvage Score) for physical function and mobility; IEFF( International Index for Erectile Function) for male sexual function; a prosthetics questionnaire to assess prosthetic use.

Mean age of the group was 55 with the mean survival of 7 years post amputation.

Quality of life results were compared to normal subjects and patients for long tern illness. Amputees had a significant reduction in quality of life concerning physical function and pain. Social function, mental health and energy levels were equivalent to patients with long term illness.

The mean TESS result was 56.9 with females having a mean score of 61.7 and male of 48. 50% of the group considered themselves as severely to completely disabled; 50% considered themselves moderately disabled. Five were in full time employment.

Six males responded to the sexual function questionnaire. Impotence was universally experienced.

Only five amputees used their prosthesis regularly. All amputees have experienced and 20 continue to experience phantom pain.

This study illustrates that hindquarter amputees have poor physical function and a low quality of life. Phantom pain is universally experienced. Male amputees experience impotence. Addressing these areas would improve the life of current and future hindquarter amputees.

Fractures of the anterior intercondylar eminence in children are relatively uncommon. There is considerable debate as to the best treatment of displaced fractures, but most methods described in the literature involve an open procedure combined with some form of fixation. Using human anatomical dissections, we have shown that the transverse meniscal ligament can become incarcerated within the fracture and act as a block to reduction. We describe an arthroscopic technique which requires no fixation device and report the results of its use in eight displaced fractures. This method gives reliable results and offers the advantage of less potential morbidity.