Aims

As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency.

Aims

The diagnosis of joint infections is an inexact science using combinations of blood inflammatory markers and microscopy, culture, and sensitivity of synovial fluid (SF). There is potential for small molecule metabolites in infected SF to act as infection markers that could improve accuracy and speed of detection. The objective of this study was to use nuclear magnetic resonance (NMR) spectroscopy to identify small molecule differences between infected and noninfected human SF.

Aims

Metabolic profiling is a top-down method of analysis looking at metabolites, which are the intermediate or end products of various cellular pathways. Our primary objective was to perform a systematic review of the published literature to identify metabolites in human synovial fluid (HSF), which have been categorized by metabolic profiling techniques. A secondary objective was to identify any metabolites that may represent potential biomarkers of orthopaedic disease processes.

Objectives

Bisphosphonates (BP) are the first-line treatment for preventing fragility fractures. However, concern regarding their efficacy is growing because bisphosphonate is associated with over-suppression of remodelling and accumulation of microcracks. While dual-energy X-ray absorptiometry (DXA) scanning may show a gain in bone density, the impact of this class of drug on mechanical properties remains unclear. We therefore sought to quantify the mechanical strength of bone treated with BP (oral alendronate), and correlate data with the microarchitecture and density of microcracks in comparison with untreated controls.

Aims

The management of open lower limb fractures in the United Kingdom has evolved over the last ten years with the introduction of major trauma networks (MTNs), the publication of standards of care and the wide acceptance of a combined orthopaedic and plastic surgical approach to management. The aims of this study were to report recent changes in outcome of open tibial fractures following the implementation of these changes.

Introduction

Different techniques for fixation of lateral malleolus have been described. We report our results of using fibula rod for unstable ankle fractures in level one major trauma centre.

Background

Injury to the ACL is a significant problem and can cause further damage to the internal structures of the knee. ACL injury is associated with injuries to other structures in the knee such as the meniscus and chondral cartilage. Such intra articular injuries pre-dispose the knee to develop arthritis. This injury is usually seen in young and active people usually related to sporting injuries. There is a paucity of literature on the influence of anthropometric features on the hamstring graft obtained in ACL reconstruction, although there are studies on the sex based differences affecting the hamstring graft. This study was undertaken to assess the influence of anthropometric measurements on the graft thickness obtained at ACL reconstruction surgery within the UK population.

Unicompartmental knee replacements (UKRs) have inconsistent and variable survivorships reported in the literature. It has been suggested that many are revised for ongoing pain with no other mode of failure identified. Using a medial UKR with an all-polyethylene non-congruent tibial component from 2004–7, we noted a revision rate of 9/98 cases (9.2%) at a mean of 39 months. Subchondral sclerosis was noted under the tibial component in 3/9 revisions with well fixed implants, and the aim of this study was to investigate this as a mode of failure. 89 UKRs in 77 patients were investigated radiographically (at mean 50 months) and with SF-12 and Oxford Knee scores at mean follow up 55 months. Subjectively 23/89 cases (25%) had sclerosis under the tibial component. We describe a method of quantifying this sclerosis as a greyscale ratio (GSR), which was significantly correlated with presence/absence of sclerosis (p<0.001). Significant predictors of elevated GSR (increasing sclerosis) were female sex (p<0.001) and elevated BMI (P=0.010) on both univariate and multivariate analysis. In turn, elevated GSR was significantly associated with poorer improvement in OKS (p<0.05) at the time of final follow up. We hypothesise that this sclerosis results from repetitive microfracture and adaptive remodelling in the proximal tibia due to increased strain. Finite element analysis is required to investigate this further, but we suggest caution should be employed when considering all polyethylene UKR implants in older women and in those with BMI >35.

Purpose

The aim of the present study was to investigate the relationship between generalised ligament laxity and requirement for revision ACL reconstruction.

Purpose

The aim of the present study was to look at survivorship and patient satisfaction of a fixed bearing unicompartmental knee arthroplasty with an all-polyethylene tibial component.

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.

This study was undertaken to assess the influence of anthropometric measurements on the graft thickness obtained at anterior cruciate ligament reconstruction surgery.

Data from fifty one consecutive patients who had undergone ACL reconstruction by the same surgeon using double loop hamstring grafts were analysed. The body mass index, height and weight of these patients were correlated with the graft thickness obtained during surgery using non parametric tests (Spearman’s correlating coefficient).

There was a statistically significant positive correlation between the body weight and graft thickness (r = 0.32, p=0.02, n= 51). There was however, no correlation between the body mass index and height with the graft thickness.

Anthropometric measurements do not have as much influence on the thickness of the graft as would have been assumed, in ACL reconstruction surgery. Although the body weight has a positive correlation, the body mass index and height do not seem to have any appreciable influence on graft thickness.

Aim: 1. To assess the role of the CT scan in management of intra-articular fractures of the calcaneum. 2. Does the scan makes any difference to the management decision, obtained from assessing the plain radiograph?.

Methodology: This study involved 24 patients with intra-articular fracture of the calcaneum who had both a plain radiograph and a CT scan as a part of their assessment. Three consultants who were blinded to the actual management and names of the subjects were independently asked to grade the radiographs and CT scans, as operative or non-operative, on different occasions. The data was matched to the actual management and was subjected to statistical analysis.

Results: The data was non-parametric and related. The SIGN test was used to analyse the agreement between the three observers and if the decisions made in each of the groups were significantly different from the actual management. There was no statistically significant difference, between the management decision from the radiographs or CT and the actual management.

The change in management that the CT scan brought about was also assessed for each of the observers using the McNemars test. The CT scan did not make any significant difference to the decision made based on the plain radiographs, on whether to operate or not.

A Cochran Q test used to assess the variability of the decisions, showed that there was more inter-observer variability in decision making, using the CT based assessment (Q=9.50, p=0.009) as compared to plain radiographs (Q=3.84, p=0.14).

Conclusion: We conclude that, the CT scan should only be requested when a decision is made to operate on the fracture, based on plain radiographs. This may help with pre-operative planning of fracture fixation. It does not have to be obtained as a routine to assess all intra-articular fractures of the calcaneum.

Purpose of the study: To determine usefulness of skyline x-ray in diagnosis of patellofemoral osteoarthritis.

Materials and Methods: 50 patients scheduled to undergo knee surgery, had standard antero-posterior, lateral and skyline x-rays of their affected knee. At operation, their patellofemoral joints were graded into two groups according to presence or absence of osteoarthritis. Their lateral and skyline x-rays were also graded into the same two groups, according to presence or absence of patellofemoral osteoarthritis. The two x-ray views were then compared individually against operative findings.

Results: The skyline view had sensitivity of 79% (95% confidence intervals (C.I.) 66% to 93%) and specificity of 80% (95% C.I. 62% to 98%). The lateral view had sensitivity of 82% (95% C.I. 69% to 95%) and specificity of 65% (95% C.I. 44% to 86%).

Conclusion: There was no statistically significant difference between the two x-ray views in terms of sensitivity and specificity in the diagnosis of patellofemoral osteoarthritis of the knee joint. Hence, we cannot recommend the skyline view as a routine radiological investigation in all cases of suspected patellofemoral osteoarthritis.

Purpose: To analyse preliminary outcomes of a new synthetic ligament used for reconstructing coraco-clavicular ligament in acromio-clavicular joint disruption.

Methods: Patients who underwent acromio-clavicular joint stabilisation using Nottingham Surgilig were followed up at average of 40 months (range 6–80 months) post operation. Apart from clinical and radiological assessment, the Constant-Murley scoring system and the Imatani scores were also used to measure outcome.

Results: Twenty patients underwent this operation and data was available on 19 of them. These patients had their operation after an average of 18 months following injury, during which period they had conservative treatment, except in 2 cases where a Weaver Dunn operation was performed initially.

The mean Constant score was 88 (s.d. 12). The mean Imatani score was 86 (s.d. 16). Most patients were satisfied with the operation (90%). There was one case of rupture through the central portion of the Surgilig, and following extensive laboratory analysis, the ligament has been modified since. One patient had a fracture of his coracoid while lifting heavy weights. In 4 patients there was clinical and radiological evidence of loosening of the screw but only 1 complained of this being a problem.

Conclusion: This is an initial medium term outcome analysis of the Nottingham Surgilig. Our results are promising and justify further use and evaluation of this relatively new technique.

Our study was undertaken to assess the inter- and intra-observer variability of the classification system of Sanders for calcaneal fractures. Five consultant orthopaedic surgeons with different subspecialty interests classified CT scans of 28 calcaneal fractures using this classification system. After six months, they reclassified the scans.

Kappa statistics were used to analyse the two groups. The interobserver variability of the classification system was 0.32 (95% confidence interval (CI) 0.26 to 0.38). The subclasses were then combined and assessment of agreement between the general classes as a whole gave a kappa value of 0.33 (95% CI 0.25 to 0.41). The mean kappa value for intra-observer variability of the classification system was 0.42 (95% CI 0.22 to 0.62). When the subclasses were combined, it was 0.45 (95% CI 0.21 to 0.65).

Our results show that, despite its popularity, the classification system of Sanders has only fair agreement among users.