Background

The decision to resurface the patella during total knee arthroplasty remains controversial. Aim of our study was to evaluate the functional difference between patients undergoing medial rotation knee (MRK) replacement with and without patellar resurfacing at our hospital.

The optimal correction of the weight bearing line during High Tibial Osteotomy has not been determined. We used finite element modelling to simulate the effect that increasing opening wedge HTO has on the distribution of stress and pressure through the knee joint during normal gait.

Subject-specific models were developed by combining geometry from 7T MRI scans and applied joint loads from ground reaction forces measured during level walking. Baseline stresses and pressures on the articulating proximal tibial cartilage and menisci were calculated. Progressive osteotomies were then simulated to shift the weight-bearing line from the native alignment towards/into the lateral compartment (between 40 – 80% of medial-lateral tibial width). Changes in calculated stresses and pressures were recorded.

Both stress and pressure decreased in the medial compartment and increased in the lateral compartment as increasingly valgus osteotomies were simulated. The models demonstrated a consistent “safe zone” for weight bearing line position at 50%-65% medial-lateral tibial width, outside of which compartment stresses and pressures substantial increased.

This study suggests a safe correction zone within which a medial opening wedge HTO can be performed correcting the WBL to 55% medio-lateral width of the tibia.

Epidemiological data about tibial plateau and associated intra-articular proximal tibial fractures provides clinicians with an understanding of the range, variety, and patterns of injury. There are relatively few studies examining this injury group as a whole. We prospectively recorded all tibial plateau and intra-articular proximal tibial fractures occurring in our regional population of 545,000 adults (aged 15 years or older) in 2007–2008. We then compared our results with previous research from our institution in 2000. There were 173 fractures around the knee, 65 of these involved the tibial plateau. Median age was 59 years (IQR, 36.5–77.5 yrs). Tibial plateau fractures were more common in women (58.5%vs 41.5%). The median age of men was 37 years (IQr, 29–52 yrs) compared to women, 73 years (IQR, 57–82 yrs). Tibial plateau fractures accounted for 0.9% overall and 2.5% of lower limb fractures. Incidence was 1.2/10,000/yr (95% CI, 0.9–1.5). We have prospectively identified and described the epidemiological characteristics of tibial plateau fractures in adults from our region. We have identified a change to the epidemiology of these fractures over a relatively short time frame as the patients at risk age.

Rugby union is the second commonest cause of sporting fracture in the UK. Yet little is known about patient outcome following such fractures.

All rugby union fractures sustained during 2007–2008 in the Lothian were prospectively recorded. Patients were contacted by telephone in February 2012 to ascertain their progress in returning to rugby.

There were 145 fractures in 143 patients, including 122 upper limb and 25 lower limb fractures. 117 fractures (81%) were followed at mean 50 months (range 44–56 months). 87% returned to rugby post injury, with 85% returning to rugby at the same level or higher. 77% returned by three months and 91% by six months. In upper limb fractures 86% returned by six months and 94% by six months. In lower limb fractures 42% returned by three months and 79% by six months. 32% had ongoing fracture related problems. 9% had impaired rugby ability secondary to fractures.

Most patients sustaining a fracture playing rugby union will return to rugby at a similar level. While one third of them will have persisting symptoms post-injury, for the majority this will not impair their rugby ability.

Alcohol remains a significant cause of disease in the UK population. Yet the effect of alcohol on fractures remains conflicting. We present a prospective analysis of self-reported alcohol consumption and the epidemiology of fractures sustained.

1950 patients over 13 years of age were prospectively interviewed after sustaining a fracture with basic epidemiological data, fracture data and average alcohol consumption recorded.

1621 (83%) of interviewees provided information on alcohol consumption. 10% admitted to drinking in excess of Scottish Health guidelines. 18.1% of males drunk to excess, compared to 4.7% of females (p<0.001). The five most frequent fractures were distal radius (20%), metacarpals (12%), ankle fractures (12%), neck of femur (10%), phallanges (10%). 48% of fractures were falls from standing height. Excess drinkers were more likely to sustain an AO grade C fractures than safe drinkers (18.1% compared to 11.2%, p<0.05). Excess drinkers sustained more open fractures than safe drinkers (5% compared to 1%, p<0.001). Excess drinkers were on average 5.66 years younger than safe drinkers at the time of injury (44.57 years compared to 50.23 years, p<0.05).

People reporting alcohol excess who have sustained a fracture are more likely to be younger and suffer more severe fractures than those drinking within current guidelines. Opportune targetting of patients consuming excess alcohol should be targetted at problem drinkers sustaining a fracture.

There is increasing interest in the placement of the femoral and tibial tunnels for anterior cruciate ligament (ACL) reconstruction, with a trend towards a more anatomically accurate reconstruction. Non-anatomical reconstruction of the ACL has been suggested to be one of the major causes of osteoarthritis in the knee following ACL rupture.

Knee surgeons from an international community were invited to demonstrate their method for arthroscopic ACL tunnel placement in an ACL deficient cadaveric knee. These positions were recorded with image intensification and compared with the native ACL insertion sites, which had previously been recorded with image intensification, before the ACL had been resected.

Some clear trends were observed; the use of three tunnel placement techniques (anatomic ridges, ‘ruler method’ and use of image intensification) was associated with most accurate position of the femoral tunnel in the centre of the native ACL femoral insertion site. The choice of arthroscopy portals also affected tunnel placement.

There is considerable variation in ACL reconstruction tunnel placement amongst experienced knee surgeons. This study provides useful information as to which tunnel placement methods are associated with the most anatomically accurate ACL reconstruction.

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures. We aim to provide a contemporary analysis and compare current clavicle fracture patterns of our adult population with historical reports.

A retrospective analysis of a prospectively collected fracture database from an institution serving 598,000 was conducted. Demographic data were recorded prospectively for each patient with an acute clavicle fractures including age, gender, mode of injury, fracture classification, and the presence of associated skeletal injuries. Fractures were classified according to the Robinson system.

A total of 312 clavicle fractures were identified, occurring with an incidence of 55.9/100,000/yr (CI 49.8–62.5) and following a bimodal male and unimodal older female distribution. Sporting activity and a simple fall from standing caused the majority of injuries. More than half of simple fall fractures affected the lateral clavicle. The incidence of clavicle fractures has risen over a twenty year period, and a greater proportion of older adults are now affected. Overall, type II midshaft fractures remain the most common, but comparison of this series with historical data reveals that the epidemiology of clavicle fractures is changing.

We have identified an increase in the average patient age and overall incidence of clavicle fractures in our adult population. The incidence, relative frequency, and average patient age of type III lateral one-fifth fractures have increased. This epidemiological trend has implications for the future management of clavicle fractures in our region.

There are limited recent epidemiological data pertaining to the patterns of skeletal injury around the knee joint in adult patients. Data on fractures of the distal femur, proximal tibia and patella have been individually reported. We aimed to describe the collective epidemiological characteristics of all fractures around the knee.

We conducted a retrospective analysis of a prospectively collected fracture database from an institution serving 545,000 adults. The demographic and injury details for all patients suffering fractures of the distal femur, proximal tibia and patella were analysed. Fractures were classified according to the AO (distal femur, patella) and Schatzker (proximal tibia) systems.

A total of 173 fractures occurred in 170 patients (60% women), representing 6.7% of all lower limb fractures. There were 36 distal femoral fractures, 82 proximal tibial fractures (metaphyseal, plateau or bony avulsions) and 55 patella fractures.

Each fracture type displayed distinct epidemiological characteristics. Injuries of the distal femur occurred in older women. A proportion of tibial plateau fractures occurred in young men following high-energy trauma, but a greater number were encountered by older men and women following low-energy injury. The majority of fractures around the knee were caused by a simple fall from standing, followed by road traffic accidents, and falls from height.

When compared with historical data from our unit, the incidence of fractures around the knee has increased. The median age of affected patients has also risen, and this is particularly true for fractures of the distal femur and tibial plateau.

The epidemiological characteristics of fractures around the knee joint in our adult population are presented. Low-energy trauma in the elderly is likely to constitute an increasing proportion of knee injuries in the future, and this has implications for the provision of trauma services in our region.

Techniques for fixation of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities.

Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and AAOS Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Background

A number of studies have described the epidemiological characteristics of clavicle fractures, including two previous reports from our institution. The Robinson classification system was described in 1998, after the analysis of 1,000 clavicle fractures.

Accurate implant alignment, prolonged operative times, array pin site infection and intra-operative fracture risk with computer assisted knee arthroplasty is well documented. This study compares the accuracy and cost-effectiveness of the pre- operative MRI based Signature custom made guides (Biomet) to intra-operative computer navigation (BrainLab Knee Unlimited).

Twenty patients from a single surgeon's orthopaedic waiting list awaiting primary knee arthroplasty were identified. Patients were contacted and consented for the study and their suitability for MRI examination assessed. An MRI scan of the hip, knee and ankle was performed of the operative side following a set scanning protocol. Following MRI, patient specific femoral and tibial positioning cutting guides were manufactured. Patients then underwent arthroplasty and intra-operative computer navigation was used to measure the accuracy of the custom made, patient specific cutting guides. A cost analysis of the signature system compared with computer navigation was made.

Our provisional results show that the accuracy of the pre-operative MRI patient specific femoral and tibial positioning guides was comparable to computer navigation.

Pre-operative, patient specific implant positioning cutting guides were as accurate as computer navigation from analysis of our preliminary results. The potential advantages of the MRI based system are accurate pre-operative planning, reduced operating times and avoidance of pin site sepsis. However, further larger studies are required to examine this technique.

Distal radial volar locking plating systems (DRVLP) are increasingly used for complex fractures of the distal radius. There have been limited studies on volar locking plating systems focusing on functional outcome and complications data. The aim of this study is to assess whether the surgeon can predict which fractures will have a good or poor outcome in terms of clinical, radiological and functional outcome assessment.

Patients who sustained a distal radial fracture managed with a radial volar locking plate were identified from hospital audit data systems. Data was collected on all patients from patient notes including radiographs performed pre- and post-operatively and functional scores using the Patient Rated Wrist Evaluation score (PRWE). The study was approved by the Barwon Health Research and Ethics Advisory Committee.

In total, there were 153 patients (105 female, 48 male) from all 11 surgeons in the unit. Patients ranged in age from 17 to 91 years, average age of 53.7 years at time of injury (IQR 41-70yr). A quarter had concomitant other injuries, and 60% had type C1-C3 fractures. Most of the patients (n = 147) had the AO Synthes DRVLP, six patients had other volar locking plate systems. Twenty-seven percent of patients (n = 42) had exogenous bone graft insertion for more unstable fracture patterns. The major complication rate was 12% (18/153) with 17 cases requiring further surgery. Post-operative radiographs demonstrated no increase in ulnar variance (median 0.0mm IQR 2.0 to1.0 mm) but an increase in radial inclination by 5 deg (IQR 0-12 deg), radial length by 3.5 mm (IQR 1.0-6.3 mm) and radial tilt by 17 deg (IQR 3-32 deg) (volar angulation) compared to pre-operative radiographs, which was statistically significant (all p<0.001). Ninety percent of patients returned a PRWE form with an average follow-up of 1.16 years (IQR 0.46-2.16yr). Median score for those aged less than 50 years was 14.00 (IQR 6.00-41.50) and did not differ from those greater than 50 years (median 16.00 IQR 4.50-36.00) (p = 1.00). PRWE score across groups categorised by classification of fracture showed large variance within each category and were not significantly different: Class A median 8.00 (IQR 3.50-26.25), Class B 13.00 (IQR 6.75-34.00) and Class C 17 (IQR 5.00-38.50) (p = 0.65).

The majority of patients were female and had a type C fracture. Post-operative x-rays displayed an increase in radial inclination, length and tilt, and restoration of radial antatomy. PRWE scores were not different across age groups or classification of the fracture. This demonstrates that predictable outcomes can be achieved with volar locking plates despite fracture complexity if attention is paid to anatomical restoration of the radius, and in more unstable patterns with void support using injectable graft. Quadratus can act as an effective barrier to prominent hardware and superficial infection. Supination range may be reduced by this approach due to a tight repair, though a palmar DRUJ capsule contracture may also be an explanation.

The Osteoarthritis Hip and Knee Service (OAHKS) was introduced in 2006 and the aim of this service was to ensure early assessment and monitoring, optimise non-operative and pre-operative management, and ensure equitable access to surgical treatment. Patients were prioritised and monitored for disease deterioration using the Multi-Attribute Arthritis Prioritisation Tool (MAPT).

All patients who were referred for assessment by the OAHKS between December 2006 and April 2009 were identified. Data was collected from the OAHKS computer database, hospital patient information computer system and the Department of Health databases. Scores were identified for patients who underwent joint replacement surgery (JRS) following pre-operative MAPT. Demographic and clinical data was collected prospectively and statistically analysed. Demographic data included sex, age and ethnicity. Patient clinical data included referral source and time to initial OAHKS appointment, BMI, co-morbidities, MAPT scores, referrals to other healthcare professionals and outcome of OAHKS appointment.

In total, 768 patients (296 males and 472 females) were referred to OAHKS between December 2006 and April 2009. Patients ranged in age from 20 to 94 years with a mean age of 68.22 years at initial review. Patients referred were from 20 different ethnic backgrounds. The median time to initial appointment was 80.5 days (IQR 36.5-99 days). There were 656 (85.4%) patients referred from their GP and 89 referrals were from other sources. Eighty-nine per cent of patients (n=686) were screened for co- morbidities. Of these patients, 58% had hypertension, 20.8% had diabetes mellitus, 19.3% had ischaemic heart disease, and 19.8% had a psychosocial illness. The mean body mass index (BMI) was 32.71 (median 32.01). Only 42.3% patients had some form of conservative management modality prior to attending OAHKS. A total of 1061 referrals to other healthcare professionals were made. Physiotherapy (48.6%), hydrotherapy (40%) and dietician (16.1%) were the most common referrals. Referrals to the orthopaedic surgeon accounted for 15.7% total referrals. MAPT scores increased in 229 patients, decreased in 306 patients and were unchanged in 25 patients. From December 2006–March 2009, 269 patients had MAPT scoring assessment pre-operatively. Of those patients who had surgery 52% had TKR, 40.5% THR, 5.5% UKR and 1.85% hip resurfacing.

The OAHKS has enabled patients with osteoarthritis to be rapidly assessed leading to a reduction in outpatient waiting times. Patients suitable for JRS are prioritised according to clinical need and MAPT scores. Thus, patients with greatest clinical need have received surgery much sooner than previously.