There is ambiguity surrounding the degree of scaphoid union required to safely allow mobilization following scaphoid waist fracture. Premature mobilization could lead to refracture, but late mobilization may cause stiffness and delay return to normal function. This study aims to explore the risk of refracture at different stages of scaphoid waist fracture union in three common fracture patterns, using a novel finite element method. The most common anatomical variant of the scaphoid was modelled from a CT scan of a healthy hand and wrist using 3D Slicer freeware. This model was uploaded into COMSOL Multiphysics software to enable the application of physiological enhancements. Three common waist fracture patterns were produced following the Russe classification. Each fracture had differing stages of healing, ranging from 10% to 90% partial union, with increments of 10% union assessed. A physiological force of 100 N acting on the distal pole was applied, with the risk of refracture assessed using the Von Mises stress.Aims
Methods
The aim of this study was to compare the cost-effectiveness of surgical fixation with Kirschner (K-)wire ersus moulded casting after manipulation of a fracture of the distal radius in an operating theatre setting. An economic evaluation was conducted based on data collected from the Distal Radius Acute Fracture Fixation Trial 2 (DRAFFT2) multicentre randomized controlled trial in the UK. Resource use was collected at three, six, and 12 months post-randomization using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality-adjusted life year (QALY) gained from an NHS and personal social services perspective. Sensitivity analyses were conducted to examine the robustness of cost-effectiveness estimates, and decision uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves.Aims
Methods
Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care. Questionnaires were sent to orthopaedic waiting list patients at the start of the UK’s first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients’ health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the ‘most deprived’ cohort and level 5 the ‘least deprived’.Aims
Methods
Scaphoid waist fractures (SWF) are notable in upper limb trauma and predominantly occur in young men. Morbidities associated with SWF include fracture non-union, premature arthritis and humpback deformity. Delayed treatment and non-adherence to fracture immobilisation increases likelihood of these complications. There is evidence that men engage in negative health behaviours such as delayed help-seeking. The Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) conducted interviews in individuals who had sustained a SWF. Although SWIFFT showed multiple social determinants for the overall injury and healing experience, a key factor this novel study considers is age and sex. This study aimed to analyse interview data from young male participants in SWIFFT to help distinguish the experience of SWF in young men, through exploring the influence of masculinity. A purposive sample of 12 young male participants were selected from SWIFFT. These participants were enrolled from a possibility of 13 different centres across Britain. There were 17 semi-structured interviews produced from these participants, and this was thought to be sufficient for data saturation. These interviews were evaluated through deductive thematic analysis with an open-coding approach, with respondents’ experiences being compared against themes documented in men's health literature. The “Braun and Clarke (2006) Six Phases of Thematic Analysis” methodology was adopted to perform this.Introduction and Objective
Materials and Methods
This systematic review places a recently completed multicentre randomized controlled trial (RCT), UK FROST, in the context of existing randomized evidence for the management of primary frozen shoulder. UK FROST compared the effectiveness of pre-specified physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and arthroscopic capsular release (ACR). This review updates a 2012 review focusing on the effectiveness of MUA, ACR, hydrodilatation, and PTSI. MEDLINE, Embase, PEDro, Science Citation Index, Clinicaltrials.gov, CENTRAL, and the World Health Organization (WHO) International Clinical Trials Registry were searched up to December 2018. Reference lists of included studies were screened. No language restrictions applied. Eligible studies were RCTs comparing the effectiveness of MUA, ACR, PTSI, and hydrodilatation against each other, or supportive care or no treatment, for the management of primary frozen shoulder.Aims
Methods
COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms. A minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory.Aims
Methods
The aims of this study were to increase the diagnostic accuracy
of the analysis of synovial fluid in the differentiation of prosthetic
joint infection (PJI) by the addition of inexpensive biomarkers
such as the levels of C-reactive protein (CRP), adenosine deaminase
(ADA), alpha-2-macrogloblulin (α2M) and procalcitonin. Between January 2013 and December 2015, synovial fluid and removed
implants were requested from 143 revision total joint arthroplasties.
A total of 55 patients met inclusion criteria of the receipt of
sufficient synovial fluid, tissue samples and removed implants for
analysis. The diagnosis of PJI followed the definition from a recent International
Consensus Meeting to create two groups of patients; septic and aseptic.
Using receiver operating characteristic curves we determined the
cutoff values and diagnostic accuracy for each marker.Aims
Patients and Methods
Our goal is to increase diagnostic accuracy of synovial fluid testing in differentiating prosthetic joint infection(PJI) by more exhaustively studying simple and inexpensive biomarkers. For that purpose, we sought to determine: 1) if synovial fluid C-reactive protein(CRP), alpha-2-macrogloblulin(A2M), procalcitonin and adenosine deaminase(ADA) concentrations are different between infected and aseptic cases; 2) performance and optimal cutoff values of each marker; 3) whether any such test may help improve diagnostic performance of traditional leukocyte count. Between January/2013 and December/2015 total hip or knee arthroplasty revision cases (regardless of preoperative diagnosis) were prospectively included provided enough synovial fluid for biomarker analysis was collected and at least four tissue samples as well as the implant for sonication were gathered for microbiological study. Definitive diagnosis was classified as infection or aseptic on the basis of the recent International Consensus Meeting definition of PJI. Using receiver operating characteristic curves, we determined cutoff values as well as sensitivity and specificity for each marker.Aim
Method
The degree of displacement of a fracture of the distal radius
is an important factor which can be assessed using simple radiographic
measurements. Our aim was to investigate the reliability and reproducibility
of these measurements and to determine if they should be used clinically. A 10% sample was randomly generated from 3670 consecutive adult
patients who had presented to University Hospitals of Leicester
NHS Trust between 2007 and 2010 with a fracture of the distal radius.
Radiographs of the 367 patients were assessed by two independent
reviewers. Four measurements of displacement of the fracture were recorded
and the inter-observer correlation assessed using the intra-class
correlation coefficient.Aims
Patients and Methods
Our aim was to compare the biomechanical strength modified side-to-side repair with modified pulvertaft technique keeping overlap length, anchor points, type of suture, suture throw and amount of suture similar. In our study, we have used turkey tendons. Two investigators performed 34 repairs during one summer month. All mechanical testing was carried out using the tensile load testing machine. Variables measured were maximum load, load to first failure, modulus, load at break, mode of failure, site of failure, tensile strain, and tensile stress. The statistical comparison was carried by Levene's test and T test for means. The mean maximum load tolerated by modified side-to-side repair was 50.3N(S.D13.7) and that by modified pulvertaft 46.96N(S.D: 16.4), overall it was 48.29 N (S.D: 14.57). The tensile stress at maximum load for modified pulvertaft and modified side-to-side repair was 4.2MPa(S.D: 3.1) and 4.7 MPa (S.D: 3.8) respectively {Overall 4.3MPa(S.D: 3.5)}. The tensile stress at yield was 4.01 MPa (S.D: 3.1) and 5.5 MPa (S.D: 3.7) respectively for modified pulvertaft and modified side-to-side repair {overall 4.44 MPa (S.D: 3.45)}. The tensile strain at maximum load respectively for side-to-side and modified pulvertaft repair was 7.87%(S.D: 33.3) and 7.84%(S.D: 34.02) respectively. We found no statistical difference between 2 repairs in terms of strength, load to first failure, and maximum load to failure. The suture cut through was the commonest mode of failure. Our study uniquely compares two techniques under standard conditions, and contrary to existing evidence found no difference.
The aim of this study was to describe the measurements of range of circumduction in normal volunteers and develop summaries of the data, develop the rate and rhythm of circumduction of the wrist with the use of Biometric electrogoniometer, reproducibility, reliability and accuracy of these measures of circumduction. Forty healthy subjects with a mean age of 42.6 years were assessed with flexible biaxial electrogoniometry in standard 90° pronated position of wrist for kinematic assessment of movement in orthogonal planes. Functional range of flexion-extension, ulnar-radial deviation and circumduction was measured and analysis of the digital output produced a visual display of the results as Lissajous's figures. This also allowed measurement of the total range of circumduction as two-dimensional area under the curve measurement. The rate and rhythm of movements were mathematically calculated and displayed over the two dimensional circumduction curves. The average arc of uniplanar flexion and extension is greater than the flexion and extension component of the circumduction curve but mean uniplanar radial ulnar deviation arc is similar to the radial-ulnar deviation component of the circumduction curve. The area of circumduction and circumference of the circumduction curve was used to measure the total range of circumduction. The four quadrants for the velocity of circumduction showed that the rate was faster in the deviation components as compared to flexion and extension. Quadrant analysis showed the changes in the rhythm was less in the deviation components compared to flexion and extension. The accuracy for measuring uniplanar movements showed a standard deviation of 6°. The accuracy for measuring circumduction showed a standard deviation of 347 °° (7%). Accuracy for measuring velocity of circumduction showed a standard deviation of 17°/s. This technique was found to be accurate and reliable in measuring the rate, range and rhythm of wrist circumduction.
Both intrinsic and extrinsic hand muscles contribute to finger flexion; however there are different ways in which individuals can flex their fingers. Due to different muscle insertions, it is possible to distinguish the mechanical effect of intrinsic muscles from extrinsic muscles. The aim of this observational study was to investigate the degree to which individuals in the population rely on either their intrinsic or extrinsic hand muscles. A high frequency camera was used to record the hands of 31 healthy participants, aged between 18 to 40, while they made a fist repeatedly. The hands were placed on a horizontal plane and the video was taken from the ulnar side, aligned horizontally with the hand. The maximum vertical distance between the fingertip and the distal palmer creases (XY) was recorded using WIN analyze 3D software. Three examiners independently analysed the videos and classified them into intrinsic dominant, extrinsic dominant or a mixed pattern. A t-test was performed on the XY values for the three different categories. The XY height difference between the intrinsic and extrinsic groups were statistically significant (P=0.001). The XY of mixed and intrinsic was also statistically significant (p=0.012) but not for mixed and extrinsic (p=0.46). Assessment of time when movement starts at each individual joint showed significant difference with intrinsic predominant moving the MCPJ before IPJ and extrinsic dominant individual moving their IPJ before MCPJ. This study shows that there is a difference in hand muscle dominance between individuals. More importantly it shows that there are individuals who rely on their intrinsic hand muscles more than their extrinsic muscles.
The use of journal clubs and, more recently,
case-based discussions in order to stimulate debate among orthopaedic
surgeons lies at the heart of orthopaedic training and education. A
virtual learning environment can be used as a platform to host virtual
journal clubs and case-based discussions. This has many advantages
in the current climate of constrained time and diminishing trainee
and consultant participation in such activities. The virtual environment
model opens up participation and improves access to journal clubs
and case-based discussions, provides reusable educational content,
establishes an electronic record of participation for individuals,
makes use of multimedia material (including clinical imaging and
photographs) for discussion, and finally, allows participants to
link case-based discussions with relevant papers in the journal
club. The Leicester experience highlights the many advantages and some
of the potential difficulties in setting up such a virtual system
and provides useful guidance for those considering such a system
in their own training programme. As a result of the virtual learning
environment, trainee participation has increased and there is a
trend for increased consultant input in the virtual journal club
and case-based discussions. It is likely that the use of virtual environments will expand
to encompass newer technological approaches to personal learning
and professional development.
Scaphoid fractures with displacement have a higher incidence of nonunion and unite in a humpback position that can cause pain and reduced movement, strength and function. The aim of this study is to review the evidence available and establish the risk of nonunion associated with management of displaced scaphoid fractures in a plaster cast. Electronic databases were searched using the MeSH (Medical Subject Headings) controlled vocabulary (scaphoid fractures, AND'd with explode displaced, or explode nonunion, or explode non-healing or explode cast immobilisation, or explode plaster, or explode surgery). As no randomised or controlled studies were identified, the search was limited to observational studies based on consecutive cases with displaced scaphoid fractures treated in a plaster cast. The criterion for displacement was limited to gap or step of more than 1mm. The ‘random effects’ calculation was used to allow for the possibility that the results from the separate studies differ more than would be expected by chance.Background
Methods
This study reviewed the efficacy of a CT arthrogram in clinical decision making for wrist disorders. Sixty four consecutive CT arthrograms done in a three year period at Glenfield Hospital were selected. All patients were referred by hand consultants at the Glenfield Hospital and all investigations were performed by a single senior musculoskeletal radiologist. CT arthrograms focussed on the following areas: scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL), peripheral and central triangular fibrocartilage complex (TFCC) tears, and articular surface disorders. Referral and clinic letters for all patients were obtained. We collected patient demographic detail, prescan diagnosis and clinical plan, CT arthrogram findings, postscan diagnosis and clinical plan and the final outcome. A decision was made whether the scan helped in the clinician's management plan and if so how it helped.Aim
Methods
Brachial plexus blocks are used widely to provide intra-operative and post-operative analgesia. Their efficacy is well established, but little is known about discharging patients with a numb or weak arm. We need to quantify the risk of complications for improved informed consent. To assess whether patients can be safely discharged from hospital before the brachial plexus block has worn off and record any complications and concerns.Introduction
Objectives
