The recruitment drive, investment and collaboration within Betsi Cadwaladr University Health Board (BCUHB) sites providing specialist lower limb arthroplasty and trauma service has evolved over last few years with aims to improve patient care and reduce reliance on tertiary referral centres. Through our service-evaluation project, we reviewed the results of treatment provided for periprosthetic femur fractures (PPFFs) presenting to BCUHB sites over last 4 years.

We retrospectively reviewed consecutive PPFFs admitted at three BCUHB sites from January’20 to June’23 with mean follow-up of 20.8 ± 13.2 (8–49) months [n=161; Mean age: 82.2 ± 8.5 (59–101) years, Females:107]. Over the review period we noted a 23% increase in service demand for care of PPFFs. Majority were managed surgically [132/161] [38 revision arthroplasties; 94 ORIFs] at BCUHB sites and two patients were referred to tertiary centre. Average time to surgery was 3.5 days. 90% of the PPFFs were managed successfully with 10% (16/159) having orthopaedic complications needing further intervention. 6.3 (10/159) had medical complications and did not need orthopaedic re-intervention. In our series, 12-month re-operation rate was 6.1% (8/132) and 1-month, 3-month and 1-year mortality rate was 6.3%, 11.3% and 21.4% respectively. These results are comparable to the published results of PPFF management at tertiary centres. Potential cost savings compared to transfer to tertiary centre for PPFF management was £2.31 million. Thus, it is possible to successfully provide adequate care for PPFFs at DGHs and efforts should be made to appropriately equip and adequately staff DGHs, to provide service for local PPFF care.

Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

In adults with brachial plexus injuries, lack of active external rotation at the shoulder is one of the most common residual deficits, significantly compromising upper limb function. There is a paucity of evidence to address this complex issue. We present our experience of isolated latissimus dorsi (LD) muscle transfer to achieve active external rotation. This is a retrospective review of 24 adult post-traumatic plexopathy patients who underwent isolated latissimus dorsi muscle transfer to restore external rotation of the shoulder between 1997 and 2010. All patients were male with a mean age of 34 years (21 to 57). All the patients underwent isolated LD muscle transfer using a standard technique to correct external rotational deficit. Outcome was assessed for improvement in active external rotation, arc of movement, muscle strength and return to work. The mean improvement in active external rotation from neutral was 24° (10° to 50°). The mean increase in arc of rotation was 52° (38° to 55°). Mean power of the external rotators was 3.5 Medical Research Council (MRC) grades (2 to 5).

A total of 21 patients (88%) were back in work by the time of last follow up. Of these, 13 had returned to their pre-injury occupation. Isolated latissimus dorsi muscle transfer provides a simple and reliable method of restoring useful active external rotation in adults with brachial plexus injuries with internal rotational deformity.

Cite this article: Bone Joint J 2013;95-B:660–3.

INTRODUCTION

Uncemented total hip replacement is on the rise worldwide. Latest studies from various European and other developed country joint registers are clearly showing that it is taking preference over the cemented joint replacements. These figures were discussed most recently at the London hip meeting. Our study is related to one single make of implant the Exceed hip (Biomet) at two hospitals in Northamptonshire, Kettering UK.

We present our experience of managing patients with iatropathic brachial plexus injury after delayed fixation of a fracture of the clavicle. It is a retrospective cohort study of patients treated at our peripheral nerve injury unit and a single illustrative case report. We identified 21 patients in whom a brachial plexus injury occurred as a direct consequence of fixation of a fracture of the clavicle between September 2000 and September 2011.

The predominant injury involved the C5/C6 nerves, upper trunk, lateral cord and the suprascapular nerve. In all patients, the injured nerve was found to be tethered to the under surface of the clavicle by scar tissue at the site of the fracture and was usually associated with pathognomonic neuropathic pain and paralysis.

Delayed fixation of a fracture of the clavicle, especially between two and four weeks after injury, can result in iatropathic brachial plexus injury. The risk can be reduced by thorough release of the tissues from the inferior surface of the clavicle before mobilisation of the fracture fragments. If features of nerve damage appear post-operatively urgent specialist referral is recommended.

Cite this article: Bone Joint J 2013;95-B:106–10.

Introduction

A 68 year old female patient underwent a left total hip replacement for primary osteoarthritis in March 2004. She was referred back by her GP 5 years as she was struggling with mobility and felt there were mice in her hip. It was squeking so loudly that it could be hear at a distance of 25 metres. There was no history of any falls or dislocation in the last 5 years. The implant used was an Exeter/ABG ceramic total hip prosthesis with Palacos cement. This ladies discomfort in her hip had been always there. She never described herself as being satisfied with the THR. However, her discomfort had worsened terribly over the last year.

Introduction

Revision surgery is generally recommended for recurrent dislocation following Total hip arthroplasty (THA). However, dislocation following revision THA continues to remain a problem with further dislocation rates upto 28% quoted in literature.

We present early results of one of the largest series in U.K. using dual mobility cemented acetabular cup for recurrent hip dislocation.

Introduction

We propose that Total Hip Replacement with correction of fixed flexion deformity of the hip and exaggerated lumbar lordosis will result in relief of symptoms from spinal stenosis, possibly avoiding a spinal surgery. A sequence of patients with this dual pathology has been assessed to examine this and suggest a possible management algorithm.

There is a difference of opinion regarding the usefulness of MR Imaging as a diagnostic tool for triangular fibrocartilage complex (TFCC) tears in the wrist. Our aim was to determine the accuracy of direct magnetic resonance arthrography (MRA) in the diagnosis of triangular fibrocartilage complex (TFCC) tears of the wrist in a district general hospital setting.

In a retrospective review of 21 patients who presented with complains of wrist pain and following a clinical examination, all had direct MR arthrography of the wrist in our hospital in a 1.5Tesla scanner. All had a diagnostic arthroscopy within 2-4 months of the MR scan. All patients had chronic ulnar sided wrist pain, although only two had a definite history of trauma. The findings of each diagnostic method were compared, with arthroscopy considered the gold standard.

Twenty-one patients were studied (10 male: 11 female), mean age 42 years (range 27-71) years). Seventeen TFCC tears were diagnosed on arthroscopy. For the diagnosis of TFCC tears MRA had a sensitivity, specificity and accuracy of 67%.

Our results echoed the opinion of some of the previous investigators with an unacceptable sensitivity or specificity for a diagnostic tool. MR arthrography needs to be further refined as a technique before it can be considered to be accurate enough to replace wrist arthroscopy for the diagnosis of TFCC tears. Other centres have reported better accuracy, using more advanced MRI technology. Until this iswidely available at all levels of healthcare the results of MRI for the diagnosis of TFCC tears should be interpreted with caution.

Introduction

Elective Orthopaedics has been targeted by the UK Department of Health as a maximum six-month waiting time for operations could not be met. The National Orthopaedic Project was initiated as a consequence and Independent Sector Treatment Centres (ISTCs) and well established private hospitals were utilised to treat NHS long wait patients.

Both acute and chronic hamstring injuries are disabling injuries, and occur almost entirely to elite athletes. We report our experience in the management of injuries of this location. Twenty seven patients (29 injuries) were included in the present study. They completed a questionnaire detailing their pre-injury activity, injury mechanism, rehabilitation and a subjective assessment of their recovery. At clinical examination pain and hip motion were evaluated.

Hamstring injuries predominantly affect males on the left side. Most procedures carried out were explorations with limited debridement and suture of the tendon. One third of patients felt they had returned to 100% of their pre-injury level, and 33% felt they had returned to 80–90% of their pre-injury level, the rest varied between < 20–80%. 45% gave a value of zero on the visual analogue pain scale independent of activity, those who gave a value above this had pain during active sports but not at rest.

Early repair leads to a much better recovery of muscle function, especially when dealing with complete avulsions. Lesions to the origin of the hamstring can be successfully managed if a high suspicion for the condition exerted.

We aimed to audit the results of one stop fragility fracture risk assessment service at fracture clinic for non-hip fractures in 50–75 years old patients at Newcastle General Hospital. Currently, fewer than 30% of patients with fragility fractures benefit from secondary prevention in the form of comprehensive risk assessment and bone protection because of multifactorial reasons. We have a fragility fracture risk assessment service staffed by an Osteoporosis Specialist Nurse equipped with a DEXA scanner located at the fracture clinic itself.

We carried out a retrospective audit of 349 patients of 50–75 years with suspected non-hip fractures referred from A& E Department from October 2006 to September 2007. Patients over 75 years were excluded because as per NICE guidelines, they should receive bone protection without need of a DEXA scan.

Out of these 349 patients with suspected fractures, 171 had fragility fractures. Median age was 64 years. 69 patients had humerus fracture, 65 had forearm fracture and 23 patients had ankle fracture and 14 had metatarsal fractures. Fracture risk assessment was carried out in 120 (70%) patients. Thirty Seven (31%) patients had osteoporosis and bone protection was recommended to GP. 38 (32%) had osteopenia and lifestyle advice was provided. 45 (37%) had normal axial bone densitometry. 90% patients had DEXA scan at the same time of fracture clinic appointment. Patients with male gender, undisplaced fracture and fewer fracture clinic appointments were more likely to miss fracture risk assessment.

Our experience suggests that locating fragility fracture risk assessment service co-ordinated by an Osteoporosis Specialist Nurse at fracture clinic is an efficient way of providing secondary prevention for patients with fragility fractures. This can improve team communication, eliminate delay and improve patient compliance because of ‘One Stop Shop’ service at the time of fracture clinic appointment.

Purpose: To present results of a series of patients treated with Trapeziectomy, Ligament Reconstruction and Tendon Interposition for treatment of 1st CMC joint arthritis.

Methods: 59 patients (65 thumbs) from Single surgeons’ practice were prospectively followed by 2 independent observers who did not participate in the study. Patient demographics, occupation, handedness, symptoms and clinical findings were recorded. Objective assessment including pinch and grip strength was carried out by the Occupational therapists. Functional outcome assessment was done using questionnaire designed by senior author. Patients were asked to evaluate the operation using the subjective assessment component of Buck-Gramcko score. Radiographs were studied for Trapezial space and arthroplasty space. Analysis was carried out using SPSS statistical software.

Results: A total of 59 patients at an average age of 62 years were followed up for an average of 25 months. Six patients had bilateral procedures. Average follow up was 3.5 years with minimum follow up being 3 years. Osteoarthritis was the commonest diagnosis accounting for 53 (91%) patients and rheumatoid arthritis in 6 (9%) of patients. 48 cases (82%) were Stage IV and 15 cases (18%) Stage V. Mean duration of symptomsbefore the surgical intervention was 36 months. 3 patients developed superficial wound infection and 4 patients developed reflex sympathetic dystrophy. The results suggested pinch strength and grip strength improved to 50% and 22.5% respectively, as compared to pre-operative value.

Conclusion: Treatment options for 1st CMC joint arthritis have evolved over time. Many prospective randomized studies have shown lack of advantage of LRTI as compared to trapeziectomy alone, but these studies are not free from limitations. The present study is one of the largest reported single surgeon series and benefits from aprospectively maintained database with minimum 3 years follow up. The study rises above the existing limitations in the literature and reinforces concept of Ligament Reconstruction and Tendon Interposition.

Level of Evidence: Level II (Prospective study)

Background: Locking plates are used frequently in distal tibial fractures. We tested two different types of locking compression plates (LCP): the metaphyseal plate (MP) and the distal tibial plate (DTP). We evaluated the strain imposed on an experimental tibial osteotomy, and the stability of plate-tibia (composite bone) construct using LCP-MP and LCP-DTP.

Materials and methods: Twin strain gauged special composite tibial bones were used to simulate the human tibiae. We tested 5 tibiae: one was used as control, two tibiae were tested using LCP-MP, and two with LCP-DTP. Strain was measured by subjecting each construct to a cyclic load of 700 N at 3 Hz in neutral, flexion, extension and torsion to simulate the normal walking cycle.

Results: When compared with the control tibia, strain during the neutral moment at the proximal and distal strain gauge site in the LCP-MP and LCP-DTP constructs decreased by 6.4%/−41.5% and −39%/−47%, respectively. In flexion, the strain increased consistently in both the proximal and distal strain gauge sites using the LCP-MP by 34% and 109%. Using the LCP-DTP, the strain at the proximal strain gauge site decreased by 0.2% and increased by 18% at the distal strain gauge site. In extension, strain decreased by 25% at the proximal strain gauge site, and by 60% at the distal strain gauge site in the LCP –MP construct. In the LCP-DTP construct, the strain decreased by 13% at the proximal strain gauge site, and by 21% at the distal strain gauge site. There were no statistically significant torsional differences between LCP-MP and LCP-DTP group (P=0.121). In this experimental setup, the LCP-DTPs offer greater control of strain than LCP-MPs. They also confer greater resistance to fracture macro-movements, and improved stiffness consistently in neutral, flexion, and torsion than LCP-MPs.

Conclusion: The strain from osteotomised tibiae stabilised with LCP-MPs and LCP-DTPs were close to the strain of the control tibia. Both these locking plates were equally good and conferred greater stiffness in all loading positions.

Purpose: Management of unstable or comminuted displaced fractures of the distal radius is difficult. We report our experience treating these fractures with AO volar plate fixation applying the principle of a volarulnar tension band platting. An attempt to introduce a new radiological classification for the accuracy of reduction is made. The classification includes 10 criteria.

Materials and Method: We reviewed clinically and radiologically 99 patients (101 fractures); 60 were type C and 41 were type A. The average follow up was 37 months (24 – 57). The average age was 46 years (19 – 81). Sarmiento’s modification of Gartland and Werley and Cooney’s modification of Green and O’Brien were used for clinical assessment. Lidstorm and Frykman used for radiological assessment.

Results: At final follow up the means of distal radius parameters were: volar tilt of 9°, radial inclination of 22°, radial height of 11mm and palmer cortical angle of 32°. The mean dorsiflexion was 61°, palmer flexion was 59°, pronation was 80° and supination was 76°. Grip strength was 86% of the opposite side. The average DASH score was 13.6. There was 13 poor results, 6 of them had a significant loss the initial reduction. There was significant correlation between our classification outcome and the clinical outcome.

Conclusion: AO volar plate fixation of unstable distal radius fractures provides a strong fixation that maintains reduction and allows early mobilisation.

Introduction: We present here the clinical features and management strategies of patients with gluteus medius and minimus enthesopathy.

Methodology: We studied seven patients with lateral hip pain and tenderness on palpation, worse over the tip of the greater trochanter. All of them had a positive Trendelenburg’s sign, and a transient relief of pain on injecting local anaesthetic in the abductor mechanism. All of these patients were tertiary referrals from the rheumatologists, who had at least once injected them with corticosteroids.

Results: Four of these seven patients underwent exploration. An insertional tendinopathy of the abductors was noted in all the patients, and was debrided. Two of the patients had, in addition, a tear in the gluteus medius tendon, which was repaired. One patient had an injection of local anaesthetic and Aprotinin in the abductor mechanism with resolution of symptoms.

Discussion: Gluteus medius and minimus enthesopathy is a distinct clinical entity. Although the condition has been described in the radiological literature, we were unable to find any reference to the orthopaedic management of this condition. We observed only a small number of patients, and we are thus unable to provide definite answers. Patients presenting with the above clinical features warrant consideration of the diagnosis of abductor enthesopathy. Ultrasound scan or MRI scan helps in confirming the diagnosis. At present, our management protocol involves injecting a local anaesthetic / Aprotinin in the abductor mechanism. However, we are cautious in injecting more than once, as, at operation, we have observed necrosis of the abductor mechanism at its insertion in two patients, similar to that described for Achilles tendon. If this fails, we undetake surgical exploration. The exact surgical procedure is difficult to predict and may involve debridement and repair of the pathological tendon.

Purpose: Management of the unstable or comminuted displaced fractures of the distal radius is difficult. We report our experience treating these fractures with AO volar plate fixation. An attempt to introduce a new radiological classification for the accuracy of surgical reduction is made. The classification includes 10 criteria and 100 points.

Methods: 124 patients had volar plate fixation performed between June 2000 and May 2003 using AO volar plate. We reviewed clinically and radiologically 101 patients; 60 were type C and 41 were type A (after failed conservative treatment). The average follow up is 37 months (24 – 57). The average age is 46 years (19 – 81). Postoperative regimen consisted of immediate physiotherapy and a wrist splint for three weeks. Cooney’s modification of Green and O’Brien and Sarmiento’s modification of Gartland and Werley were used for clinical assessment. Lidstorm and Frykman used for radiological assessment.

Results: At final follow up the means of distal radius parameters were: volar tilt of 9 degrees, radial inclination of 22 degrees, radial height is 11mm and palmer cortical angle of 32 degrees. The mean dorsiflexion was 61 degrees, palmer flexion was 59 degrees, pronation was 80 degrees and supination was 76 degrees. Grip strength was 86 percent of the opposite side. The average DASH score was 13.6. There was 14 poor results, 6 of them had significant loss the initial reduction. There was significant correlation between our classification and the clinical outcome.

Conclusion: AO volar plate fixation of unstable distal radius fractures provides strong fixation that maintains reduction and allows early mobilisation.