There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion.Aims
Methods
The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs. Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants’ self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors.Aims
Patients and Methods
Payments by the NHS Litigation Authority continue to rise each year, and reflect an increase in successful claims for negligence against NHS Trusts. Information about the reasons for which Trusts are sued in the field of trauma and orthopaedic surgery is scarce. We analysed 130 consecutive cases of alleged clinical negligence in which the senior author had been requested to act as an expert witness between 2004 and 2006, and received information on the outcome of 97 concluded cases from the relevant solicitors. None of the 97 cases proceeded to a court hearing. Overall, 55% of cases were abandoned by the claimants’ solicitors, and the remaining 45% were settled out of court. The cases were settled for sums ranging from £4500 to £2.7 million, the median settlement being £45 000. The cases that were settled out of court were usually the result of delay in treatment or diagnosis, or because of substandard surgical technique.
Shoulder rotator cuff tears can be very debilitating and painful. Whilst massive tears may defy attempts at surgical repair due to the size of the defect, various biological materials have been proposed to reinforce tenuous repairs; initial results have been promising. It has been suggested that these materials may be used to bridge defects in the rotator cuff as a ‘patch’ or ‘interposition implant’ to provide pain relief and even offer some hope of functional recovery. A porcine dermal collagen implant (Permacol ©) has been engineered and introduced for the repair and reconstruction of soft tissues in the human body. In orthopaedics, it has been successfully used in the reinforcement and augmentation of rotator cuff repairs by suturing it over the repaired tendon. Proper et al reported good short term results in using this implant to bridge defects in massive rotator cuff tears and suggested it was good solution for this group of patients, reporting improvement in all aspects of the Constant Score. We have used Permacol © to reinforce cuff repairs with satisfactory results and thus considered its use as a salvage procedure to bridge massive rotator cuff defects, both of traumatic and degenerate origins. Unfortunately, we have seen with great concern that our results have been less than satisfactory. In a cohort of 20 patients who underwent Permacol © interposition / rotator cuff repair, 4 of these have failed, despite a promising initial recovery phase with good pain relief. We believe that use of this and similar implants to bridge a defect in the cuff is not indicated; MRI and dynamic ultrasound examination showed an inflammatory response in the shoulder, and resulting weakness/failure of the implant. We present clinical, radiographic, and histological findings of our experience and a discussion as to the probable cause for the failure of this implant in this particular group of patients.
To investigate the incidence of complications arising from clavicle fractures in children and the need for multiple review in fracture clinic.
Retrospective analysis of 200 children with isolated clavicle fractures. The number of clinic visits was documented along with the mechanism of injury and any complications attributable to the fracture. Plain radiographs allowed classification of the fractures both in terms of site and type of fracture. Prospective analysis of 60 children with isolated clavicle fractures. All patients were discharged with a patient information sheet after their first fracture clinic appointment and were reviewed a minimum of 6 months post injury to assess clinical outcome/complications and patient satisfaction. Retrospective review failed to provide any evidence of long term complications from isolated clavicle fractures. Two patients complained of a non-specific tingling in the arm which had settled within 2 weeks. No intervention other than rest in a broad arm sling was deemed necessary in any of the 200 children. Despite this, the average number of clinic appointments was 2.8. In the prospective study there were no complications arising from an isolated clavicle fracture. Two patients returned (one at 6 weeks and one at 12 weeks) with concerns about the cosmetic appearance of the fracture site - both patients were reassured and discharged. All patients were satisfied with the cosmetic appearance and function of their shoulder when reviewed at a mean of 7.3 months post injury (range 6–10 months). All patients and/or guardians were satisfied with the patient information sheet. Isolated clavicle fractures in children are rarely complicated by injuries such as skin necrosis or a neuro-vascular deficit. Despite this, children are commonly reviewed many times by juniors in a busy fracture clinic. We suggest that such review is unnecessary and that uncomplicated fractures may be safely discharged with a patient information sheet after the first clinic appointment.
Three cases of posterior dislocation of the Kinemax Posterior- Stabilized total knee replacement are reported, and predisposing factors, including operative technique and prosthesis design, are discussed. All three patients underwent posterior-stabilised knee replacement surgery at the Avon Orthopaedic Centre for osteoarthritis, between 1984 and 2000. In all cases the patient represented to the Emergency Department of a local hospital with posterior dislocation, at between 9 months and 6 years postoperatively. The mechanism for dislocation was hyperflexion of the knee. The dislocations could not be reduced under sedation because of obstruction by the protruding tibial insert, and required general anaesthesia to disengage the components. In all cases posterior dislocation became recurrent problem, and further surgery was required to address the instability. Two of the three patients underwent exchange of their stabilised tibial inserts for thicker versions of the same design, in order to reduce the excessive laxity present in flexion. The third patient underwent exploratory surgery and it was found that his patellar button had separated from the underlying bone. The patella was therefore resurfaced, restoring the integrity of his extensor mechanism. No further dislocations have occurred in any of the three patients. The causes of posterior dislocation of posterior-stabilized total knee replacements are multifactorial. They include malrotation of the tibial component, although this was not found to be the case in the three patients reported here. The design of the prosthesis may also contribute, and the upsloping and relatively shallow tibial spine of the Kinemax prosthesis (Howmedica) appears to be less forgiving than others. This is particularly the case if soft tissue lateral release or excessive resection of the posterior condyles has produced an increased flexiongap and therefore excessive flexion laxity. Our cases demonstrate the pitfalls that can produce this uncommon but serious complication, some of which can be predicted preoperatively, particularly in the patient with a valgus knee or deficiency of the extensor mechanism.
