Introduction

Intramedullary lengthening devices have been in use in older children with closed /open growth plates with good success. This study aims to present the early experience of the FITBONE nail since withdrawal of the PRECICE nail.

This study investigated concurrent talar dome injuries associated with tibial pilon fractures, mapping their distribution across the proximal talar dome articular surface. It compared the two main mechanisms of injury (MOI), falling from a height and motor vehicle accident (MVA), and whether the fractures were open or closed.

From a previously compiled database of acute distal tibial pilon fractures (AO/OTA 43B/C) in adults of 105 cases, 53 cases were identified with a concurrent injury to the talar dome with a known mechanism of injury and in 44 it was known if the fracture was open or closed. Case specific 2D injury maps were created using a 1x1mm grid, which were overlayed in an Excel document to allow for comparative analyses. A two-way ANOVA was conducted that examined the effect of both MOI and if the fracture was open or closed on what percentage of the talar dome surface was injured.

There was a statistically-significant difference between the average percentage of injured squares on the talar dome by both whether the fracture was open or closed (f(1)=5.27, p= .027) and the mechanism of injury (f(1)=8.08, p= .007), though the interaction between these was not significant (p= .156). Open injuries and injuries that occurred during an MVA were more likely to increase the surface area of the talar dome injuries.

We have identified both MOI and if the fracture was either open or closed impacts the size of the injury present on the talar dome. Future research will investigate the aetiology of the differences noted, highlighting the clinical implications.

Surgeons treating tibial pilon fractures caused by either a MVA or an open fracture, should be aware of an increased risk of large injuries to the surface of the talar dome.

Tibial pilon fractures are typically the result of high-energy axial loads, with complex intra- articular fractures that are often difficult to reconstruct anatomically. Only nine simultaneous pilon and talus fractures have been published previously, but we hypothesised the chondral surface of the dome is affected more frequently.

Data was acquired prospectively from 154 acute distal tibial pilon fractures (AO/OTA 43B/C) in adults. Radiographs, photographs, and intra-operative drawings of each case were utilised to document the presence of any macroscopic injuries of the talus. Detailed 1x1mm maps were created of the injuries in each case and transposed onto a statistical shape model of a talus; this enables the cumulative data to be analysed in Excel. Data was analysed using a Chi-squared test.

From 154 cases, 104 were considered at risk and their talar domes were inspected; of these, macroscopic injuries were identified in 55 (52.4%). The prevalence of talar dome injury was greater with B-type fractures (53.5%) than C-type fractures (31.5%) (ρ = .01). Injuries were more common in men than women and presented with different distribution of injuries (ρ = .032). A significant difference in the distribution of injuries was also identified when comparing falls and motor vehicle accidents (ρ = .007).

Concomitant injuries to the articular surface of the dome of the talus are relatively common, and this perhaps explains the discordance between the post-operative appearance following internal fixation and the clinical outcomes observed. These injuries were focused on the lateral third of the dome in men and MVAs, whereas women and fall mechanism were more evenly distributed.

Surgeons who operatively manage high-energy pilon fractures should consider routine inspection of the talar dome to assess the possibility of associated macroscopic osteochondral injuries.

Aims

During the COVID-19 pandemic, drilling has been classified as an aerosol-generating procedure. However, there is limited evidence on the effects of bone drilling on splatter generation. Our aim was to quantify the effect of drilling on splatter generation within the orthopaedic operative setting.

Aims

Perthes’ disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children’s Orthopaedic Surgery through the James Lind Alliance’s prioritization of work to determine/identify surgical versus non-surgical management of Perthes’ disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018.

The majority of hip fracture patients receive operative treatment, although the National Hip Fracture Database (NHFD) 2012 suggest 2.6% were treated conservatively. One of only a few published reports on the outcomes of these patients has demonstrated that mortality rates beyond 30 days remain comparable to patients receiving surgery. We have assessed the outcomes of conservatively managed patients in our unit.

Patients treated conservatively at our hospital between 2010 and 2012 inclusive were identified using the NHFD. Data collection included mobility status, ASA grade, Nottingham Hip Fracture Score (NHFS), mortality (30 days and 1 year) and pain scores.

The study group (N=31) had a mean age 85, mean ASA was 4 and mean NHFS mortality risk 21.3%. Morbidity included one case of pneumonia and one infection from another source, however there were no pressure sores or VTE. Three patients later received surgery once their health had improved. Pain control was achieved in 91% patients (21/23) and although mobility decreased, 34.8% of patients were able to mobilise with either two aids or a frame.

Given the selection bias for conservative treatment in unwell patients, the higher mortality figure is not unexpected. Although the 30 day mortality data is higher than the national average for operative management, those patients surviving 30 days have a mortality similar to those managed operatively. Despite mobility decreasing from the pre-admission status, a significant number of patients were pain free and could mobilise. Therefore conservative management can produce acceptable results in these patients.

Introduction

The aim of this study was to assess whether routine X-Rays at six weeks altered the subsequent management of patients who underwent a Scarf osteotomy.

Introduction: Hallux Rigidus(HR) is a progressive arthritic process of the first MTP joint that causes pain, stiffness and uncomfortable enlargement of the joint, thus resulting in significant morbidity.

Current treatment options include cheilectomy, resection arthroplasty, distal osteotomies (eg Moberg) or arthrodesis (Gold standard). Resurfacing of the metatarsal head, and concurrent joint release allow successful treatment of all stages of Hallux Rigidus, also offering the advantages of maintenance of metatarsal length, and movement.

Method: Patients with stage II-IV hallux rigidus, who had failed conservative management, had good bone stock, no previous signs of osteomyelitis and neurovascularly intact status were offered this new procedure. All procedures were performed by the senior author, in a single centre. The HemiCap^® MTP prosthesis was implanted using a dorsal approach to the 1st MTPJ. The joint was decompressed and dorsal / lateral bone shaping performed to maximise movement. Pre op and post op scoring at 6 weeks, 3, 6 and 12 months were recorded using AOFAS forefoot, NPS and SF12 scores.

Results: 36 First metatarsal head resurfacing procedures were performed on 32 patients. Follow up ranges from 6 weeks to 18 months. Pre op scores averages were AOFAS 22.06 (8–52), SF12 35.55 (14–61.3) and NPS 8.03 (4–10). At 12 months, these average scores had improved significantly to AOFAS 82.57 (55–95) SF12 56.01 (27.5–63.4) and pain scores 0.69 (0–4). There was significant improvement of 60 points on the AOFAS forefoot score, 20 points on the SF12 scoring system, and significant decrease in pain scores of 7.34.

Discussion: Initial results of MTPJ resurfacing are encouraging. This technique provides an advantage over cheilectomy which is of limited use in late stage rigidus, and over resection arthroplasty which shortens the 1st MT and risks transfer metatarsalgia. In our practice metatarsal head resurfacing is providing a useful alternative to fusion in active patients who require movement of the MTPJ. Should patients not tolerate the procedure well, the added advantage is easy conversion to the gold standard of fusion. We continue to follow these patients and add further subjects to this study.

Introduction and Aims: The treatment of femoral shaft fractures in skeletally immature patients has changed dramatically over the past 30 years. This is due in part to the advances in intramedullary nail outcomes pioneered in the adult orthopaedic trauma literature. We examined the results of reamed, locked nails in a pediatric population.

Method: The medical records of 224 children with femoral shaft fractures treated with reamed, locked intramedullary nails (RLIMN) at our institution between 1987 and 2000 were reviewed (largest series in the literature). Patients were treated with nails placed through the greater trochanter. Of those patients, 72 patients had long-term clinical (> 24 months) and radiographic (AP pelvis and leg length CT scanogram) follow-up. Functional status and radiographic parameters (femoral neck-shaft angle, leg length, presence of osteonecrosis) were recorded. Patients lacking two-year clinical and radiographic follow-up were evaluated via telephone follow-up.

Results: At our institution, over 200 skeletally immature patients have successfully undergone reamed, locked, intramedullary nailing of femur fractures. Average age at the time of treatment was 10.3 years. No case of osteonecrosis of the femoral head occurred. All fractures united after treatment with RLIMN at an average of 71 days. No patient manifested a gait abnormality after healing. Complications included delayed union in two patients, (one patient was treated with exchange IMN and one patient healed after dynamisation) superficial wound infection in one patient, (treated with oral antibiotics) and coxa valga in one patient. The patient that developed coxa valga was 7.7 years old at the time of intramedullary nailing. The only other procedures performed were removal of hardware in patients who remained skeletally immature at the time of healing. All patients returned to pre-injury activity level. The average leg length difference was 0.6cm (longer on the injured extremity). Average articulo-trochanteric distance was 0.28cm (longer on injured extremity).

Conclusion: Our results demonstrate that femoral shaft fractures in skeletally immature patients can be safely treated with reamed, locked intramedullary nails placed through the greater trochanter. We recommend careful placement of the nail through the greater trochanter to avoid damage to the blood supply of the femoral head.