Introduction

Current undergraduate trauma and life-support training inadequately equips medical students with the knowledge, practical skills and confidence to manage trauma patients. Often first to the scene of medical emergencies, it is imperative junior doctors feel confident and competent from day one. No UK university currently includes advanced trauma and life support (ATLS) in their curriculum. This study piloted an ATLS course for Cardiff final-year medical students to improve confidence and knowledge in management of the trauma patient.

Abstract

The widespread dissemination of high-quality research facilitates keeping up to date with evidence-based practice, but the vast quantity can be overwhelming to physicians and surgeons. Information graphics, abbreviated to infographics, convey information using visualisations and images in an engaging manner. This format of presenting research format is preferable to 80% of clinicians when compared to text articles, and the long-term retention of information has been shown to be improve by a factor of 6.5 when methods were compared. Journal club was audited in our institution over 3 months. A multi-choice questionnaire was constructed weekly so as to test the attendees' recall of the research presented on a weekly basis. After five weeks, infographics were introduced, and the attendees' recall was assessed again on a weekly basis at the end of each journal club. The introduction of infographics to journal club saw improved test results from the journal club attendees. Not only was information retention improved, but the duration of journal club reduced following the intervention. Research can be disseminated efficiently using infographics in place of conventional journal club presentations. Satisfaction rates among clinicians, both with information retention and journal club duration, demonstrate the benefit of their use in teaching hospitals.

Aims

Computer hexapod assisted orthopaedic surgery (CHAOS), is a method to achieve the intra-operative correction of long bone deformities using a hexapod external fixator before definitive internal fixation with minimally invasive stabilisation techniques.

The aims of this study were to determine the reliability of this method in a consecutive case series of patients undergoing femoral deformity correction, with a minimum six-month follow-up, to assess the complications and to define the ideal group of patients for whom this treatment is appropriate.

Introduction

Active patients may benefit from surgical repair of the achilles tendon with the aim of preserving functional length and optimising push-off power. A mini-open device assisted technique has the potential to reduce wound complications, but risks nerve injury. We present the largest published series of midsubstance achilles tendon repairs using the Achillon® device.

Percutaneous grafting of non-union using bone marrow concentrates has shown promising results, we present our experience and outcomes following the use of microdrilling and marrowstim in long bone non-unions.

We retrospectively reviewed all patients undergoing a marrowstim procedure for non-union in 2011–12. Casenotes and radiographs were reviewed for all. Details of injury, previous surgery and non-union interventions together with additional procedures performed after marrowstim were recorded for all patients. The time to clinical and radiological union were noted.

We identified 32 patients, in sixteen the tibia was involved in 15 the femur and in one the humerus. Ten of the 32 had undergone intervention for non-union prior to marrowstim including 4 exchange nailings, 2 nail dynamisations, 3 caption graftings, 2 compression in circular frame and 1 revision of internal fixation. Three underwent adjunctive procedures at the time of marroswstim. In 18 further procedures were required following marrowstim. In 4 this involved frame adjustment, 5 underwent exchange nailing, 4 revision internal fixation, 2 additional marrowstim, 2 autologous bone grafting and 3 a course of exogen treatment.

In total 27 achieved radiological and clinical union at a mean of 9.6 months, of these ten achieved union without requiring additional intervention following marrowstim, at a mean of 5.4 months. There were no complications relating to marrowstim harvest or application.

Marrowstim appears to be a safe and relatively cheap addition to the armamentarium for treatment of non-union. However many patients require further procedures in addition to marrowstim to achieve union. Furthermore given the range of procedures this cohort of patients have undergone before and after marrowstim intervention it is difficult to draw conclusions regarding it efficacy.

Revision hip arthroplasty requires a comprehensive appreciation of abnormal bony anatomy. Advances in radiology and manufacturing technology have made three-dimensional representation of actual osseous anatomy obtainable. These models provide a visual and tactile reproduction of the bony abnormality in question.

Life size three dimensional models were manufactured from CT scans of two patients. The first had multiple previous hip arthroplasties and bilateral hip infections. There was a pelvic discontinuity on the right and a severe postero-superior deficiency on the left. The second patient had a first stage revision for infection and recurrent dislocations. Specific metal reduction protocols were used to reduce artefact. The dicom images were imported into Mimics, medical imaging processing software. The models were manufactured using the rapid prototyping process, Selective Laser Sintering (SLS).

The models allowed accurate templating using the actual prosthesis templates prior to surgery. Acetabular cup size, augment and buttress sizes, as well as cage dimensions were selected, adjusted and re-sterilised in advance. This reduced operative time, blood loss and improved surgical decision making. Screw trajectory simulation was also carried out on the models, thus reducing the chance of neurovascular injury.

With 3D printing technology, complex pelvic deformities can be better evaluated and can be treated with improved precision. The life size models allow accurate surgical simulation, thus improving anatomical appreciation and pre-operative planning. The accuracy and cost-effectiveness of the technique were impressive and its use should prove invaluable as a tool to aid clinical practice.

Introduction:

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe a purely arthroscopic technique for excising talocalcaneal coalitions. We present a retrospective two-surgeon case series of the first eight patients (nine feet).

Symptomatic tarsal coalitions failing conservative treatment are traditionally managed by open resection. Arthroscopic excision of calcaneonavicular bars have previously been described as has a technique for excising talocalcaneal bars using an arthroscope to guide an open resection. We describe an entirely arthroscopic technique for excising talocalcaneal coalitions and present a retrospective two-surgeon case series of the first eight patients (nine feet).

Outcome measures include restoration of subtalar movements, return to work and sports, visual analogue pain scales and Sports Athlete Foot and Ankle Scores (SAFAS). Follow-up ranges from 1 year to 5.5 years.

Subtalar movements were improved in all feet. Deformity was not always fully corrected but pain and SAFAS scores improved in all patients bar one. They all had a rapid return to good function apart from this same patient who required subsequent fusions. The posterior tibial nerve was damaged in one patient.

Minimal destruction of bone and soft tissues allows early mobilization and minimizes pain. We acknowledge the risk of neurological damage from any operative technique. Patient selection and preoperative planning are crucial. This series from two independent surgeons supports the feasibility and effectiveness of this technique.

Thoracic kyphosis increases with age. The resultant increase in compression forces on the anterior vertebral bodies leads to further kyphotic deformity and, an increased likelihood of vertebral collapse. This study aimed to determine the relative efficacy of two therapeutic strategies commonly used to treat hyperkyphosis.

69 subjects (26 male: 43 female) were randomised into 4 groups: strengthening, postural re-education (PEd), both and control. The strengthening group attended a gym 3 times a week for 12 weeks to perform seated extension exercises. The PEd group had 3 physiotherapy sessions within a 12 week period in which they received postural assessment and a home exercise programme. The combined group received both interventions while the control group received neither. Outcome measurements were assessed at baseline and 12 weeks. They included static (inclinometer) and 6-hour angular measurements (using flexible electrogoniometer (FEG)) and physical function tests.

There were no significant differences between the marginal means of the angular measurements for any of the intervention groups. However, the group which received both interventions demonstrated reduced kyphosis as measured by the FEG angles (apex of the curve between T3 and T11), while the strengthening group showed reduced inclinometer angles (between T1 and T12). The strengthening group showed improvement in back extensor strength (BES) (0.6 +/− 0.2 N/kg, p < 0.01), time to walk 10 metres (−0.3 +/− 0.6 s, p < 0.05), and time to stand and sit 5 times (−0.9 +/− 0.6 s, p < 0.05). However, there was no relationship between change in BES and change in kyphotic angle. The PEd group showed the greatest improvement in the timed up and go test but this was not significant. Improvement in inclinometer angle over the 12 weeks was associated with degree of kyphosis at baseline (upright inclinometer r = −0.47, p=0.0001) but this relationship was not apparent in the FEG measurements. Both the FEG and inclinometer angles showed a marked decrease in degree of improvement in subjects aged >70.

(50/50). A combination of strengthening and PEd was most effective at reducing hyperkyphosis. BES was improved with resisted strengthening but not with home-based postural exercises. However, increased BES was not associated with decreased kyphosis. Larger baseline kyphosis was associated with greater angular improvement. Subjects aged >70 were less likely to improve.

Magnetic resonance imaging (MRI) scans are widely used in the assessment of knees, often prior to arthroscopic procedures. The reporting of chondral damage on MRI scans can be variable. The correlation between MRI reports of chondral damage and that found at arthroscopy is often inconsistent. The aim of this study was to identify how well MRI reports correlated with the extent of chondral damage found at arthroscopy. A retrospective case-note review of a single-surgeon series of 175 arthroscopic procedures was performed. 83 patients were included in the study. The remainder were excluded if an MRI scan had not been performed, or had been performed more than 3 months prior to surgery. The condition of the articular cartilage demonstrated by MRI was compared to that found at arthroscopy. Data was analysed for presence and extent of chondral damage. Comparison between MRI and arthroscopy findings showed high Specificity (90%) and Negative Predictive Values (89%) for chondral damage, but low Sensitivity (46%). Cohen's kappa values < 0.2 revealed very poor correlation for the extent of damage. This study demonstrates that MRI is good at describing whether articular damage is present but does not reliably describe the extent of the damage.

Introduction: Muscle strength has been incorporated in the outcome assessment tools of many joints such as the shoulder and the hand. The purpose of this study was to examine the reliability and therefore the suitability of muscle strength around the ankle joint to be incorporated in foot and ankle assessment tools.

Participants: Sixty-nine healthy volunteers participated in this study (35 females and 34 males); the average age was 35 years (range: 21 to 71 years).

Methods: Three measurements of plantar flexion strength and of dorsiflexion strength of each ankle were performed using the Nottingham Mecmesin Myometer. Measurements were repeated at 2 weeks interval. The averages from first and second occasions were statistically compared.

Results: The average plantar flexion strength was 20.2 kg (range 11 to 41 kg). The average dorsiflexion strength was 14.7 kg (range 7 to 26 kg). The ninety five percent limits of agreement were −5.9 (29%) to +5.2 (26%) kg for the planter flexion and −4.9 (33%) to +5.2 (35%) kg for dorsiflexion.

Discussion/Conclusion: Both plantar flexion and dorsiflexion strengths showed repeatability. Nevertheless, the reliability of planter flexion is higher. Furthermore, this reliability is similar to those of grip strength and shoulder abduction strength. Hence, we advise to incorporate ankle planter flexion strength in foot and ankle outcome assessment tools.

Cement pressurisation in the distal humerus is technically difficult due to the anatomy of the humeral intramedullary (IM) cavity. Conventional cement restrictors often migrate proximally, reducing the effect of pressurisation during arthroplasty. Theoretically with a better cement bone interdigitation, the longevity of the elbow replacement can be improved.

The aim of this cadaveric study was to evaluate the usefulness of a novel technique for cementation.

Eight paired cadaveric elbows were used. The sides were randomly allocated to the conventional cementation group and pressurisation using a foley cathetre used as a cement restrictor. The cathetre was inserted into the IM canal after thorough washout and drying the cavity. The balloon inflated to act as a cement restrictor. Cementation was then performed and the cathetre removed just prior to cement setting. Radiographs of each pair was taken. Each distal humerus sample was cut in 1 cm increments starting from proximal part of the coronoid fossa. The slices were also radiographed to assess cement-bone interdigitation. The area of IM canal and the cement were calculated. The paired samples were compared.

The new technique consistently and significantly achieved a better cement interdigitation into the cancellous bone. The maximum penetration was observed in the proximal 1–3 cms from the coronoid fossa. According to previous studies, this area is the most common part involved in cement failure and loosening.

This study confirms the effectiveness of a foley cathetre as a cement restrictor. The ease of the technique and excellent pressurisation achived support its use.

We present a series of 16 patients requiring revision forefoot procedures in Musgrove Park Hospital, Taunton.

The primary procedures were carried out in a local Independent Sector Treatment Centre as part of a regional initiative to reduce waiting times to meet national targets. Several of these patients were primarily listed for surgery at our institution. The majority of the procedures performed were first ray procedures in the time period from February 2006 to February 2009.

We present a summary of the indications for these revision procedures and some of the issues surrounding the management of these patients. We also present a summary of the costs incurred by Musgrove Park Hospital as a result of this extra workload.

Introduction: Utilisation of day case surgery units for orthopaedic trauma is an uncommon concept. Limited reports of its use in specific orthopaedic trauma cases have been encouraging. There is currently no formal provision for day case surgery for trauma patients at our institution. The aim of this study was to identify the proportion of trauma patients that would be suitable for daycase surgery and the proportion of these that currently undergo procedures as a day case, with a view to establishing a more formalised daycase trauma service.

Methods: We undertook prospective data collection on all trauma referrals in our institution over a 1 month period in January 2008. Information was recorded for date and time of referral, admission, operation and discharge. Nature of injury, type of procedure performed, grades of surgeon involved and length, nature and reason for any pre or post-operative delay was also recorded. All patients requiring surgery were assessed on their suitability for day case as defined by pre-determined patient-related and surgery-related criteria.

Results: Of all the patients referred during the study period 129 patients required surgery. Of the operated patients 80 (62%) had a procedure suitable to be performed as a day case as defined by surgical factors. Of these, 57 (44%) patients met criteria for day surgery as defined by patient factors. Of those eligible for day case surgery (n=57), only 27% had their procedures performed as a day case. The total number of additional days spent in hospital by day case eligible patients was 69. 34 days were due to pre-operative delay and 35 were due to post operative delay. The mean number of pre operative days in hospital was 1.33(range 0–3) and post operative days 1.85 (range 0–8). There was a wide case mix of procedures performed that were deemed appropriate for day case surgery. 76% were upper limb or soft tissue procedures.The causes for pre-operative delay established two main issues. Limited dedicated operating theatre capacity for day case eligible procedures resulting in their de-prioritisation and limitations on dedicated bed availability. The cause for postoperative delay was more variable but on the whole was for reasons which with appropriate protocols could have been avoided.

Conclusions: This study has identified that a significant proportion of orthopaedic trauma workload would be appropriate to be carried out as a day case. Without an appropriate day case surgery setup, current delays are causing 69 unnecessary bed days per month in our institution. Causes for current delays are related to lack of synchrony between timing of admission and surgery and lack of appropriate discharge protocols. We are in the process of developing a plan for implementation of a dedicated day case trauma service at our institution and suggest that this may be an appropriate use of day case facilities in other trusts.

The Biometrics Flexible Electrogoniometer (FEG) is a lightweight device which when attached over joints can record angular displacements for periods of up to 10 hours.

The aim of this study was to examine the validity of the FEG for measuring the thoracic spine using the Cobb angle and functional activities.

12 subjects (6 F, 71±11years; 6 M, 65±11) were X-rayed in upright and “slumped” standing with the FEG attached to their thoracic spine. Three Cobb angles were obtained from the vertebrae underlying the FEG at the outer margins (OEB); the inner margins (IEB), and the mid points (MEB), of the FEG end blocks.

Comparisons of FEG and Cobb angles were derived with intraclass correlation coefficients (ICC).

In a separate experiment, 12 subjects (8F, 43±13; 4M, 35±17) performed 7 functional activities one week apart in order to assess day-to-day reliability of the FEG. Time 1 and time 2 angles were compared with an ICC.

The mean FEG angles for upright and “slumped standing” were 31±7° and 39±8° (mean ± SD) respectively. The corresponding mean OEB Cobb angles were 48±13° and 52±12°; the mean IEB Cobb angles were 24±11° and 29±10°; and the MEB Cobb angles were 36±13° and 41±10°.

The correlation between the FEG and OEB Cobb was ICC(2,1)=0.85; between FEG and IEB Cobb was ICC(2,1)=0.77 and between FEG and MEB Cobb was ICC(2,1)=0.87.

The second experiment compared day-to day reliability of the FEG when used over the thoracic spine. For the 7 activities performed: standing erect, standing slumped, reaching up, reaching down, and walking on-the-spot, the mean correlation between the measures on day 1 and day 2 was ICC(2,1)=0.96 (range 0.94 to 0.98).

This study has shown that the FEG demonstrates excellent internal and external validity in the thoracic spine. Further, it has demonstrated that the FEG measures the segment of the spine between the mid-endblocks. Future studies are planned which will use the FEG to evaluate interventions aimed at treating thoracic kyphosis

We report a case of malignant fibrous histiocytoma of the hip which occurred 30 years after the insertion of a single chrome-cobalt alloy screw for a slipped femoral epiphysis. The possible aetiological association between malignant tumours and metallic implants is discussed.