Aims

There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures.

Global surgical literature suggests that female trainees have less operative autonomy than their male counterparts. This pilot study had the primary objective to identify difference in autonomy by gender, and to power a national study to carry out further quantitative and qualitative research on this.

This was a retrospective, cross-sectional study utilising eLogbook data for all orthopaedic trainees (ST2-8) and consultants with CCT date 2016–2021 in a single Scottish deanery. The primary outcome measure was percentage of procedures undertaken as lead surgeon. 15 trainees and four recent consultants participated, of which 12 (63%) were male (mean grade 5.2), and 7 (37%) were female (mean grade 4.3). Trainees were lead surgeon on 64% of procedures (17595/27558), with autonomy rising with grade (37% ST1 to 85% ST8, OR 9.4). Operative autonomy was higher in male vs female trainees (66.5% and 61.4% respectively, p=<0.0001), with female trainees more likely to operate with a supervisor present (STU/S vs P/T, f 48%:13%, m 45%:20%).

This pilot study found that there was a significant difference in operative autonomy between male and female trainees, however this may be explained by differences in mean grade of male vs female trainees. Five trainees took time OOT, 4/5 of whom were female. Extension to a national multi-centre study should repeat the quantitative method of this study with additional qualitative analysis including assessing effect of time OOT to explore the reason for any gender discrepancies seen across different deaneries in the UK.

Background

To compare quality of life during treatment in children and adolescents with tibial fracture treated with either a definitive cast or Ilizarov frame.

Purpose

To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss.

We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit.

An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended.

Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment).

We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100).

Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment.

Level of evidence: IV (case series)

Management of irreparable rotator cuff tears is challenging and controversial. Surgeons have been utilising biological tissue scaffolding to augment repairs, but there are concerns regarding viability and function. We wished to investigate this viability and clinical outcome in a small group of patients.

All procedures were performed by a single surgeon over a three-year period. Inclusion criteria were patients with large cuff tears and failure of non-operative treatment. Exclusion criteria were patients with glenohumeral arthritis and where cuff repair could not be successfully performed. Open rotator cuff repair followed by augmentation with Graft Jacket® Regenerative Tissue Matrix (Wright Medical) was performed in all patients. A structured cuff repair physiotherapy protocol was then followed. Follow-up was at six months and at minimum twenty-four months post-operatively where Constant scores (CS) and Oxford Shoulder scores (OSS) were noted and a repeat ultrasound performed.

Fourteen patients underwent the procedure. No patient was lost to follow-up. There were seven males and seven females with a mean age of 63 years (range 31–77). At minimum twenty-four month follow-up, thirteen patients had flexion and abduction above 90 degrees and symmetrical external rotation. Mean CS was 81 (range 70–91) and mean OSS was 46 (range 41–48). Shoulder ultrasound revealed an intact Graft Jacket® in all thirteen patients. The final patient had lower functional movement and lower CS (34) and OSS (25) and ultrasound identified a re-rupture.

This study indicates that augmentation of large rotator cuff repairs with biological tissue scaffolding is a viable option and has good functional results.

This study explores the relationship between delay to surgical debridement and deep infection in a series of 364 consecutive patients with 459 open fractures treated at an academic level one trauma hospital in North America.

The mean delay to debridement for all fractures was 10.6 hours (0.6 to 111.5). There were 46 deep infections (10%). There were no infections among the 55 Gustilo-Anderson grade I open fractures. Among the grade II and III injuries, a statistically significant increase in the rate of deep infection was found for each hour of delay (OR = 1.033: 95% CI 1.01 to 1.057). This relationship shows a linear increase of 3% per hour of delay. No distinct time cut-off points were identified. Deep infection was also associated with tibial fractures (OR = 2.44: 95% CI 1.26 to 4.73), a higher Gustilo-Anderson grade (OR = 1.99: 95% CI 1.004 to 3.954), and contamination of the fracture (OR = 3.12: 95% CI 1.36 to 7.36). These individual effects are additive, which suggests that delayed debridement will have a clinically significant detrimental effect on more severe open fractures.

Delayed treatment appeared safe for grade 1 open fractures. However, when the negative prognostic factors of tibial site, high grade of fracture and/or contamination are present we recommend more urgent operative debridement.

Cite this article: Bone Joint J 2014;96-B:379–84.

Pain produced by the tourniquet is a common source of complaint for patients undergoing carpal tunnel decompression. Practice varies as to tourniquet position. There is little evidence to suggest benefit of one position over another. Our aim was to compare the experience of both the patient and the surgeon with the tourniquet placed either on the arm or the forearm.

Ethical approval was granted. Following power calculation and a significance level set at 0.05, 100 patients undergoing open carpal tunnel decompression under local anaesthetic were randomised to arm or forearm group. Visual Analogue Scores (VAS) (0–100) for pain, blood pressure and heart rate were taken at 2 minute intervals. The operating surgeon provided a VAS for bloodless field achieved and obstruction caused by the tourniquet.

The demographics of the groups was similar. There were no statistically significant differences in any measure between the groups.

Average tourniquet times were 8.8 minutes (forearm) and 8.2 minutes (arm). The average VAS score for forearm and arm was 13 and 11 respectively for bloodless field, 9 and 2 for obstruction. Average overall VAS for pain was 27 in each group, however interval VAS scores for pain were higher in the arm group. The average change Mean Arterial Pressure was −5 mmHg (forearm) −2 mmHg (arm) pulse rate was −1 bpm (forearm) and −2 bpm (arm).

Tourniquet placement on the arm does not result in significant difference in patient pain, physiological response or length of operation. Surgeons reported less obstruction and better bloodless fields with an arm tourniquet, however there was a trend for forearm tourniquet to result in less pain for the patient.

Two knee arthroplasty implants with very different design principles were previously available in our region. Kinemax is PCL retaining with a fixed bearing and cemented components. LCS is PCL sacrificing, fully uncemented and incorporates a rotating bearing. The aim of this study was to compare the outcome of these two radically different knee designs.

Between 1994 and 2004, 300 consecutive patients were recruited and underwent a knee replacement performed by the senior author. Each patient was randomised via sealed envelopes to receive either LCS or Kinemax implants. All patients were followed up by an audit nurse and patient satisfaction and Knee Society Scores (KSSs) were recorded.

By 2012, 135 patients had complete data at a minimum of 10-years of follow-up. The remaining 165 had either died before 10-year review or had not reached the 10-year mark. No patient was lost to follow-up. There were 69 patients in the Kinemax group and 68 in the LCS group. The pre-operative demographics were not significantly different between the two groups.

At 10-years of follow-up, each implant design demonstrated significant improvements in the KSS (p=0.001 kinemax, p=0.001 LCS) over pre-operative values. No significant difference could be identified between the two designs at 10 years. There were only two revisions in the whole study population and both were for kinemax implants at less than five years post-operatively.

In conclusion, there was no statistically significant difference in outcome between the two radically different knee designs at ten years with both designs performing equally well.

Digital Mucous Cysts (DMCs) arise from the distal inter-phalangeal joints of the digits. They often rupture spontaneously and nail deformities are common. Although surgical excision is recognised as the most successful treatment, there is no clear consensus as to the most appropriate operative technique.

We performed a retrospective review identifying all patients who underwent excision of a DMC using a local rotation skin flap by the senior author over a ten-year period. Patients were all seen pre-operatively and at a minimum of six months post-operatively. Sixty-nine patients were included in the study and were reviewed at an average of 37.7 months post-operatively. No patients were lost to follow-up. There was only one cyst recurrence (1.4%). Sixty-seven (97.1%) patients were happy with the scar and sixty-three patients (91.3%) said they would have the procedure performed again. Sixty-six patients (95.7%) were content with their post-operative range of movement, which was on average 8.1° less than pre-operative values. Thirty-six patients had a nail deformity pre-operatively and twenty-one reported that the deformity grew out following the procedure. Only one patient (3.0%) developed a new deformity post-operatively. Five patients reported infection post-operatively with four prescribed oral antibiotics, but all resolved following one week of treatment.

This study, which is one of the largest analyses of an operative treatment for DMCs, demonstrates that cyst excision with a local rotation skin flap is a safe and effective technique with a low recurrence rate and a high patient satisfaction.

Introduction

Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3×2ml) and single (1×6ml) dosing regimens of hylan G-F 20