Introduction

Diabetic foot disease is a major public health problem with an annual NHS expenditure in excess of £1 billion. Infection increases risk of major amputation fivefold. Due to the polymicrobial nature of diabetic foot infections, it is often difficult to isolate the correct organism with conventional culture techniques, to deliver appropriate narrow spectrum antibiotics. Rapid DNA-based technology using multi-channel arrays presents a quicker alternative and has previously been used effectively in intensive care and respiratory medicine.

Aims

Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme.

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.

Purposes and Background

Musculoskeletal disorders are leading causes of work disability. Our purpose was to develop a predictive model in a cohort from 2012 and validate the model in 2016 data.

The effect of BMI on patient-reported outcomes following total ankle replacement (TAR) is uncertain and the change in BMI experienced by these patients in the 5 years following surgery has not been studied. We report a series of 106 patients with complete 5-year data on BMI and patient-reported outcome scores.

Patients undergoing TAR between 2006 and 2009, took part in the hospital joint registry, which provides routine clinical audit of patient progress following total joint arthroplasty; therefore, ethics committee approval was not required for this study. Data on BMI, Foot and Ankle Score (FAOS) and SF-36 score were collected preoperatively and annually postoperatively.

Patients who were obese (BMI >30) had lower FAOS scores pre-operatively and at 5 years, however this did not reach significance. Both obese (p = 0.0004) and non-obese (p < 0.0001) patients demonstrated a significant improvement in FAOS score from baseline to 5 years. This improvement was more marked for the non-obese patients. No significant differences were seen for SF36 scores between obese and non-obese patients either at baseline or 5 years. There was a trend for improved score in both groups.

Mean pre-operative BMI was 28.49. Mean post-operative BMI was 28.33. The mean difference between pre- and post-operative BMI was −0.15, which was not statistically significant (p=0.55). There were no significant differences in revisions in the obese (2) and non-obese (1 and one awaited) groups at 5 years.

This data supports use of TAR in the obese population, as significant increases in mean FAOS score were seen in this group at 5 years. Obesity did not have a significant influence on patients' overall health perceptions, measured by the SF36 and a trend for improvement was seen in both obese and non-obese patients. TAR cannot be relied upon to result in significant post-operative weight-loss without further interventions.

Platelet rich plasma has been advocated for the treatment of plantar fasciitis but there are few good quality clinical trials to support its use. We report a pilot double blind randomised controlled trial of platelet rich plasma versus normal saline.

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.

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.

Subacromial corticosteroid injections are a well-recognised management for chronic shoulder pain and are routinely used in general practice and musculoskeletal clinics. Mycobacterium tuberculosis (TB) of a joint is a rare presentation in the United Kingdom. International literature exists for cases of reactivated latent tuberculosis following intra-articular corticosteroid injections in a knee; however there are no reports of a primary presentation of undiagnosed TB in a joint following therapeutic corticosteroid injections.

A seventy-four year old lady presented with a one-year history of a painful shoulder, which clinically manifested as a rotator cuff tear with impingement syndrome. Following three subacromial depo-medrone injections, the patient developed a painless “cold” lump which was investigated as a suspicious, possibly metastatic lesion. This lump slowly developed a sinus and a subsequent MRI scan identified a large intra-articular abscess formation. The sinus then progressed to a large intra-articular 5×8 cm cavity with exposed bone (picture available). The patient had no diagnosis of TB but had pathogen exposure as a child via her parents.

The patient underwent three weeks of multiple débridement and intravenous amoxicillin/flucloxacillin to treat Staphylococcus aureus grown on an initial culture. Despite best efforts the wound further dehisced with a very painful and immobile shoulder. Given the poor response to penicillin and ongoing wound breakdown there was a suspicion of TB. After a further fortnight, Mycobacterium tuberculosis was eventually cultured and quadruple antimicrobial therapy commenced. Ongoing débridement of the rotator cuff and bone was required alongside two months of unremitting closed vacuum dressing. The wound remained persistently open and excision of the humeral head was necessary, followed by secondary wound closure. There were no extra-articular manifestations of TB in this patient. At present the shoulder is de-functioned, the wound healed and shoulder pain free.

This unique case study highlights that intra-articular corticosteroid can precipitate the first presentation of Mycobacterium tuberculosis septic arthritis. The evolution of symptoms mimic many other shoulder complaints making confident diagnosis a challenge. The infective bone and joint destruction did not respond to the management described in the current literature. There remains a further management issues as to whether arthroplasty surgery can be offered to post-TB infected shoulder joints.

Taking a TB exposure history is indicated prior to local immunosuppressant injection, particularly in the older age group of western populations and ethnicities with known risk factors.

Degree of early integration of titanium alloy implants into bone is an important predictor of long term implant success in arthroplasty. The correlation between observations on early cell adhesion and the ability of modified surfaces to affect osseointegration of implants in in vivo models is unclear. We hypothesised that observation of increased focal adhesion complexes in early cultures of osteoblasts would correlate with increased osseointegration of treated implants in an animal model. Longer term culture of rat osteoblasts for alkaline phosphatase activity indicated that cells cultured on the 9V treated surfaces were displaying greater alkaline phosphatase activity at 14 days. Bone nodule formation at 28 days demonstrated a trend towards smaller area of bone nodules on the surfaces treated at 9V then those treated at 3V and 5V. A rat model was employed for testing mechanical push-out strength of experimental implants and demonstrated a trend towards increased yield strength of the bone-implant interface for implants treated at 3V180s and 5V180s. Histomorphometry was performed and no statistically significant differences in percentage area of contact with mineralised bone matrix were seen, although there was a trend for greater mineralised matrix contact on the polished and 9V180s treated implants. Previous experiments demonstrated cells on the 9V treated surfaces were well spread and had significantly increased size and number of focal adhesions. This was regarded as indicating more successful cell adhesion. The above results demonstrate that this early trend disappeared in longer term culture did not persist in experiments in an animal model.

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.

Background

Traditional recommendations suggest that open fractures require urgent surgical debridement to reduce infection. However, this has recently been challenged by a number of investigations. However, in many cases, these studies were not able to control for important confounding factors. The purpose of our study was to evaluate the relationship between delay to definitive surgical debridement while controlling for important confounders.

Background

Uncemented implants are an important part of the arthroplasty armamentarium. Risk of aseptic loosening and failure of these components is related to initial osseointegration - the formation of a seamless bone-implant interface without interposition of fibrous tissue.

Background

Unicompartmental knee replacements (UKR) converted to total knee replacements (TKR) have often been viewed with scepticism because of the perceived difficulty of the revision and because revision procedures generally do less well than primaries.

There have been marked changes in the management of Juvenile Idiopathic Arthritis (JIA) over recent decades, mainly with earlier use of methotrexate (MTX). Our aim was to describe orthopaedic interventions in a large group of adults with JIA followed up over several decades.

This was a retrospective observational study of adult JIA patients attending a teaching hospital clinic, with information collated on JIA subtype, disease duration, orthopaedic interventions and exposure to MTX.

The study included 144 patients with median disease duration of 19 years. Survival analysis showed that joint surgery was observed in the majority (75%) of patients with disease duration over 40 years with a trend for less joint surgery in patients with oligoarticular JIA. In total 41 patients (28.5%) had received joint surgery and 17/41(41%) have required multiple procedures. Of those who have required joint surgery, 20/41(48%) had started MTX in their adult years, with only 5/41 (12%), starting MTX prior to first joint replacement and none within five years of disease onset. Of the patients who have not had joint surgery to date, most (46/103, 45%) were receiving MTX or another immunosuppressive agent, in the majority of cases MTX was started within two years of disease onset.

Many adults with JIA require joint replacement surgery and ongoing immunosuppressive treatments, emphasising that JIA is not a benign disease. Many patients who have had joint replacement surgery have had exposure to MTX albeit after many years after disease onset; it remains to be seen whether patients who have received MTX therapy early in their disease course will ultimately have less requirement for joint surgery.

Distal radius fractures are commonest injury managed by junior doctors in accident and emergency department. Technique of manipulation is very well described and doctors are prepared from the days of medical school. Though manipulation is done in good position at initial management many patients require re-manipulation and surgical stabilisation due to loss of position on subsequent examination. Many Senior surgeon thinks this is due to inadequate plastering and moulding technique.

Material and methods: We retrospectively, randomly selected 50 patients from 210 manipulations done in one year at District General Hospital. All these patients x-rays were reviewed and data collected for classification of fracture (Frykmann’s classification), radial height, ulnar varience, radial angulation, and Radial inclination measurements. Three Senior Orthopaedic Surgeons reviewed pre and post manipulation x-rays and asked for acceptability of initial reduction, plaster position and moulding signs on x-rays and asked to predict those requiring re-manipulation or loss of position.

Results: 70% of the fractures were frykmann I or II as intra articular fractures Prediction of senior surgeon was right for more than 60 percent of the cases. Average radial angulation was 14 degree on post manipulation films. Radial height and inclination was average 6 mm and 18 degrees respectively.

Discussion: Post manipulation is very important factor for maintaining reduction and poor moulding can lead to loss of position and require unnecessary additional operative procedure for initially well reduced fracture. Teaching of Plastering and moulding technique is very important skill development for junior doctors to improve outcome of these simple injuries

The process of training orthopaedic registrars in the technique of lower limb arthroplasty (hip & knee) requires a long learning curve. The practice of consultant supervised operating should not compromise the final outcome and patient care.

The aim of this study was to compare complication rates of lower limb arthroplasties performed by orthopaedic trainees with the national average.

We reviewed specialist registrar operating over a one year period between January 2003–January 2004 with reference to lower limb arthroplasty surgery (hip and knee replacements).

A postal questionnaire was sent to 24 specialist registrars on The Welsh Orthopaedic Higher Training Programme in confidence. Complications enquired about were:

infection;

Data obtained was analysed and individual complication rates were compared with the national United Kingdom average.

Complication rates for registrar operated patients were comparable if not lower than the national average. Outcomes after lower limb arthroplasty did not differ between consultants and trainees with regards to complications.

The authors conclude that consultant supervised lower limb arthroplasties performed by trainee orthopaedic surgeons is safe and not associated with higher complication rates as one would believe.

Objective of the Study: To assess the clinical effectiveness of ultrasound guided injection in the management of Morton’s Metatarsalgia.

Patients and Methods: Patients, that were clinically diagnosed to with interdigital Morton’s neuroma were treated with ultrasound guided injection of local anaesthetic and steroid. Fifty three patients were available for follow-up, and all had detailed telephone questionnaires completed. These questionnaires included a pre and post injection symptom score, as well as a Johnson Satisfaction score.

Results: 69% of patients had ultrasound diagnosis of Morton’s neuroma and 31% had an ultrasound diagnosis of intermetatarsal bursa. Mean follow up was11.4 months (Range: 3-23 months).67% of the patients were satisfied with the results of treatment. At follow up 63% of patients had no limitation in activity levels, and had no need to modify their shoe wear. Of all patients included in the study, only 3 patients have gone on to require surgery for ongoing symptoms.

Conclusion: Some studies have suggested that neither injection nor imaging have a role in the treatment of Morton’s neuroma. This study, however, demonstrate that ultrasound guided placement of local anaesthetic and steroid in either an intermetatarsal bursa or Mor-ton’s neuroma gives a good short and medium term symptom relief and in the majority of cases avoids the need for surgery.

Intervertebral disc function and dysfunction is governed by its structural architecture of concentric layers of highly ordered collagen fibres. This architecture is important at the mm scale for overall mechanical performance of the disc; and at the micron scale for mechano-transduction signalling pathways of the disc cells that are responsible for matrix maintenance and therefore disc health. To understand such mechanical behaviour 3-dimensional collagen fibre architecture must be quantified in intact intervertebral discs. Conventional imaging modalities lack either the spatial resolution (e.g. x-ray diffraction) or penetration (e.g. optical, electron or confocal laser microscopy) to yield mechanically important information. Preliminary studies of scanning acoustic microscopy (SAM) at 50 MHz visualises alternating layers of fibre texture, however exactly what is being imaged requires both explanation and validation. Three-dimensional SAM data sets obtained from intact discs were compared to polarised-light and scanning electron micrographs of individual layers of fibres, peeled by micro-dissection from discs. The dimensions of the structural features were measured and recorded. Optical and electron microscopy revealed that each layer consisted of highly oriented collagen fibres of diameter 5 μm with regularly spaced splits between fibres with a spacing of approximately 20–30 μm. The SAM data sets showed layers with a uniform highly oriented fibre texture that reversed between adjacent layers. Resolution of the texture was limited by the acoustic system to approximately 30 μm. It is clear that SAM at 50 MHz cannot resolve and therefore image individual collagen fibres. However, the regular defects in the fibre layers can be visualised and convey complete information about local collagen fibre architecture. SAM therefore provides an effective way of quantifying the fibrous structure of intact, hydrated, unfixed intervertebral discs.