Abstract

Abstract

The aim of our study was to compare the incidence of post-operative anterior knee discomfort after anterograde tibial nailing by suprapatellar and infrapatellar approaches.

95 subjects presenting with a tibial fracture requiring an intramedullary nail were randomised to treatment using a suprapatellar (SP) or infrapatellar (IP) approach. Anterior knee discomfort was assessed at 4 months, 6 months and 1 year post operatively using the Aberdeen Weightbearing Test-Knee (AWT-K), knee specific patient reported outcome measures and the VAS pain score. The AWT-K is an objective measure which uses weight transmitted through the knee when kneeling as a surrogate for anterior knee discomfort.

53 patients were randomised to an SP approach and 42 to an IP approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared to the uninjured leg when kneeling in the SP group compared to the IP group at all time points at all follow-up visits. This reached significance at 4 months for all time points except 30 seconds. It also reached significance at 6 months at 0 seconds and 1 year at 60 seconds.

We conclude that the SP approach for anterograde tibial nailing reduces anterior knee discomfort post operatively compared to the IP approach.

This prospective Randomised Controlled Trial compared two surgical approaches with respect to accuracy of guidewire and tibial nail position.

Sixty-seven patients with tibial fractures were randomised to semi-extended (SE) or standard (S) approaches of nail insertion. Fluoroscopy was performed at guidewire insertion and final nail position. The SE approach is more proximal with the guidewire inserted posterior to the patella, theoretically allowing a better angle for more accurate nail placement.

Measurements were taken in the Anteroposterior and lateral planes of both the nail and guidewire to determine deviation from the optimal angle of insertion (relative to the long axes of the tibial shaft). Thirty-nine and twenty-eight patients were treated with semiextended and standard approaches respectively.

The semiextended approach resulted in improved nail placement to statistical significance in both planes, with mean deviation from the optimal angle of insertion as below:

Guidewire AP 3.2° (SE) versus 4° (S) Lateral 27.1° (SE) versus 30.2° (S)

Nail AP 2.4° (SE) versus 4.2° (S) Lateral 17.9° (SE) versus 21.8° (S)

Poor positioning of the guidewire leads to excessive anterior placement of the nail by eccentric reaming. Anterior positioning of the guidewire and nail in the lateral plane was assessed. This was expressed as a percentage from the anterior cortex of the tibia.

Guidewire: Lateral 9.7% (SE) versus 9.3% (S)

Nail: Lateral 23.4% (SE) 19.3% (S) (p 0.043)

Semiextended nailing allows a better angle for guidewire placement and a more optimal final nail position. This facilitates accurate nail placement particularly in difficult proximal third fractures.

Failure to treat acute compartment syndrome (ACS) early leads to significant morbidity. Current practice depends on using clinical signs and intracompartmental pressure (ICP) monitoring to diagnose the syndrome but there is still debate regarding their accuracy and interpretation.

Patients admitted with injuries at risk of ACS underwent intramuscular (IM) pH and ICP monitoring combined with regular clinical assessment. Fasciotomies were performed on those with clinical and/or pressure based evidence of ACS. All patients were subsequently assessed for evidence of a missed ACS at at 6 & 12 months.

Of the 62 patients, 51 completed the protocol and were included in the analysis. They were divided into 2 groups: those who had ACS, either initially (fasciotomies; 13), or diagnosed at follow up (no fasciotomies; 7), and those with no evidence of ACS (31).

The sensitivity and specificity for the worst values for each variable were calculated and receiver operator characteristic (ROC) curves generated. The area under the curve for pH was 0.92, 0.73 for absolute pressure and 0.59 for delta pressure. To achieve a sensitivity of 95%, an absolute pressure of >30mmHg was 30% specific, a delta pressure of <33mmHg was 27%, while IM pH of 6.38 was 80% specific.

This study highlights the issues concerning current diagnostic methods for ACS. By comparison, IM pH radically out performed both the highest ICP and the lowest delta pressure, identifying patients early and accurately.

Intro

Distal radial fractures are a commonly encountered fracture & anatomical reduction is the standard. Dorsal angulation is the traditional method of assessment but is inaccurate in rotated lateral xrays. Previously a relationship has been demonstrated between the dorsal cortex (DC) of the radius & the superior pole of the lunate (SL) & its sensitivity for assessing dorsal angulation & translation.

Introduction

Several clinical and radiological studies have confirmed the benefits of using Volar Locking Plates (VLPs) to treat unstable distal radius fractures. The “theoretical” advantage of VLPs compared to standard plate fixation is that VLPs, through their design, intrinsically provide angular stability for most fracture configurations including comminuted fractures and, quite possibly, osteoporotic fractures. However few studies have compared the clinical results of patients of different ages who have been treated using VLPs.

Volar Locking Plates (VLP) have revolutionised the treatment of distal radius fractures allowing the anatomic reduction and stable fixation of the more comminuted and unstable of fractures. The benefits of this in terms of range of movement (ROM), pain and earlier return to work and daily activities is documented. However we were interested in was what improvements in wrist function patients made from 6 to 12 months after injury?

Background

Angular stable volar locking plates have become increasingly popular for more comminuted fractures of the distal radius. Newer designs of plates have been thicker in profile and incorporate more options for distal fragment fixation. Although they have been shown to be successful at maintaining reduction to allow early mobilisation the main drawback is from screw cut-out. In our practice we have noticed that the newer style of plates that offer more rigid fixation has lead to more instances of screw cut-out. We aimed to quantify the minimum number of locking pegs and or screws need to maintain the operative reduction.

Due to its popularity of intramedullary nails (IMN) high success rate, newer design (titanium) IMN system have been introduced to replace stainless steel system. However the stability provided by the titanium IMN

may not be adequate, there by influencing the union rate.

We aimed to compare the results of both IMN systems via prospective clinical study and biomechanical testing using RSA.

Despite the variety of implants or techniques that exist to treat displaced distal radial fractures, the majority fail to provide sufficient stability to permit early functional recovery. However, locking plates have the advantage over other implants in that locking screws add considerably to the overall stability.

The aim of this study was to assess the functional outcome of patients with displaced distal radial fractures treated with a volar distal radial locking plate (Synthes).

During a two year period, details of 98 patients admitted to our unit with inherently unstable dorsally displaced distal radial fractures treated with volar locking plates were collected prospectively. For the purpose of this analysis, only those patients (55) with unilateral fracture, able to attend the study clinic at 6 months post-injury were considered. Patients were immobilised in wool and crepe for a 2 week period.

The group consisted of 15 males and 40 females with an average age of 54 (28 to 83). At 6 months, patients' perceived functional recovery averaged 80%. Objective assessment was considered in relation to the uninjured side: grip strength 73%; pinch strength 83%; palmarflexion 77%, dorsiflexion 80%; radial deviation 74%; ulnar deviation 74%; pronation 93%, and supination 92%. Seven patients complained of symptoms relating to prominent metalwork.

Good/excellent early subjective and objective functional recovery was made following open reduction and internal fixation using volar locking plates of dorsally displaced distal radial fractures. We suggest that objective assessment of grip strength and dorsiflexion can be used as a measure of patient perception of function.

Viscosupplementation with hyaluronic acid (HA) is an established intervention for pain control in patients with mild to moderate osteoarthritis (OA) of the hip and knee. It is highly concentrated at the surface of the articular cartilage and the superficial layers of the synovial membrane. In the synovial fluid, HA acts as both a lubricant and a shock absorber. Due to the meshwork it forms with aqueous solutions, it acts as a semi-permeable barrier regulating metabolic exchanges between cartilage and the synovial fluid, and a viscoelastic shield around synoviocytes and adjacent nerve endings. Through its molecular size HA hinders the free movement of lytic enzymes and inflammatory mediators, and enhances chondrocyte metabolism. Osteoarthritis is associated with a decrease in concentration and average molecular weight of native HA in synovial fluid.

The mechanism of action of administered intra-articular HA is not completely understood, but as its clinical benefit exceeds its intra-articular presence, it is thought to perhaps induce native biosynthesis of HA and other extracellular matrix components and in particular suppress the inflammatory response and inhibit substance P, in addition to contributing to shock absorption by means of its viscoelastic properties.

Problems include inconvenience, expense and the logistical problems associated with multiple injections, injection technique and level of skill required by the administering physician, variable clinical response and adverse reactions.

In this independent, prospective, randomized trial, we compare efficacy and complications associated with treatment 100 athletes (112 knees) using durolaneTM and synvisc oneTM using the Visual Analogue Score, SF-36 V2 questionaire, and Oxford knee scores. Range of movement and absence from sporting activity is recorded at each visit. These assessments are repeated at 3, 6, 9 and 12 months. Significant improvement is seen in the VAS, SF 36 V2 and Oxford Knee Scores (p=0.01) and reduction in the use of analgesics and anti-inflammatories is seen with both products at 3 months post injection, with a significant advantage to the duro-lane group (p=0.001). At 6 months, this difference is extended even further. A small but statistical difference is noted in the time taken for the athlete to return to sporting activity following a rest period due to pain. Adverse reactions occur significantly less with the more effective product. We conclude that intra-articular HA a useful intervention in patients with mild to moderate OA of the knee, can produce sustained pain relief at 6 months, and can reduce the requirement for analgesia and anti-inflammatory medication during this time.

Introduction: In recent years both patients and clinicians have benefitted from using volar locking plates (VLPs) to treat otherwise difficult to stabilise displaced distal radius fractures. However, it is not clear whether the newer VLP systems offer real clinical advantages over the original systems. AIM: To assess the clinical outcome of patients treated using two VLP systems.

Methods: Two cohorts of patients treated with a distal radius VLP were assessed prospectively by an independent assessor at 6 months following surgery using Visual Analogue Scales (pain & function), range of movement, grip and pinch strength. Complications were also recorded. 68 patients treated with the original Synthes VLP and 51 with a Periloc VLP (Smith & Nephew) were available for clinical review. There were no differences in patient demographics or injury types between the groups.

Results: Treatment with both VLP systems resulted in good or excellent clinical outcomes for both patient groups. Using either the median or the mean results, there were no differences between either of the VLP groups with respect to pain, subjective function, grip or pinch strength, palmar flexion, dorsiflexion, radial or ulnar deviation, or forearm rotation. The complication rates were also very similar, the most common problem relating to prominent metal work necessitating removal after fracture healing in 7 – 9% of out patients. Conclusion: VLPs are excellent implants for restoring wrist function and reducing longterm symptoms. The potential advantages of the newer generation of VLPs over the simpler original VLP designs remain unproven.

In recent years volar locking plates (VLP) have revolutionised the treatment of more complex distal radial fractures, but doubt still exists as to whether this is an operation for all suitably qualified orthopaedic surgeons, in particular experienced trainees, or remains the domain of consultants or better still upper limb surgeons.

Aims: To assess changes in a Level 1 Trauma Unit’s practice over a 5 year period and to compare the clinical outcomes of patients operated upon by experienced orthopaedic trainees and consultant surgeons.

Methods: Two prospective cohort studies were undertaken using (a) the Synthes VLP (January 2003–January 2005), and (b) the Periloc (Smith & Nephew) VLP (January 2007–February 2008). All patients were assessed at 6 months following surgery for range of movement, grip and pinch strength, and subjective levels of pain and function using Visual Numerical Scales. 65 and 36 patients were available for 6 month review in the Synthes and Periloc groups respectively. Operations undertaken by, or assisted directly by, the consultant were considered to be ‘consultant’ procedures, with all others being undertaken by trainees.

Results: No significant patient demographical differences, or differences in fracture type were identified for the two cohorts. Clinical outcomes for the two cohorts were likewise similar at 6 months although there was a suggestion that pain, pinch and grip strength were marginally better in the Periloc group although this was not statistically significant. In the Synthes VLP cohort, 32 operations were undertaken by consultants and 33 by trainees, compared with 9 and 27 operations being undertaken by consultants and trainees respectively in the Periloc group. Although there was a tendency for the more difficult fractures to be operated upon by consultants, especially in the earlier cohort, trainees were left to deal with many of the more complex injuries in the Periloc cohort. The incidence of minor complications requiring further surgery (all relating to prominent metalwork) was also low in both groups (7 in the first group and 2 in the second group) with all but one of the index operations having been performed by a trainee.

Discussion: Despite the complexity of many distal radial fractures, VLP treatment of distal radial fractures has become a common place procedure that, in our unit, are frequently left to experienced trainees to operate upon without supervision. Our prospectively cohort studies clearly show that, over time, experienced trainees obtain clinical results that are similar to their consultant colleagues with respect to clinical outcome and incidence of complications.

Conclusions: As our unit’s experience of treating patients with distal radial fractures with VLPs has grown, experienced trainees appear to obtain clinical results that are similar to consultants.

Proximal Humeral fractures are common injuries that are difficult to treat satisfactorily despite the variety of operative and conservative treatment options that are available. To make any real sense of the literature concerning the treatment of these injuries, it is important that the tools that clinicians use to assess clinical outcomes accurately reflect each patient’s level of symptoms and function.

Aim: To assess how well commonly used subjective, and composite clinical scoring systems reflect patients’ perceptions of pain and functional recovery.

Methods: We invited all patients who had sustained a proximal humeral fracture that had been treated using a PHILOS (Synthes) Locking plate to attend for review. All patients were reviewed at a minimum of 14 months following surgery by which time they had all been discharged from regular clinical review months before. All patients completed subjective Visual Numerical Scales (VNSs) for pain, and for function, that were used to compare more commonly used shoulder/upper limb scores (UCLA, Modified Constant, Oxford, and Quick DASH scores).

Results: 33 patients were available for review. 55% were women. Age range 25–83 years (Ave. 57 years). Timing of review after index procedure (Range 14–58 months, ave. 30 months). Patients appeared to find the numerical VNSs easier to understand, and interestingly, analysis of the pain component of the each of the commonly used scores were answered inconsistently when the scores were compared. With respect to patient perception of pain and subjective level of function, both the Oxford and Quick DASH scores consistently overscored both parameters placing the majority of patients in higher (clinically better) categories, while the Constant score underscored the majority of patients placing them in lower categories (satisfactory or poor). The UCLA score was marginally better than the Constant score in relation to the VNSs for pain and function.

Discussion: Despite our dependence upon the more commonly used Clinical Outcome Scoring systems to help guide us with choosing the best treatment options for our patients with proximal humeral fractures, our study confirms our suspicions that none of these outcome scores truly reflect our patients perception of function and pain. In addition, the terminology and sentence structure that is used in all of the commonly used scoring systems may bias the results by confusing many of our patients.

Conclusion: Currently, none of our commonly used shoulder outcome scores truly reflect the clinical outcome of patients who have sustained proximal humeral fractures. Instead, it may be better to use subjective VNSs that are easy for patients to understand and are quick to use.

Despite advances in Locking Plate (LP) design, distal femoral fractures remain challenging injuries to treat especially in the elderly where approximately 15–30% develop nonunions secondary to failure of fixation.

Aim: To establish the mechanisms of nonunion in our patient population using two different LP systems.

Methods: Between December 2002-May 2008, we prospectively collected data on all 67 patients with distal femoral fractures who were treated using a suitable distal femoral LP (LISS, 35 cases, or Periloc, 32 cases). 72% of the patients were female; ages ranged from 25–94 years (ave. 67 years). Many of our patients had a number of significant co-morbidities.

Results: The presence of significant co-morbities e.g. Rheumatoid arthritis, long term systemic steroid use, cerebrovascular accidents resulting in ambulatory problems, previous major joint arthroplasty including ipsilateral knee replacements, paralysis, and severe dementia, did not appear to influence fracture union significantly. However, old age was strongly correlated with nonunion with all failed cases (7 patients - 10% of the study group) presenting with failure of fixation. 2 of the LP system failures resulted in malunion and the 5 other cases required revision surgery. Of note, all 7 patients were elderly, 6 being over 80 years of age. The mechanism of fixation failure was specific to each of the LP systems. All 4 of the failures treated with LISS, resulted from poor proximal stability as a consequence of unicortical screw fixation. Two patients required to have the proximal fixation revised through the insertion of bicortical screws which subsequently resulted in successful union. The other two patients were treated in long leg casts as the varus deformities were considered acceptable given each patient’s needs. All 3 of the failures who had been treated with a Periloc LP, resulted from fracturing of the plate at the metaphyseo-diaphyseal junction at the level of the main extra-articular component of the fracture. The plates all fractured through the unfilled screw holes, and all 3 patients required revision of fixation to bring about union.

Discussion: The LISS failures can all be attributed to poor proximal fixation that is associated with the use of unicortical screws in osteoporotic bone and confirms the need for bicortical screw fixation. However, modern LP systems manufactured from stainless steel offer increased implant stability that may in turn stress any fracture bridging segments of the LP.

Conclusion: Although we are aware of the importance of bicortical screws in osteoporotic patients, it is also seems likely that excessive plate rigidity should be avoided, by using long plates with well spaced out screws.

Aim: The use of volar plates in the management of distal radius fractures has increased dramatically over the last decade. Our aim was to ascertain if long term outcome could be predicted at clinical review four months following operation.

Patients and Methods: Between January 2003 and January 2005, all patients presenting with unilateral distal radius fractures and treated with volar locking plate fixation (Synthes) were invited to participate in long-term follow up. The decision to use a volar plate and the operative procedure itself was undertaken by the on-call consultant and his team. Patients who agreed to enter the study were evaluated at 4, 6 and 12 months following operation. Patient demographics, hand dominance and fracture type were recorded. Assessment of grip strength and wrist movements were undertaken and expressed as a percentage of the contralateral, uninjured side.

Results: A total of 76 out of 100 eligible patients agreed to participate in the study. Of those patients, 23 (30%) failed to attend all their follow-up appointments, leaving a dataset of 53 patients (70%) available for analysis. There were 28 females (53%) and the mean patient age was 55 years (range 28–83).

Grip strength, pinch grip, wrist flexion, wrist extension, radial deviation, ulnar deviation, pronation and supination all showed graded improvement in the year following fracture, achieving a mean range of 73% to 95% of function compared to the contralateral side at 12 months. Wrist flexion and ulnar deviation showed near maximum improvement by 6 months, whereas the other variables continued to show significant improvement between 6 and 12 months.

Logistic regression analysis suggested that improvement in wrist extension at four months was the best predictor of a good outcome at one year.

Discussion: Use of volar plate fixation is an increasingly common method of managing distal radius fractures. Our study suggests that good functional results can be achieved by this method of treatment. Failure to regain reasonable wrist extension by four months appears to predict higher risk of poor outcome and therefore patients in this group should be followed up more closely.

Hip fracture is a common serious injury in the elderly. Between 1982 and 1998 the number of hip fractures reported annually in Scotland in patients over 55 years rose from 4,000 to 5,700. The optimum method of treatment for the various fracture types remains in contention. The purpose of this study was to compare outcome measures between displaced, intracapsular fractures in patients over 70 years fixed with cannulated screws and sliding hip screw with side plate. Between 1998 and 2005 a total of 30,482 patients were reviewed by the Scottish Hip Fracture Audit (SHFA). Of these 15,823(53.3% of the total) had sustained intracapsular fractures. 13,587 of these occurred in patients aged 70 or over. Of these 2,428 had undisplaced and 11,159 displaced fractures. We performed a Chi test statistical analysis comparing outcome measures in this group of displaced intracapsular fractures with respect to aspects of early failure. 534(3.9%) of patients were treated conservatively. 509 (4.7%) fractures were fixed using cannulated screws and 499 (4.6%) using a sliding hip screw. Readmission within 120 days for any cause occurred in 62 patients(14.1%) treated with cannulated screw fixation and in 63 patients(15.7%) for those treated with a sliding hip screw(P=0.509). Of these 36 patients(8.2%) in the former and 23 patients(5.7%) in the latter group were readmitted for complications related to hip fracture(P=0.033). Mortality within this period included 69 patients(13.5%) in the CS and 98(19.6%) in the SHS group. In terms of re-operation within 120 days of the original admission, 53 patients(10.6%) receiving cannulated screws compared to 24 patients(4.8%) treated with a sliding hip screw requiring further surgery(P=0.0006). The fracture was seen to displace in 12(22.6%) patients originally treated with cannulated screws compared to 6 patients(25%) treated with sliding hip screw(P=0.156). More significantly the fixation device was seen to have migrated in 24(45.3%) of the cannulated screw as compared to 7(29.2%) patients in the sliding hip screw group(P=0.002). Periprosthetic fractures were recorded in 4(7.5%) of the former and 3(12.5%) in the latter group(P=0.708). Wound infection was higher in the SHS group(2 patients) as compared to the screw fixation group(1 patient)(P=0.565). Statistical analysis demonstrates a dramatic difference exists between these 2 fixation types in terms of re-operation within 120 days of the original admission for which published literature has previously only recorded biomechanical, in vitro comparisons. Data regarding specific implant factors such as number of screws, position, configuration, starting point, thread length and use of washers in cannulated screws, and position, tapping, supplementary screw and compression screw in sliding hip screws was not recorded and may be considered to bias our results.

Introduction: Current existing joint designs, principally flexible silastic spacers, satisfy the initial requirements but commonly lack durability. In particular all flexible silastic joints are prone to early breakage due to abrasion against bone and constant loading of the central section of the flexible implants. The aim of our new small joint design is to overcome many of the deficiencies of the flexible silastic designs while maintaining their main advantage of stabilising joint alignment throughout the flexion range.

Aim: To investigate the wear properties of the new small joint design in both static and dynamic applied loads using finite element analysis (FEA).

Materials: The design is essentially a cross between a flexible spacer and a surface replacement, whereby the spanning flexible spacer is located within the long axes of direct load bearing metacarpal and phalangeal ‘housings’. We have investigated a number of parameters, using finite element analysis (FEA), focussing principally upon the load bearing and wear properties of the new design to both static and dynamic applied loads with reference to the test protocol developed by the Durham group.

Results: Detailed FEA of the new joint design has highlighted the extreme potential durability of the housings and the internal flexible spacer. Our results suggest that the wear characteristics of both housings manufactured from PEEK (Polyetheretherketones) may result in the generation of considerably less wear debris compared with conventional alloy/plastic articulations. In addition, polyurethanes would appear to have better load bearing and wear characteristics than existing silastic materials.

Conclusions: Clearly, if our FEA findings were to be reproduced with biomechanical testing, we would be well placed to introduce durable and readily affordable small joint arthroplasties that may well resolve our current difficulties of treating patients with moderate joint disease in addition to being a realistic alternative for patients with advanced destructive small joint arthritis.

Introduction: The current techniques used for locking the distal end of intramedullary nails with cross screws remain a technical operative challenge for many clinicians. The surgeon uses his/her experience and judgement to locate the distal holes in the intramedullary nail, relying heavily on the use of two dimensional intra operative X-ray images (fluoroscopy) to undertake a three dimensional task. As a result, a large number of X-ray images are frequently required, significantly increasing the radiation exposure to both the patient and the operative team. Also there is an overall proportional increase in the operating time.

Aim: We aimed to develop a simple new radiological alignment jig that would allow the accurate placement of distal locking cross screws during intramedullary nailing, with minimal radiation exposure and without having to visualise the distal screw holes.

Materials and method: Laboratory tests were conducted using plastic femora (Sawbones Limited) fixed with intramedullary nails. Tests were performed three times using each of the different femoral intramedullary nails (Russell-Taylor, Smith & Nephew) investigating whether the length or diameter of the nail had any influence upon the accuracy of distal screw insertion. After successfully concluding the laboratory tests, a limited clinical study was conducted using the new alignment jig to insert distal locking screws in patients.

Results: Both the bench tests and limited clinical study were 100% successful and permitted the clinician to identify the distal holes correctly without needing to visualise the distal screw holes radiologically.

Conclusion: Our initial bench tests and clinical study show that the new alignment jig allows simple and accurate insertion of the distal locking screws with minimal radiological guidance. It also has considerable potential to reduce the overall operating time.